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This chapter scrutinises Mujuru’s role as ZANLA’s chief of operations in the liberation war from 1977 onward. Relying on oral accounts by Mujuru and ZANLA guerrillas, the chapter reconstructs preparation for significant guerrilla incursions such as Mount Casino in 1977 and some turning point battles with Rhodesian forces in the late 1970s. The oral history accounts of FRELIMO veterans bring to light under-researched evaluations of their military partnership with ZANLA. The chapter argues that without this at times conflictual military collaboration, Mujuru and ZANLA’s successes would have been held back. It was in a wider transnational purview, not strictly the nation, that Southern African liberation movements’ anti-colonial wars were fought, won or lost. The chapter also argues that although the Rhodesian forces had a degree of success in infiltrating and dividing ZANLA and ZANU, a great deal of the divisions were internally generated. Because of repeated internal divisions, ZANLA’s war progressed in stops and starts that delayed the path to independence, much to the concern of host states incurring heavy costs for Zimbabwe’s freedom. The costs pushed host states such as Mozambique to order ZANU to agree an independence settlement in 1979.
Attempts to define selective serotonin reuptake inhibitor (SSRI) withdrawal with the term ‘discontinuation syndrome’ are not supported by evidence. Acknowledging that SSRI use can result in dependence and withdrawal allows patients to be better informed around decisions related to these drugs, and helps inform strategies for safe tapering as appropriate.
Substance use disorders pose a significant global social and economic burden. Although effective interventions exist, treatment coverage remains limited. The lack of an adequately trained workforce is one of the prominent reasons. Recent initiatives have been taken worldwide to improve training, but further efforts are required to build curricula that are internationally applicable. We believe that the training needs of professionals in the area have not yet been explored in sufficient detail. We propose that a peer-led survey to assess those needs, using a standardised structured tool, would help to overcome this deficiency. The findings from such a survey could be used to develop a core set of competencies which is sufficiently flexible in its implementation to address the specific needs of the wide range of professionals working in addiction medicine worldwide.
Malnutrition and acute kidney injury (AKI) are common complications in hospitalized patients, and both increase mortality; however, the relationship between them is unknown. This is a retrospective propensity score matching study enrolling 46,549 inpatients, aimed to investigate the association between Nutritional Risk Screening 2002 (NRS-2002) and AKI, and to assess the ability of NRS-2002 and AKI in predicting prognosis. In total, 37,190 (80%) and 9,359 (20%) patients had NRS-2002 scores < 3 and ≥ 3, respectively. Patients with NRS-2002 scores ≥ 3 had longer lengths of stay (12.6±7.8 days vs. 10.4±6.2 days, P < 0.05), higher mortality rates (9.6% vs. 2.5%, P<0.05), and higher incidence of AKI (28% vs. 16%, P < 0.05) than normal nutritional patients. The NRS-2002 showed a strong association with AKI, that is, the risk of AKI changed in parallel with the score of the NRS-2002. In short- and long-term survival, patients with a lower NRS-2002 score or who did not have AKI achieved a significantly lower risk of mortality than those with a high NRS-2002 score or AKI. Univariate Cox regression analyses indicated that both the NRS-2002 and AKI were strongly related to long-term survival (area under the curve (AUC) 0.79 and 0.71) and that the combination of the two showed better accuracy (AUC 0.80) than the individual variables. In conclusion, malnutrition can increase the risk of AKI, and both AKI and malnutrition can worsen the prognosis, that the undernourished patients who develop AKI yield far worse prognosis than normal nutritional patients.
Although alcohol withdrawal is common, the recognition of benzodiazepine-resistant alcohol withdrawal is a relatively new concept. To provide a framework for both literature review and future research, we assessed clinicians’ personal definition of resistant alcohol withdrawal.
We developed a cross-sectional web-based survey. Administrators from collaborating toxicology and emergency medicine associations deployed the survey directly to their respective memberships. Only physicians, pharmacists, and other clinicians routinely treating alcohol withdrawal were eligible to participate. Respondents selected their preferred definition among the three most common author sources – JB Hack, NJ Benedict, D Hughes – or provided their own. Additional criteria to define resistant alcohol withdrawal were explored.
384 individuals answered the survey. Respondents were mostly attending physicians (79%), in full-time practice (90%), in emergency medicine (70%), and from North America (90%). The majority (64%) described resistant alcohol withdrawal as a high benzodiazepine dosage. Seizures (26%) and persistent tachycardia (16%) were also main characteristics. The median dose to describe high benzodiazepine dose (n = 146) was 40 mg per hour of diazepam equivalents (IQR 20–50). Available definitions were ranked equally as the preferred one: Hack (27%); Benedict (28%); Hughes (28%).
Our results did not identify one single preferred definition for resistant alcohol withdrawal even though a high total dose of benzodiazepine is a major component. Hourly requirements of 40 mg of diazepam equivalents or more emerged as a possible threshold. These findings serve as a base to explore consensus guidelines or future research.
This chapter examines the debate over the right and ability of countries to grant compulsory licenses on patented pharmaceutical products, including biologic drugs produced in living organisms, as a means of ensuring access to medicines. Opponents of such measures sometimes label them as “theft.” This chapter contemplates the validity of such theft rhetoric from an unconventional perspective: that of biblical teachings on what it means to steal. After an introduction to the issue, Part II describes the use of theft rhetoric in relation to intellectual property infringement broadly and drug patent compulsory licenses in particular. Part III challenges the contention, suggested by theft rhetoric, that compulsory licenses are morally wrong as a form of stealing, by considering the meaning of theft in the context of its Judeo-Christian origins. Part IV considers the cogency of the accusation that the issuance of compulsory licenses in developing countries destroys pharmaceutical company innovation incentives. Part V concludes that expanding the definition of theft to include, as the Bible does, the possibility that a property owner may be stealing from the poor, can help us to properly evaluate the morality of drug patent compulsory licenses.
Cannabis is the most commonly used substance among patients in methadone maintenance treatment (MMT) for opioid use disorder. Current treatment programmes neither screen nor manage cannabis use. The recent legalisation of cannabis in Canada incites consideration into how this may affect the current opioid crisis.
Investigate the health status of cannabis users in MMT.
Patients were recruited from addiction clinics in Ontario, Canada. Regression analyses were used to assess the association between adverse health conditions and cannabis use. Further analyses were used to assess sex differences and heaviness of cannabis use.
We included 672 patients (49.9% cannabis users). Cannabis users were more likely to consume alcohol (odds ratio 1.46, 95% CI 1.04–2.06, P = 0.029) and have anxiety disorders (odds ratio 1.75, 95% CI 1.02–3.02, P = 0.043), but were less likely to use heroin (odds ratio 0.45, 95% CI 0.24–0.86, P = 0.016). There was no association between cannabis use and pain (odds ratio 0.98, 95% CI 0.94–1.03, P = 0.463). A significant association was seen between alcohol and cannabis use in women (odds ratio 1.79, 95% CI 1.06–3.02, P = 0.028), and anxiety disorders and cannabis use in men (odds ratio 2.59, 95% CI 1.21–5.53, P = 0.014). Heaviness of cannabis use was not associated with health outcomes.
Our results suggest that cannabis use is common and associated with psychiatric comorbidities and substance use among patients in MMT, advocating for screening of cannabis use in this population.
Nitrous oxide (N2O) misuse is widespread in the UK. Although it is well-known that it can cause devastating myeloneuropathy, psychiatric presentations are poorly described. There is little understanding of who it affects, how it presents, its mechanism of action and principles of treatment. We begin this article with a case study. We then review the literature to help psychiatrists understand this area and deal with this increasing problem, and make diagnosis and treatment recommendations. We describe a diagnostic pentad of weakness, numbness, paraesthesia, psychosis and cognitive impairment to alert clinicians to the need to urgently treat these patients. Nitrous oxide misuse is a pending neuropsychiatric emergency requiring urgent treatment with vitamin B12 to prevent potentially irreversible neurological and psychiatric symptoms.
After reading this article you will be able to:
•understand the epidemiological and clinical features of nitrous oxide misuse
•understand the mechanisms of action of nitrous oxide
•describe potential treatment options in nitrous oxide misuse.
There are few topics that divide public opinion as sharply as the use of psychoactive substances and it is easy to see why. Substance use is complex and can be examined from numerous perspectives, including legal, health, economic, cultural and ethical. These varying approaches can lead to a range of different conclusions. Here we explore some of the common approaches adopted towards drug policy and suggest a number of principles, which may inform a psychiatrist's own view.
Substance use disorder explains much of the excess risk of violent behaviour in psychotic disorders. However, it is unclear to what extent the pharmacological properties and subthreshold use of illicit substances are associated with violence.
Individuals with psychotic disorders were recruited for two nationwide projects: GROUP (N = 871) in the Netherlands and NEDEN (N = 921) in the United Kingdom. Substance use and violent behaviour were assessed with standardized instruments and multiple sources of information. First, we used logistic regression models to estimate the associations of daily and nondaily use with violence for cannabis, stimulants, depressants and hallucinogens in the GROUP and NEDEN samples separately. Adjustments were made for age, sex and educational level. We then combined the results in random-effects meta-analyses.
Daily use, compared with nondaily or no use, and nondaily use, compared with no use, increased the pooled odds of violence in people with psychotic disorders for all substance categories. The increases were significant for daily use of cannabis [pooled odds ratio (pOR) 1.6, 95% confidence interval (CI) 1.2–2.0), stimulants (pOR 2.8, 95% CI 1.7–4.5) and depressants (pOR 2.2, 95% CI 1.1–4.5), and nondaily use of stimulants (pOR 1.6, 95% CI 1.2–2.0) and hallucinogens (pOR 1.5, 95% CI 1.1–2.1). Daily use of hallucinogens, which could only be analysed in the NEDEN sample, significantly increased the risk of violence (adjusted odds ratio 3.3, 95% CI 1.2–9.3).
Strategies to prevent violent behaviour in psychotic disorders should target any substance use.
This study analyzes whether Guatemalan success with the kingpin decapitation strategy of bringing major drug traffickers to justice has accomplished its greater objectives of reducing cocaine trafficking and drug-related violence. The analysis finds little evidence of success for the first objective in Guatemala but notable success for the second. One of the few studies to examine the application of this strategy outside Mexico and Colombia, its findings are interpreted in light of their contrasting experiences. The article provides an overview of drug trafficking in Guatemala and concise studies of two of its most important organizations targeted by the kingpin strategy.
Before drawing conclusions on the contribution of an effective intervention to daily practice and initiating dissemination, its quality and implementation in daily practice should be optimal. The aim of this process evaluation was to study these aspects alongside a randomized controlled trial investigating the effects of a multidisciplinary biannual medication review in long-term care organizations (NTR3569).
Process evaluation with multiple measurements.
Thirteen units for people with dementia in six long-term care organizations in the Netherlands.
Physicians, pharmacists, and nursing staff of participating units.
The PROPER intervention is a structured and biannually repeated multidisciplinary medication review supported by organizational preparation and education, evaluation, and guidance.
Web-based questionnaires, interviews, attendance lists of education sessions, medication reviews and evaluation meetings, minutes, evaluation, and registration forms.
Participation rates in education sessions (95%), medication reviews (95%), and evaluation meetings (82%) were high. The intervention’s relevance and feasibility and applied implementation strategies were highly rated. However, the education sessions and conversations during medication reviews were too pharmacologically oriented for several nursing staff members. Identified barriers to implementation were required time, investment, planning issues, and high staff turnover; facilitators were the positive attitude of professionals toward the intervention, the support of higher management, and the appointment of a local implementation coordinator.
Implementation was successful. The commitment of both higher management and professionals was an important factor. This may partly have been due to the subject being topical; Dutch long-term-care organizations are pressed to lower inappropriate psychotropic drug use.
Only one-third of patients with major depressive disorder achieve remission. One new and promising treatment, ketamine, may prove challenging to implement because of its abuse potential. Although clinicians' views have been sought, we need patients' views before large scale roll-out is considered.
To explore patients’ and carers' views to inform policy and practical decisions about the clinical use of ketamine.
We carried out a mixed-methods study using data from 44 participants in 21 focus groups in three sessions and an online survey with patients, carers and advocates during a consultation day. Focus groups explored participant's views about ketamine as a form of treatment and the best way for ketamine to be prescribed and monitored. The qualitative data were analysed by two patient–researchers using an exploratory framework analysis and was supplemented by a survey.
The ten themes generated were monitoring, information, effect on daily life, side-effects, recreational use, effectiveness, appropriate support, cost, stigma and therapy. Participants wanted better evidence on the safety of ketamine after long-term use and felt that monitoring was required. Collecting this information would provide evidence for ketamine's safe use and administration. There were, however, concerns about the misuse of this information. Practical issues of access were important: repeated travelling to clinics and a lack of sufficiently informed medical staff were key barriers.
Clinicians have some similar and some different views to those of patients, carers and advocates, which need to be considered in any future roll-out of ketamine.
Declaration of interest
R.M. has had UK National Institute for Health Research grant funding to study ketamine, is participating in trials of esketamine, runs a clinic that provides ketamine treatment, and has consulted for Johnson & Johnson and Eleusis.
Uncertain future risks pose cognitive and analytical challenges to household decision makers. Risks with uncertain probabilities, coupled with potentially severe outcomes pose problems for decision-making and are prone to overreactions. Imprecision in risk estimates generates behavioral distortions such as ambiguity aversion. This article presents new empirical results indicating household overvaluations of uncertain threats posed by several drinking water risks: traces of prescription drugs in drinking water, plastic water bottles with bisphenol-A, and the weed killer atrazine in drinking water. Negative reactions reflect responses to ambiguous risks, but policies driven by these concerns may misallocate regulatory resources due to risk conservatism and “no-regrets” responses.
This chapter looks empirically at the field of health technology assessment (HTA) and argues that it is possible to identify the ‘defence’ style of hyper-active governance posited in the previous chapter. HTA is the crucial expert policy area, involving deciding which drugs and other medical treatments are safe and cost-effective to be prescribed by a local doctor or hospital. HTA has been described by international organisations promoting its use as ‘the systematic evaluation of the properties and effects of a health technology, addressing the direct and intended effects of this technology, as well as its indirect and unintended consequences, and aimed mainly at informing decision making regarding health technologies’ (www.inahta.org). It is a process for making delicate decisions about whether a country will fund a medicine, often based on variants of cost–benefit analysis. In this sense, HTA is a classic arena of expert governance: it is the attempt to turn highly emotive decisions about life and death – about who gets access to new potentially life saving drugs and medical treatments – into rational, evidence-based questions of medical science.