Effectiveness of training health professionals to provide smoking cessation interventions: systematic review of randomised controlled trials

OBJECTIVE

To assess the effectiveness of interventions that train healthcare professionals in methods for improving the quality of care delivered to patients who smoke.

DESIGN

Systematic literature review.

SETTING

Primary care medical and dental practices in the United States and Canada. Patients were recruited opportunistically.

SUBJECTS

878 healthcare professionals and 11,228 patients who smoked and were identified in eight randomised controlled trials. In each of these trials healthcare professionals received formal training in smoking cessation, and their performance was compared with that of a control group.

MAIN MEASURES

Point prevalence rates of abstinence from smoking at six or 12 months in patients who were smokers at baseline. Rates of performance of tasks of smoking cessation by healthcare professionals, including offering counselling, setting dates to stop smoking, giving follow up appointments, distributing self help materials, and recommending nicotine gum.

METHODS

Trials were identified by multiple methods. Data were abstracted according to predetermined criteria by two observers. When possible, meta-analysis was performed using a fixed effects model and the results were subjected to sensitivity analysis.

RESULTS

Healthcare professionals who had received training were significantly more likely to perform tasks of smoking cessation than untrained controls. There was a modest increase in the odds of stopping smoking for smokers attending health professionals who had received training compared with patients attending control practitioners (odds ratio 1.35 (95% confidence interval 1.09 to 1.68)). This result was not robust to sensitivity analysis. The effects of training were increased if prompts and reminders were used. There was no definite benefit found for more intensive forms of counselling compared with minimal contact strategies.

CONCLUSIONS

Training health professionals to provide smoking cessation interventions had a measurable impact on professional performance. A modest, but non-robust, effect on patient outcome was also found, suggesting that training alone is unlikely to be an effective strategy for improving quality of care, unless organisational and other factors are also considered.

Short-range repression permits multiple enhancers to function autonomously within a complex promoter

Transcriptional repressors play a key role in establishing localized patterns of gene expression in the early Drosophila embryo. Several different modes of repression have been implicated in previous studies, including competition and direct interference with the transcription complex. Here, we present evidence for "quenching," whereby activators and repressors co-occupy neighboring sites in a target promoter, but the repressor blocks the ability of the activator to contact the transcription complex. This study centers on a zinc finger repressor, snail (sna), which represses the expression of neuroectodermal regulatory genes in the presumptive mesoderm. We show that sna can mediate efficient repression when bound 50-100 bp from upstream activator sites. Repression does not depend on proximity of sna-binding sites to the transcription initiation site. sna is not a dedicated repressor but, instead, appears to block disparate activators. We discuss the importance of quenching as a means of permitting separate enhancers to function autonomously within a complex promoter.

The problems of tracing a geographically widespread outbreak of salmonellosis from a commonly eaten food: Salmonella typhimurium DT193 in north west England and north Wales in 1991

Geographically widespread outbreaks involving commonly isolated organisms and where the vehicles of infection are commonly eaten foodstuffs pose particular difficulties at a technical and organizational level. An outbreak of Salmonella typhimurium infection, affecting 39 people, spread over a wide area in North West England and North Wales in April and May 1991, was detected thanks to the practice of sending specimens to the national reference laboratory where phage typing and characterizing of antibiotic resistance patterns enabled the identification of a cluster of distinctive isolates (S. typhimurium DT193 resistant to sulphonamides, trimethoprim and furazolidone). An investigation, involving twenty environmental health departments in addition to health authorities and the Public Health Laboratory Service, showed an association between the illness and eating loose sliced cooked ham (P = 0.004). Detailed tracing of the chain of supply of the ham showed this to be particularly cooked ham originating from a single small local producer (P = 0.00003). Further investigation of that producer revealed that a batch of ham distributed on one day in early April was undercooked due to a malfunction in cooking equipment.

Inner-city pharmacies: can they meet the OBRA '90 mandates?

Visits were made to 21 pharmacies in two poor Chicago neighborhoods as one component of the University of Illinois at Chicago's commitment to help improve health care delivery, ensure that pharmacy services are not overlooked in local health reform efforts, and understand the implications of the Omnibus Budget Reconciliation Act of 1990 (OBRA '90). Pharmacists report that Medicaid reimbursement policies result in: (1) prescribing patterns that have no consistent therapeutic or economic rationale; (2) dispensing of expensive drugs, some of which are then sold on the street or to other pharmacies; and (3) dispensing of unnecessary and often expensive legend drugs when other legend drugs and generics or over-the-counter products would perform just as well. On the positive side, 76% of the pharmacies possess computerized patient-profile systems, and 72% maintain background information on their prescribers. These results suggest that OBRA '90's mandates should contribute toward improving the Medicaid program, but that implementation is likely to be difficult and uneven.

Mast cell density and PGP 9.5-immunostained nerves in angioleiomyoma: their relationship to painful symptoms

Angioleiomyoma is frequently painful and the cause of the pain is unknown. The purpose of this study was to compare the mast cell population and innervation of painful and painless angioleiomyomas. Twenty-four cases of angioleiomyoma were examined; 16 painful and 8 painless cases. Pinacyanol erythrosinate and antibodies to protein gene product (PGP) 9.5 were used to demonstrate mast cells and nerves respectively. PGP 9.5-immunoreactive nerve fibres were found in most of the painful (13/16 cases) and painless lesions (5/8). Mast cells were not seen in half of the painful lesions but were seen in most of the painless lesions (7/8). The median mast cell density was 1.1 cells/mm2 for the painful lesions and 21.9 cells/mm2 for the painless lesions (P = 0.048, Mann-Whitney test). The lower mast cell density in the painful lesions may reflect increased mast cell degranulation. It is proposed that neural and vascular events, similar to those occurring in the triple response to mild cutaneous injury, may produce pain in angioleiomyoma and other painful skin tumours.

Serum lipids of adults 20-74 years: United States, 1976-80

This report presents descriptive and analytic data for serum total cholesterol, cholesterol lipoproteins, and triglycerides for adults 20-74 years of age by age, sex, and selected subgroups of the population at risk of developing coronary heart disease. This information is from the second National Health and Nutrition Examination Survey, which was conducted during the years 1976-80.

Medical Television Network--an expanding, interactive teleconference facility

Using proven satellite technology, Medical Television Network has set up a series of permanent UK receive sites for regular, interactive medical teleconferences. The format of the programmes regularly transmitted educates and updates busy doctors in fast-changing fields of medicine, encourages peer-group discussion, and enables the audience to question the expert faculty. This article describes the rationale for this development, the importance of shared 'ownership' with the postgraduate medical centres (PGMCs), the evaluation of audience response, and exciting areas for future growth and development.

The lipooligosaccharide immunotype as a virulence determinant in Neisseria meningitidis

We have studied the antigenic (immunotype) and physical characteristics of the lipooligosaccharide (LOS) of epidemiologically related Neisseria meningitidis case (36) and carrier (76) isolates associated with a virulent clone of meningococci (ET-5 complex). LOS immunotypes were determined by dot blotting using immunotype specific monoclonal antibodies and physical characteristics were determined from silver stained SDS-PAGE following proteinase K digestion. The genetic similarity of the different isolates was confirmed by analysis of the restriction fragment length polymorphisms. An association between LOS immunotype expression and invasive disease was found; 97% of case isolates expressed the L3,7,9 immunotype, of which 13% additionally expressed the L1,8,10 determinant. The LOS immunotypes of carrier strains were much more heterogeneous. The predominant immunotype was L1,8,10 (70%) and only 24% expressed L3,7,9 alone. Genotypically related case isolates from Norway (6) and Austria (18) expressed the L3,7,9 immunotype with similar frequency to the U.K. isolates. The combination of LOS immunotype and capsule expression appears to be related to the virulence of these meningococcal strains.

Acute sporadic hepatitis E in children living in Cairo, Egypt

Seventy-three pediatric patients with acute hepatitis and 19 control patients without liver disease living in Cairo, Egypt, were evaluated with a newly developed Western blot assay for IgM antibody to hepatitis E virus (IgM anti-HEV). The mean age of acute hepatitis patients was 6.4 years (range, 1-13 years); 56% were male. Among the 73 acute cases, hepatitis A was diagnosed in 30 (41%), possible acute hepatitis B in three (4%), hepatitis E in nine (12%), and by exclusion, non-A, non-B hepatitis in 29 (40%). Two additional acute cases were positive for both IgM anti-HAV and IgM anti-HEV. None of the 19 control subjects had IgM anti-HEV. Parenteral risk factors were associated with cases of non-A, non-B hepatitis but were not associated with acute hepatitis E. Contact with a family member with jaundice was associated with acute hepatitis A. In contrast to prior epidemics of enterically-transmitted non-A, non-B hepatitis, HEV was found to be a common cause of acute hepatitis in a pediatric population. This study provides additional evidence that HEV may be a frequent cause of acute sporadic hepatitis among children living in some developing countries.

A comparison of the shear strength of chemically versus electrolytically etched metal retainers

The recent popularity of acid-etched, resin-bonded retainers (RBR) has initiated improvements in design, technique, and etching. This study compared the shear strength of chemically etched Biobond retainers with electrolytically etched retainers bonded to enamel using identical cement. Shear fracture loads were recorded using Instrom testing for all specimens. The mean fracture load for the electrolytically etched castings was greater than that of the chemically etched castings. Electrolytically etched specimens also recorded the greatest and the least fracture load values. These results indicated that, while there were significant differences between the two groups with greater shear strength values for electrolytic etching, there was also more variation in shear fracture load with electrolytic etching.

Risk of viral hepatitis among military personnel assigned to US Navy ships

A prevalence study of 2072 male US shipboard military personnel scheduled for deployment to South America/West Africa and the Mediterranean was conducted to determine whether serologic evidence of prior hepatitis A, B, or C infection is associated with exposure in foreign countries. There were 210 subjects (10.1%) who had antibodies to hepatitis A virus (anti-HAV), 76 (3.7%) to hepatitis B core antigen (anti-HBc), and 9 (0.4%) to hepatitis C virus (anti-HCV). By multivariate analysis, anti-HAV seropositivity was independently associated with age, non-white racial/ethnic groups, birth outside of the United States, and prior Caribbean deployment for less than 1 year. Anti-HBc seropositivity was independently associated with black and Filipino race/ethnicity, foreign birth, a history of a sexually transmitted disease, South Pacific/Indian Ocean deployment (less than 12 months), and South Pacific or Mediterranean duty for (greater than 1 year). No geographic risk factors were associated with anti-HCV positivity. These data indicate that military personnel deployed outside the United States are at increased risk of viral hepatitis infection and should be considered for vaccination.

The effect of staff stress on patient behavior

A "natural experiment" examined the effects of staff turmoil caused by personal and group issues during and after the merger of two formerly separate neuropsychiatric evaluation units, on patient acting-out behaviors. Interviews with staff members identified the periods of high staff stress, and then two periods of personal resolution (3 to 4 months after the merger) and group reconstitution (8 to 12 months later). Patient acting-out behaviors (1:1 supervision, length of time on 1:1, use of the quiet room, seclusion, and restraints) tended to peak at times of staff peace. Behaviors under patient control (72-hour notices and discharges against medical advice) were also frequent during these periods, but showed additional activity in the time between personal and organizational resolution. While the relationship between staff issues and patient behavior is by no means straightforward, analysis of quantitative and qualitative data gathered here provides some support to the "reverse hypothesis" that when staff are upset, patients will not act out and vice versa. Implications for management, clinical practice, and research are presented.

Single-stage laryngotracheal reconstruction

The mainstay for repairing subglottic and tracheal stenosis has been the rib graft with prolonged stenting. A refinement of this treatment was the use of the anterior cricoid decompression (split). We present single-stage reconstruction of the airway as an additional refinement of the laryngotracheoplasty. This article describes the experience of two institutions with single-stage reconstruction and offers some observations on the principles of the technique.

Manual and oral praxis in adults with Down's syndrome

Mentally handicapped adults with and without Down's syndrome performed single movements and movement sequences following both verbal and demonstration cueing conditions. While the type of cue did not influence the performance of control subjects, Down's syndrome individuals exhibited more error following verbal cueing. These findings could not be explained on the basis of verbal encoding differences between the groups. The results support the notion that Down's syndrome persons suffer from a dissociation of the functional system responsible for speech perception and the system involved with the organization of complex movement.

New laryngeal surgery may improve voice

Laryngeal framework surgery has increased the options the otolaryngologists have available to treat voice disorders ranging from unilateral vocal cord paralysis to pitch disorders.

Phonosurgery: indications and pitfalls

Twenty-five patients underwent type 1 thyroplasty (external medialization of abducted true vocal cord) during a 2-year period 1986 to 1988) at the University of Iowa. The most common indication for thyroplasty was post-thyroidectomy vocal cord paralysis. Eighteen patients (72%) had either a good or an excellent initial result. Five patients were revised. Postrevision, 21 patients (84%) had achieved either a good or an excellent result. Complications were limited to one case of significant vocal cord edema and another instance of vocal cord hemorrhage. No patient required a tracheotomy. No prosthesis extruded. We feel that phonosurgery has the advantages over traditional Teflon injection of allowing the patient's head to be in a neutral position during the operation; of allowing local anesthesia; of permitting a predictable, graduated end point of the procedure; and of being infinitely adjustable, with preservation of the vocal cord mucosal wave.

Pediatric liver transplantation: a 3-year experience

From September 1, 1984 to March 1, 1988, 201 patients were evaluated for liver transplantation. Ninety-one orthotopic liver transplants were performed on 80 children ranging in age from 3 months to 15 years. The average waiting time for a transplant was 5 months, with children less than 10 kg in weight waiting a disproportionately long time. The average operative time was 10.6 hours and the average blood product replacement was 2.7 blood volumes. There was a steady improvement in both operative time and blood loss from 1985 to 1987. The overall hepatic arterial thrombosis rate was 9%; complex reconstructions having a thrombosis rate of 39%, and end-to-end anastomoses having a thrombosis rate of 1.4%. The average hospital stay was 37 days, and the major causes of postoperative morbidity and mortality were rejection (75%), infection (50%), and diarrhea (76%). The 1- and 3-year survival rates were 75% and 73%, respectively. Children with a successful transplant returned to home and school. After transplantation, 60% of the children exhibited catch-up growth and 88% have normal liver function. Pediatric liver transplantation is an effective modality in the treatment of children with terminal liver disease. Increased pediatric organ donation and the investigation of new operative techniques and types of preservation are necessary to meet the needs of an expanding recipient pool.

Nonshivering thermogenesis and brown fat in spontaneously hypertensive rats

Oxygen consumption was measured before and during infusion of the catecholamine isoproterenol in age-matched spontaneously hypertensive (SHR) and Wistar-Kyoto (WKY) normotensive rats. Mass-independent rates of oxygen consumption of anesthetized 7-week-old rats were similar in the WKY and SHR rats (11.08 +/- 0.74 and 11.33 +/- 0.82 ml O2 min-1 kg-.67, respectively). Catecholamine infusion elicited increased total oxygen consumption in both WKY and SHR animals (15.0 +/- 1.0 and 14.9 +/- 1.2 ml O2 min-1 kg-.67, respectively), and the magnitude of these increases did not significantly differ. To assess whether there were changes in the metabolic state of brown adipose tissue, the major site of catecholamine-induced thermogenesis in rats, enzymes whose activity is proportional to aerobic capacity were assayed in vitro. In both the interscapular and cervical brown fat depots, maximal citrate synthase and maximal HOAD (beta-hydroxyacyl-CoA dehydrogenase) activities were similar in SHR and WKY rats. There were also no significant differences in brown fat protein content, suggesting no differential growth of this tissue in the two rat strains. Our results indicate that the nonshivering thermogenic capacity of the hypertensive SHR rats does not differ from that of the normotensive WKY animals.

Histologic investigation of hyperphonated canine vocal cords

Vocal cord injury and its effect on the larynx are topics of considerable importance, yet a clear understanding of acute vocal cord injury from excessive phonation remains elusive. The inability to develop an animal model for vocal abuse has hampered research in this area. This project describes the development of a canine model for acute vocal cord injury from excessive phonation. The method of phonation consisted of a humidified, temperature-controlled, constant flow of air delivered subglottally by an external compressor. A small group of dogs underwent phonation for 2 and 4 hours. Vocal cord injury is described using histologic techniques. Damage to the vocal cords, other than hemorrhage (rare in dogs) and edema, proved to be too elusive for routine microscopy. Scanning and transmission electron microscopy showed extensive surface damage with destruction and loss of the surface microridges and premature desquamation of the vocal cord squamous epithelium. Injury extended to the lamina propria, where the collagen fibers were detached from the basement membrane.

Nasal presentation of an intracranial vascular anomaly

Intracranial vascular anomalies uncommonly present as a nasal mass. We report the first documented intranasal extension of a venous angioma of the anterior and middle cranial fossas. The diagnostic evaluation and differential diagnosis of an intranasal vascular mass is emphasized. In addition, recommendations are offered regarding the surgical approach of such a lesion.

Otolaryngologic manifestations of chronic granulomatous disease

Patients with chronic granulomatous disease (CGD) have a greatly increased incidence of infection, particularly in the region of the head and neck. For this reason the health care team treating the patient with CGD often includes an otolaryngologist. Because the disease process is associated with an altered host defense mechanism, standard medical and surgical plans must often be modified. In this paper, a representative case is presented illustrating the symptoms, clinical course, and therapeutic regimen of a typical patient. The necessity for aggressive treatment is emphasized.

Adjunctive measures for successful laryngotracheal reconstruction

The field of reconstructive surgery of the laryngotracheal complex has been the object of considerable enthusiasm in recent years. New surgical techniques, better surgical tools, and improved diagnostic skills all have contributed to a more confident approach to severe laryngotracheal stenosis. Just as the surgeon's judgment is crucial for a successful primary laryngotracheal reconstruction, so are his or her skill and judgment vitally important in managing the various problems that frequently are found following reconstructive surgery of the larynx and trachea. These problems, although seemingly minor, may prevent successful decannulation if not managed appropriately. This paper discusses the various problems that have been encountered while achieving decannulation following laryngotracheal reconstruction. An approach to such frustrating problems as suprastomal collapse, granulation tissue, and the inability to decannulate are presented.

Dexamethasone suppression test in depression: association with duration of illness

Plasma cortisol response to 1 mg dexamethasone suppression test was investigated in 37 patients with primary major depressive illness. Non-suppression of plasma cortisol was found in 14 of 37 (38%) patients. Duration of the index episode of illness was significantly shorter in the non-suppressors (11.1 +/- 9.1 weeks) than in the suppressors (29.7 +/- 25.6 weeks). The two groups were not distinguished by age, sex, polarity or severity of depressive symptoms. Eighty per cent of the non-suppressors (4/5) and 57% of the suppressors (8/14) had severe life events or major difficulties in the 6 months preceding the onset of illness, but this difference failed to reach statistical significance.

Strapping of joints

Strapping with adhesive tape plays a significant part in the prevention of joint injuries, particularly at the ankle and hand, and is important during early management of injury and rehabilitation. Recurrence of injury when the athlete recommences training is less likely when supportive strapping is applied.

Studies of glucose intolerance in cirrhosis of the liver

Patients with hepatic cirrhosis often have demonstrable glucose intolerance. We studied 21 patients with cirrhosis of the liver. Oral glucose tolerance tests (OGTT), intravenous arginine stimulation tests (IVAST), and intravenous insulin tolerance tests (IVITT) were performed, and timed blood samples were obtained for the assay of glucose immunoreactive insulin (IRI), C-peptide (C-P), and immunoreactive glucagon (IRG). The 125I-insulin binding to circulating monocytes was studied in some of the patients. All results were compared to those of similar studies performed on healthy controls. During OGTT significant glucose intolerance was demonstrable in the patients with cirrhosis (2 hr plasma glucose 198.8 +/- 14.3 mg/dl in cirrhosis and 116.4 +/- 4.2 in controls; p less than 0.001). Two-hour plasma IRI, C-P, and IRG were significantly higher in the cirrhotic patients than in controls (p less than 0.001; less than 0.001; less than 0.025). In response to IVAST, the patients with cirrhosis showed a greater first-phase insulin secretion and controls had a slightly better second-phase insulin release. Plasma IRG rose from a basal value of 446 pg/ml to 1100 in the patients with cirrhosis and from 171 pg/ml to 494 in controls. After intravenous insulin administration, there was only a 40% decline in plasma glucose concentration from basal values in the patients with cirrhosis whereas the controls showed a 60% decline, demonstrating that the patients with cirrhosis had significant insulin resistance. Moreover, the half-life of insulin was prolonged in the patients with cirrhosis (t 1/2 = 15.5 min in cirrhosis and 10.3 in controls; p less than 0.001); and the ratio of C-P to insulin during OGTT was also reduced, indicating that the patients with cirrhosis have reduced hepatic clearance of insulin. The specific binding of 125I-insulin to circulating monocytes was 2.7% in cirrhosis, 2% in obese controls, and 4% in lean controls. There was a significant negative correlation between the fasting plasma insulin values and the specific binding of insulin. In conclusion, patients with hepatic cirrhosis have significant glucose intolerance characterized by hyperinsulinemia, hyperglucagonemia, insulin resistance, and down-regulation of insulin receptors. Although hyperinsulinemia is probably caused by reduced hepatic clearance of insulin, hyperglucagonemia is primarily due to increased pancreatic secretion.

Paraoxonase phenotype distribution in Canadian Indian and Inuit populations

Test objects were the sera of 57 North American Indian and 67 Inuit subjects. The paraoxon-hydrolyzing activity, a, was determined, as well as the paraoxonase-phenotyping ratio, c/b, a ratio designating enzyme activation by Na+ in the presence of Ca2+. The values of c/b were clearly bimodally distributed. Location of the modes and of the antimodal gap were in perfect agreement with the results previously obtained on Caucasian sera. This allowed us to retain the criterion which had been already established in the study of Caucasians, i.e., c/b less than 1.5 = "low-activity" phenotype, and c/b greater than 1.5 = "high-activity" phenotype. The proportions of individuals in each mode differed, however. In Caucasians, the frequency of the "low-activity" phenotype had been estimated as 51.2%. In Indians and Inuits, it was 7.0% and 6.0%, respectively. Independent of phenotype, Indian and Inuit sera displayed lower paraoxon-hydrolyzing activity than did Caucasian sera.

Desipramine hydroxylation: variability and effect of antipsychotic drugs

Steady-state plasma concentrations of desipramine (DMI), unconjugated 2-OH DMI, and total 2-OH DMI were measured in 82 depressed inpatients, 35 of whom were concurrently receiving a phenothiazine or butyrophenone antipsychotic drug. In the patients not on an antipsychotic, the ratio of unconjugated metabolite to parent varied from 0.01 to 1.5, with a median of 0.48, and was inversely related to the parent drug level. Antipsychotic drug was associated with higher DMI levels and a lower proportion of OH-metabolite (median, 0.23). In both groups the unconjugated form accounted for only about 10% of the total metabolite. No relationship of age, sex, drinking history, or smoking to DMI or 2-OH DMI levels was found.

Imipramine and brief therapists-aided exposure in agoraphobics having self-exposure homework

Forty-five chronic agoraphobics were randomly assigned to treatment by placebo or imipramine in doses up to 200 mg/day for 28 weeks. All patients also had systematic self-exposure homework with an instruction manual. In addition, half of each drug group had therapist-aided exposure and half had therapist-aided relaxation, each totalling three hours. Patients in both drug groups improved substantially and maintained their gains for one year of follow-up. Imipramine had no significant therapeutic effect despite satisfactory plasma levels and significant drug side effects. Patients' low initial Hamilton depression scores might explain the absence of any drug effect. Antidepressants may be ineffective for agoraphobics who have normal mood. Brief therapist-aided exposure improved phobias and panics to a significant but limited extent, and is a useful adjuvant to self-exposure homework, which can be a powerful therapeutic agency by itself.

Prognosis in chronic mental disability

In a replication study three performance variables measured at the beginning of 200 patients' rehabilitation courses were combined to form an index to quantify the degree of initial disability. The Index score was significantly associated with the ten-year outcome, and hence has predictive value. With it a level of disability can be specified beyond which a patients' prospect of resettlement is predictably hopeless from the outset, despite prolonged and intensive rehabilitative efforts. On the other hand, many less disabled patients cannot achieve resettlement unless such efforts are made. There are, therefore, humanitarian and economic reasons for seeking to distinguish these two groups.

Steady-state plasma concentrations of cis- and trans-10-OH amitriptyline metabolites

Plasma concentrations of the geometric isomers of 10-OH amitriptyline (10-OH AT) and 10-OH nortriptyline (10-OH-NT) were determined by reversed-phase high-pressure liquid chromatography. Steady-state concentrations of At, NT, and the four 10-OH metabolites were measured in 27 patients taking AT for depression. All of the unconjugated hydroxylated metabolites were usually detectable and trans-10-OH NT always predominated. Mean concentrations, expressed as percentage of the sum of all six compounds, were: AT 30%, NT 27%, cis-10-OH AT 1.1%, trans-10-OH AT 4.0%, cis-10-OH NT 4.0%, and trans-10-OH NT 33%. Repeated measurements on 10 patients over several weeks indicated that interindividual variations in absolute and relative 10-OH metabolite concentrations are much greater than day-to-day variations. Five patients who also received a phenothiazine had a lower proportion of 10-OH metabolites.