Liberal perioperative fluid administration is an independent risk factor for morbidity and is associated with longer hospital stay after rectal cancer surgery

INTRODUCTION Recent studies have advocated the use of perioperative fluid restriction in patients undergoing major abdominal surgery as part of an enhanced recovery protocol. Series reported to date include a heterogenous group of high- and low-risk procedures but few studies have focused on rectal cancer surgery alone. The aim of this study was to assess the effects of perioperative fluid volumes on outcomes in patients undergoing elective rectal cancer resection. METHODS A prospectively maintained database of patients with rectal cancer who underwent elective surgery over a 2-year period was reviewed. Total volume of fluid received intraoperatively was calculated, as well as blood products required in the perioperative period. The primary outcome was postoperative morbidity (Clavien-Dindo grade I-IV) and the secondary outcomes were length of stay and major morbidity (Clavien-Dindo grade III-IV). RESULTS Over a 2-year period (2012-2013), 120 patients underwent elective surgery with curative intent for rectal cancer. Median total intraoperative fluid volume received was 3680ml (range 1200-9670ml); 65/120 (54.1%) had any complications, with 20/120 (16.6%) classified as major (Clavien-Dindo grade III-IV). Intraoperative volume >3500ml was an independent risk factor for the development of postoperative all-cause morbidity (P=0.02) and was associated with major morbidity (P=0.09). Intraoperative fluid volumes also correlated with length of hospital stay (Pearson's correlation coefficient 0.33; P<0.01). CONCLUSIONS Intraoperative fluid infusion volumes in excess of 3500ml are associated with increased morbidity and length of stay in patients undergoing elective surgery for rectal cancer.

Breaking Barriers to Successful Implementation of Day Case Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy is a common procedure performed in both emergency and elective settings. Our aim was to analyse the trends in laparoscopic surgery in Ireland in the public and private healthcare systems. In particular we studied the trend in day case laparoscopic cholecystectomy. National HIPE data for the years 2010-2012 was obtained. Similar datasets were obtained from the three main health insurers. 19,214 laparoscopic cholecystectomies were carried out in Ireland over the 3-year period. More procedures were performed in the public system than the private system from 2010-2012. There was a steady increase in surgeries performed in the public sector, while the private sector remained static. Although the ALOS was significantly higher in the public sector, there was an increase in the rate of day case procedures from 416 (13%) to 762 (21.9%). The day case rates in private hospitals increased only slightly from 29 (5.1%) in 2010 to 40 (5.9%) in 2012. Day case laparoscopic cholecystectomy has been shown to be a safe procedure, however significant barriers remain in place to the implementation of successful day case units nationwide.

Tissue and corneal donation and transplantation in the UK

NHS Blood and Transplant (NHSBT) was established in 2005 as a Special Health Authority when the National Blood Authority and UK Transplant merged. This helped to bring tissue banking and organ transplantation services under one umbrella organization. This merger means that ~!95% of all deceased donors (whether tissue, organ or both) are now facilitated by one organization. NHSBT Tissue Services is the largest tissue establishment in the UK, and is a multi-tissue bank that specializes in the consent, retrieval, processing, storage, and dispatch of donated tissue coordinated from a purpose built, state-of-the-art tissue bank in Liverpool. Tissue donations can come from either tissue-only donors or solid organ donors who also donate tissue. Annually there are ~450 multi-tissue donors and 2500 eye donors in the UK, resulting in many thousands of transplants, including 3564 cornea transplants in 2010-2011. The separation of tissue- and organ-specific donors is largely artificial, and while organ transplantation can be life-saving, tissue transplantation can also have a dramatic effect on a patient's quality of life. It is hoped that all donors, both organ and tissue, will be recognized for the gift they make to society after their death.

Fas mRNA expression in blood is reduced during episodes of human corneal graft rejection

BACKGROUND

Our purpose is to examine levels of Fas mRNA expression in blood during human corneal transplant rejection.

METHODS

Fas mRNA expression was detected by reverse transcription-PCR in blood from normal controls, corneal recipients at the time of transplantation and during episodes of rejection.

RESULTS

Samples taken at the time of a corneal rejection episode showed Fas mRNA levels were significantly lower in these patients than either normal controls (P = 0.017) or corneal transplant recipients not undergoing graft rejection (P = 0.00052). Serial samples from five patients who suffered an episode of rejection showed that the level of Fas mRNA is reduced during the rejection episode and subsequently recovers.

CONCLUSIONS

These results indicate low levels of Fas mRNA in blood may have a role in corneal transplant rejection.

Persistent activation of ERK contributes to glutamate-induced oxidative toxicity in a neuronal cell line and primary cortical neuron cultures

Oxidative stress can trigger neuronal cell death and has been implicated in several chronic neurological diseases and in acute neurological injury. Oxidative toxicity can be induced by glutamate treatment in cells that lack ionotrophic glutamate receptors, such as the immortalized HT22 hippocampal cell line and immature primary cortical neurons. Previously, we found that neuroprotective effects of geldanamycin, a benzoquinone ansamycin, in HT22 cells were associated with a down-regulation of c-Raf-1, an upstream activator of the extracellular signal-regulated protein kinases (ERKs). ERK activation, although often attributed strictly to neuronal cell survival and proliferation, can also be associated with neuronal cell death that occurs in response to specific insults. In this report we show that delayed and persistent activation of ERKs is associated with glutamate-induced oxidative toxicity in HT22 cells and immature primary cortical neuron cultures. Furthermore, we find that U0126, a specific inhibitor of the ERK-activating kinase, MEK-1/2, protects both HT22 cells and immature primary cortical neuron cultures from glutamate toxicity. Glutamate-induced ERK activation requires the production of specific arachidonic acid metabolites and appears to be downstream of a burst of reactive oxygen species (ROS) accumulation characteristic of oxidative stress in HT22 cells. However, inhibition of ERK activation reduces glutamate-induced intracellular Ca(2+) accumulation. We hypothesize that the precise kinetics and duration of ERK activation may determine whether downstream targets are mobilized to enhance neuronal cell survival or ensure cellular demise.

Corneal epithelial-specific cytokeratin 3 is an autoantigen in Wegener's granulomatosis-associated peripheral ulcerative keratitis

PURPOSE

In a previous investigation it was demonstrated that circulating antibodies to a 66-kDa corneal epithelial antigen (BCEA-A) are associated with peripheral ulcerative keratitis (PUK) in patients with Wegener's granulomatosis (WG). The aim of this study was to identify BCEA-A.

METHODS

The 66-kDa antigen was purified from a bovine corneal epithelial protein extract, using DE52 ion exchange chromatography. Purified protein was used to raise rabbit polyclonal antibodies. These antibodies were used to screen a bovine corneal epithelial cDNA expression library. Positive clones were purified and sequenced. Clones were identified by DNA sequence homology searches of the GenBank DNA database.

RESULTS

A cDNA clone that demonstrated strong binding to both the rabbit polyclonal antibody and patient sera, showed 85% homology to rabbit cytokeratin 3 (K3). K3 is a basic cytokeratin specific to corneal epithelium. No bovine DNA sequence for K3 is available. However, bovine K3 is larger than rabbit K3, with a molecular weight of 66 kDa. Immunofluorescence using both patient sera and the rabbit antibody demonstrated a cytoplasmic binding pattern on human corneal epithelium.

CONCLUSIONS

This evidence suggests that the 66-kDa autoantigen (BCEA-A) associated with PUK in WG is cytokeratin 3, and this may form the basis of a diagnostic/prognostic test.

Serum levels of vascular endothelial growth factor (VEGF) are markedly elevated in patients with Wegener's granulomatosis

OBJECTIVES

Necrotizing vasculitis and granuloma formation are the predominant features of Wegener's granulomatosis (WG). We have investigated the importance of vascular endothelial growth factor (VEGF) in monitoring disease activity in WG.

METHODS

Serum VEGF levels were determined in 23 patients with active WG, 21 healthy controls and 25 patients with urinary infection, by ELISA using commercially available antibodies to VEGF.

RESULTS

VEGF levels were enormously elevated in patients with WG compared to both controls and patients with urinary infection (P < 0.0001). Of the 23 patients, 21 (91.3%) had VEGF levels above the cut-off value (3.3 ng/ml, calculated as the mean of the controls + 2 S.D.). Further analysis of the data showed that VEGF levels did not correlate with age, sex, incidence of classic antineutrophil cytoplasmic antibodies (c-ANCA) or duration of the disease (P > 0.05), but there was correlation with disease activity (r = 0.51, P < 0.01). VEGF levels were higher in patients with major compared to those with minor disease activity (P < 0.01). However, there was no significant correlation between VEGF levels and the Birmingham scores for vascular activity and damage.

CONCLUSION

VEGF levels are raised in WG patients compared to normal controls and may be a marker of disease activity. Further studies on serial blood samples from a large cohort of patients with WG and other systemic vasculitides are needed to evaluate the specificity and usefulness of VEGF levels in monitoring disease activity.

Characterization of two corneal epithelium-derived antigens associated with vasculitis

PURPOSE

In a previous investigation into corneal autoimmunity, it was demonstrated that a putative autoantigen, a protein of 66 kDa, present in bovine corneal epithelium, binds circulating autoantibodies in approximately 60% of patients with Wegener's granulomatosis (WG). The aim of the present study was to characterize and identify the 66-kDa protein.

METHODS

A purification protocol was established for the 66-kDa protein using standard chromatography techniques. During the purification procedure it became clear that the 66-kDa protein detected in patients' sera was in fact two proteins, both running at 66 kDa on sodium dodecyl sulfate-polyacrylamide gel electrophoresis, that eluted in different fractions on DE-52 chromatography columns. These two proteins have been labeled bovine corneal epithelial antigen-A and -B (BCEA-A and BCEA-B). Further investigations of antibody binding have demonstrated that patients' sera bind to either one or the other of these proteins with no cross-reactivity between them. Separated BCEA-A and BCEA-B protein extracts were immunoblotted with 27 WG patients' sera, 10 Churg-Strauss syndrome (CSS) patients' sera, 31 rheumatoid arthritis (RA) patients' sera, and 40 healthy control subjects' sera from the blood bank.

RESULTS

Forty-six percent of WG patients' sera had antibodies to one of the 66-kDa antigens, whereas none of the healthy control subjects' sera had 66-kDa antibodies (P < 10(-5)). In the WG group, 31% were positive to BCEA-A (versus controls, P = 0.0023), and 15% were positive to BCEA-B. WG patients with peripheral ulcerative keratitis (PUK) had a significant association with anti-BCEA-A antibodies when compared with healthy control subjects (50%, P < 10(-6)). However, in the RA group with no eye disease there was an association with BCEA-A (25%, P = 0.011) but not in the RA group with PUK. The frequency of anti-BCEA-B antibodies was significantly increased in patients with CSS (60%, P < 10(-7)).

CONCLUSIONS

In summary, it has been shown that vasculitis patients have antibodies to two 66-kDa corneal antigens and that autoantibodies to these antigens are mutually exclusive. It has also been shown that antibodies to BCEA-B are associated with CSS, whereas BCEA-A antibodies are associated with WG and RA.

T cell responses to human type II collagen in patients with rheumatoid arthritis and healthy controls

OBJECTIVE

To study the prevalence of T cell responses to human type II collagen (CII) in patients with rheumatoid arthritis (RA) with or without antibodies to CII, and in healthy controls.

METHODS

Assays were performed to study T cell proliferative responses to CII in peripheral blood from 69 patients with RA (11 with anti-CII antibodies and 58 without) and 28 healthy controls. Further analysis was made of the time course of the response and the epitopic specificity, using peptides derived from the cyanogen bromide 11 (CB11) fragment of CII.

RESULTS

Significant proliferative responses to CII were found in 50% of patients with anti-CII, 5.3% of RA patients without these antibodies, and 35.7% of healthy controls. Responses in RA patients differed from those in healthy controls; the former had kinetics suggestive of a recall response and the latter that of a primary response. Some common epitopes within CB11 were recognized by T cells from patients and controls.

CONCLUSION

Proliferative T cell responses to CII occur in some healthy individuals, suggesting that thymic tolerance for this antigen may be incomplete. Most patients with RA have no evidence of a T cell response to CII, possibly indicating the development of peripheral tolerance to this antigen as a consequence of cartilage breakdown. However, in a minority of patients, T and B cell responses to CII persist, and may contribute to joint damage.

Cytoplasmic metallothionein overexpression protects NIH 3T3 cells from tert-butyl hydroperoxide toxicity

Metallothioneins (MT) are ubiquitous low molecular weight metal-binding proteins that may act as antioxidants. We examined the sensitivity of NIH 3T3 cells transfected with a plasmid containing mouse metallothionein-I gene (NIH3T3/MT) to the membrane permeant oxidant, tert-butyl hydroperoxide (tBH). NIH3T3/MT cells had a 4-fold increase in intracellular metallothionein as compared to cells transfected with a plasmid containing an inverted gene (NIH3T3/TM). Newly expressed metallothionein appeared to be localized to the cytoplasm as determined by immunofluorescence and confocal microscopy. NIH3T3/MT cells were 6 times more resistant than NIH3T3/TM cells to the cytotoxic effects of tBH. The antioxidant activity of NIH3T3/MT cells was greater than NIH3T3/TM cells, since exposure to tBH resulted in significantly less: (a) thiobarbituric acid-reactive substances and (b) fluorescence after loading cells with the oxidant-sensitive dye, 2'7'-dichlorodihydrofluorescein diacetate. Furthermore, homogenates of NIH3T3/MT cells were more capable of scavenging in vitro generated phenoxyl radicals as quantified by electron spin resonance detection. In contrast, overexpression of cytoplasmic MT did not protect against tBH-induced DNA damage, suggesting that subcellular location of MT is important for its function and that DNA damage is not a key determinant of cytotoxicity. These data provide direct support for an antioxidant role for MT, since physiologically relevant elevations in cytoplasmic MT interfere with tBH-induced cytotoxic peroxidation.

The prevalence of serum IgG antibodies to type II collagen in American patients with rheumatoid arthritis

Serum IgG antibody levels to native and denatured bovine type II collagen were elevated in 31.5 and 21.5% sera respectively from 200 American patients with RA. The prevalence of serum antibodies to native type II collagen is significantly higher than previously found in large studies of the prevalence of this autoantibody in Britain and Japan when using the same methodology.

Serotonin increases DNA synthesis in rat proximal and distal pulmonary vascular smooth muscle cells in culture

Cultured smooth muscle cells obtained from rat lung periphery (RPC) and proximal pulmonary artery (RSMC) expressed mRNA for serotonin (5-HT) type 2 receptor (5-HT2) and 5-HT transporter (by Northern blot analysis). Functional expression of these genes was evident since both cell types 1) bound 125I-labeled lysergic acid diethylamide (LSD; 5-HT2 receptor antagonist) that was equally effectively displaced by either ketanserin or mianserin; and 2) transported 5-[3H]HT in an imipramine-sensitive manner. Serotonin (10(-9)-10(-5) M) stimulated DNA synthesis (as measured by [3H]thymidine uptake) in RPC and RSMC. The 5-HT-induced increase in DNA synthesis was significantly inhibited in both cell types by the 5-HT2 receptor antagonist, ketanserin (10(-7)-10(-6) M), and by fluoxetine (10(-6) M), a putative 5-HT transport inhibitor. Acute exposure to 5-HT (1-100 microM) caused an abrupt rise in intracellular calcium ([Ca2+]i) in single pulmonary vascular smooth muscle cells as microspectrofluorometrically determined using the calcium-sensitive dye, fura 2. The 5-HT-induced change in [Ca2+]i was completely abolished in the presence of 10(-6) M ketanserin as well as imipramine or fluoxetine (10(-6) M). The calcium transients due to 5-HT persisted in a Na(+)-free condition (in which the transporter activity was completely abolished) and imipramine and fluoxetine (and ketanserin) were effective inhibitors of 5-HT under these conditions. Therefore, the 5-HT2 receptor, but not the transporter, is responsible for initiating the acute effects (e.g., calcium transients) of 5-HT in cultured rat pulmonary vascular smooth muscle cells and fluoxetine (1 microM) may have 5-HT2-receptor antagonist properties.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibodies to type II collagen in early rheumatoid arthritis

Antibodies to native and denatured type II collagen were investigated in a group of 79 patients with rheumatoid arthritis (RA) of disease duration less than 12 months (median 8 months; range 3-12 months). Using a solid-phase ELISA to measure these antibodies, the incidence of patients with levels above the upper limit of normal (mean of normal plus 3 SD) was low as compared to previous findings in patients with established disease. The majority of positive sera contained small amounts of IgM antibodies to denatured type II collagen whilst a few had IgG antibodies to native and denatured type II collagen. These findings suggest that the production of high levels of serum anti-type II collagen antibodies in patients with RA is a secondary phenomenon, which may exacerbate the disease rather than be a primary cause of disease.

Identification of an immunodominant B-cell epitope in bovine type II collagen and the production of antibodies to type II collagen by immunization with a synthetic peptide representing this epitope

Using epitope scanning of 272 short, synthetic peptides representing the amino acid sequence of the CB-11 peptide of type II collagen, we have shown that five strains of rat, immunized with type II collagen, produce antibodies to a region 37-45 amino acids from the amino end of CB-11 peptide. Antibodies to this region always gave the highest binding values suggesting that it is an immunodominant region. Wistar rats immunized with a synthetic peptide representing this region, coupled to keyhole limpet haemocyanin, produced antibodies to this peptide which could still be detected at 1:4000 to 1:8000 dilution but none developed clinical arthritis. All sera also showed binding of antibodies to denatured bovine type II collagen but not to native type II collagen, keyhole limpet haemocyanin or to bovine serum albumin by ELISA. Sera from peptide-immunized rats were examined for antibody binding to the 272 short peptides of the CB-11 peptide and to the synthetic peptides representing shortened forms of the immunodominant region and forms of it with substituted amino acids. These results showed that the antibodies in the peptide-immunized rats were not identical to those produced to that peptide by rats immunized with type II collagen but may represent subpopulations of them. These findings suggest caution in interpreting the role of antibodies to individual peptides in arthritis induction without knowledge of their fine specificity.

Genetic control of the immune response to collagen by the major histocompatibility complex in the rat: I. Humoral responses to bovine and chick type II collagen

A number of congenic and recombinant rat strains with different RT1 haplotypes on a PVG/c background were immunised with native bovine or chick type II collagen. Only strains with the "u" haplotype were good responders to bovine type II collagen whilst all strains responded to chick type II collagen. However, the "u" haplotype was again associated with the production of the highest amounts of antibody. All the strains responded to a non-collagenous antigen, keyhole limpet haemocyanin, showing that this effect was not a general one relating to all antigens. When antibodies were produced to the immunising collagen, binding of antibodies to native rat type II collagen was also seen. This association, of high amounts of antibody with the "u" haplotype, was inherited in a dominant fashion when F1 and F2 hybrids between low responder (RT1a) and high responder (RT1u) were examined. The recombinant r1 (class I av1, class II c) and r8 (class I av1 and class II u) strains showed that "u" haplotype at class II rather than at class I was associated with the strong response to type II collagen. The absence of arthritis in the "u" haplotype rats, suggests that the "u" haplotype alone is insufficient for arthritis induction after immunisation with type II collagen. It suggests that background genes outside the RT1 complex influence arthritis production as Wistar rats with the RT1u haplotype (but different minor genes outside RT1 complex) give an arthritis incidence of 50% under identical immunisation protocols.

A crisis team for the mentally ill: the effect on patients, relatives and admissions

A Crisis Team staffed by eight psychiatric nurses provided a 24-hour service to the seriously and chronically mentally ill who were experiencing psychiatric crisis. Immediate and continuing help was provided to patients and their relatives in their homes. Effects on patients, relatives and hospital admissions were studied. The sample consisted of 69 patients seen during a three-month study period. Six months later, 80% of patients and 73% of their relatives were interviewed by an independent psychologist. Of the sample, 80% had previous psychiatric admissions and were diagnosed as suffering from one of the functional psychoses--mainly schizophrenia or manic depression. The crises that led to the Team's interventions were mostly psychotic episodes and aggressive or suicidal behaviours; 47% occurred at night. Hospital records confirmed reports from staff, patients and relatives that the Team had halved admissions. Most patients and relatives were "very satisfied" with the treatment received from the Team and considered it had helped "greatly". They especially liked the home visits, the 24-hour availability and the friendly staff who provided them with support, medication and where needed, accommodation. In spite of the interventions of the Team, some 40% of patients were admitted during the research period, and at follow-up most were still experiencing symptoms and difficulties. Relatives, more than patients, expressed a need for additional rehabilitation and easier access to hospital, especially for those severely ill patients whom they found too difficult to live with. While the work of the Crisis Team proved highly beneficial for both patients and relatives, and reduced hospital admissions by half during the study period, it is clear that there is still a need for long-term support and rehabilitation.

Adolescent marijuana use: risk factors and implications

A sample of 1,270 students in Years 7, 10 and 11 attending seven State high schools in a middle class area of Sydney answered a self-report questionnaire designed to measure many aspects of their family situation, school performance, spare time activities, drinking and drug taking behaviour and sexual activity. Data on the reported prevalence of marijuana use and the variables significantly associated with marijuana use are presented and discussed. Marijuana use was reported by 4.2% of 12 year olds (Year 7), 26.5% of 15 year olds (Year 10) and 26.7% of 16 year olds (Year 11). More than half of those who had ever used marijuana had used it during the week prior to the survey and there were no significant differences in the characteristics between these recent and the remaining users. Marijuana users reported significantly poorer family relationships than non-users and were about twice as likely as non-users to come from a broken home and/or to have a mother who works full-time, which is often a consequence of marital break-up. Marijuana users also displayed poorer school performance, spent less time on homework and had more school absenteeism than non-users. Marijuana users were more than three times as likely as non-users to have had heterosexual intercourse, drunk alcohol 3 or more times in the past week and to smoke cigarettes. Also, the reported use of stimulants, hallucinogens, narcotics (heroin) and sedatives was almost entirely restricted to those who reported marijuana use. Improvements in the quality of family life may prevent the use of marijuana and other probably more harmful drugs, as well as the indulgence in other acting-out behaviours.

Lack of serum antibodies to native type II collagen in leprosy

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The role of family difficulties in adolescent depression, drug-taking and other problem behaviours

A comprehensive self-report questionnaire that covered many aspects of adolescents' lives was administered to 1270 students in Years 7, 10 and 11 who attended seven State high schools in Sydney. The prevalences of unhealthy and acting-out behaviours increased significantly between the ages of 12 and 15 years (Years 7 and 10) and then levelled out. By the age of 15 years, 15% of adolescents were drinking alcohol at least three times a week; 30% of adolescents smoked cigarettes; 15% of adolescents had used marijuana in the past week; and 18% of adolescents had had previous sexual experience. Nine per cent of all adolescents often felt "so down or low that life has lost its meaning". The quality of the family relationship was found to be associated closely with the presence or absence of adolescent depression and unhealthy or acting-out behaviours. Where the family relationship was not close or loving, the prevalence of depression was three times as high and the prevalences of alcohol, cigarette and marijuana use and early sexual activity were about twice as high as among adolescents who perceived that their families were close and loving. The majority of adolescents with poor family relationships felt that their parents could do more to help them. Help in the form of more understanding, support, trust, time, interest and freedom was wanted much more frequently than was help in the form of material items such as pocket-money. Parental divorce or separation and having a mother who was working full-time were also associated with a perceived lack of family closeness and love. The implications of these findings for the prevention of the establishment of health-threatening behavioural patterns and suicide among adolescents are discussed.

Light and electron microscopic analysis of insulin binding sites on neurons in dissociated brain cell cultures

The distribution of insulin binding sites on primary cultured neurons and glia from the fetal rat was examined by the immunoperoxidase method using a specific insulin receptor antiserum. Light and electron microscopic analysis revealed a homogenous distribution of insulin binding sites on selective neuron-like cells of the dissociated cell culture system. To determine the influence of medium insulin on the distribution of insulin binding sites, dissociated cell cultures were maintained in the presence or absence of porcine insulin for varying time periods. We observed a significant increase in the number of insulin stained neuron-like cells maintained in insulin free defined medium compared to neuron-like cells maintained in insulin supplemented defined medium. Further, we examined the distribution of insulin binding sites after incubation with the antibody, which has agonistic properties in peripheral tissues, for varying time periods prior to fixation. Under these conditions, the light microscopic analysis revealed a heterogeneous (patchy) distribution of immunoreactive insulin binding sites, suggesting that the ligand receptor complex migrates. These results demonstrate the presence and distribution of insulin binding sites on neurons maintained in vitro, and provide morphological evidence to support a functional role for insulin in CNS tissues.

The relatives of the mentally ill. A comparative trial of community-oriented and hospital-oriented psychiatric care

One hundred and twenty patients presenting for admission were randomly allocated into two groups. Control patients received standard psychiatric hospital care and aftercare. Experimental patients were not admitted, if possible; they and their relatives were provided with comprehensive community treatment, including a 24-hour crisis service. Patients with a diagnosis of alcohol or drug dependence, organic brain disorder, or mental retardation were excluded. The great majority of patients were diagnosed as suffering from one of the functional psychoses--mainly schizophrenia. During the study year, control patients spent an average of 53.5 days in psychiatric hospitals, experimental patients spent an average of 8.4 days. Psychiatric patients were treated more effectively and economically in the community, without shifting the burden onto the relatives. Nearly all the relatives of experimental patients preferred community treatment; they considered it to be significantly more helpful to the patients and themselves than standard psychiatric hospital care and aftercare.

Schizophrenia. A comparative trial of community orientated and hospital orientated psychiatric care

Sixty-five schizophrenic patients presenting for admission were randomly allocated into two groups. Control patients received standard hospital care and after-care. Experimental patients were not admitted if this could be avoided; instead they were taken back to the community by the Community Treatment Team who provided them and their relatives with comprehensive community treatment and a 24-h crisis service. During the 12 months study period 68% of the schizophrenic patients in the experimental group were not admitted; 10% were admitted two or more times and for 5 weeks or longer. All the schizophrenic patients in the control group were admitted--two-thirds or more times and for 5 weeks or longer. It was feasible to treat most schizophrenic patients in the community. Community treatment was considered by patients and their relatives to be the more satisfactory and helpful form of treatment and achieved a superior clinical outcome.

Community orientated treatment compared to psychiatric hospital orientated treatment

One hundred and twenty patients presenting for admission to a state psychiatric hospital were randomly allocated into two groups. Control patients received standard hospital care and after-care. Experimental patients were not admitted if this could be avoided; instead they and their relatives were provided with comprehensive community treatment and a 24-hour crisis service. Patients with a primary diagnosis of alcohol or drug dependence, organic brain disorder or mental retardation were excluded. Most patients were suffering from psychotic disorders--more than half specifically from schizophrenia. During the 12 months study period 96% of the control patients were admitted--51% more than once. Of the experimental patients 60% were not admitted at all and only 8% were admitted more than once. Control patients spent an average of 53.5 days in psychiatric hospital, experimental patients spent an average of 8.4 days. Community treatment did not increase the burden upon the community, was considered to be significantly more satisfactory and helpful by patients and their relatives, achieved a clinically superior outcome, and cost less than standard care and after-care. The ingredients differentiating comprehensive community-based care from prevailing methods of psychiatric care are discussed.

Psychiatric hospital versus community treatment: the results of a randomised trial

One hundred and twenty patients presenting for admission were randomly allocated into two groups. Controls received standard hospital care and after-care. Projects were not admitted if this could be avoided; instead they and their relatives were provided with comprehensive community treatment and a 24-hour crisis service. Patients with a primary diagnosis of alcohol or drug dependence, organic brain disorder or mental retardation were excluded. During the 12 months study period, 96% of controls were admitted, 51% more than once. Of the projects, 60% were not admitted at all and only 8% were admitted more than once. Controls spent an average of 53.5 days in psychiatric hospitals; projects spent an average of 8.4 days. Community treatment did not increase the burden upon the community, was considered to be significantly more satisfactory and helpful by patients and their relatives, achieved a clinically superior outcome, and cost less than standard care and after-care.

A controlled study of psychiatric hospital versus community treatment - the effect on relatives

One hundred and twenty patients presenting at Macquarie Hospital for admission were randomly allocated into two groups. The control group patients received standard hospital care and follow-up. The project group patients were not admitted if this could be avoided; instead they were taken back to the community by the project team who provided them and their relatives with comprehensive, assertive and prolonged follow-up treatment backed by a 24-hour crisis service. The majority (63%) of the project group had no admission during the 10 month study period. Initially, the burden on the relatives of the project group was higher, but by one month it was somewhat lower and by four months it was significantly lower than the burden on the control group relatives. Relatives of the project group patients were significantly more satisfied with the treatment than control group relatives. It is clearly feasible to treat most psychiatric patients in the community without increasing the burden on their relatives.

The prevalence of psychosocial problems. A study of 37,678 Sydney adults

Australian household surveys have indicated the prevalence of emotional or psychological disturbance as about 25 per cent of the population. Among those attending general practitioners' surgeries, the prevalence is even higher - 33 to 40 per cent. Morevoer, such psychosocial problems have an important effect on people's mental and physical health.

Heavy drinkers--their prevalence, attitudes and characteristics

Heavy drinkers were defined as those admitting to drinking six or more drinks every day or most days. This pattern of alcohol consumption which is equivalent to 80 or more grams of ethanol per day, puts them at 'high risk' of physical and/or psychosocial complications. Eleven percent of 23,673 males and 1% of 19,803 females who had a Medicheck screening were heavy drinkers. The most frequent reasons given for heavy drinking were relaxation, social contact and enjoyment of the taste. Most heavy drinkers felt that they drank more than was good for them but did not consider themselves to be 'sick' people in need of treatment. Heavy drinkers had a higher prevalence of psychosocial problems than moderate or light drinkers.

Early adolescent antecedents of narcotic abuse

A retrospective study of the sociocultural and behavioral characteristics of 200 persons under treatment for narcotic addiction was done and the results compared with those of 200 matched nonaddict peers. Twenty-eight of the original 104 items tested were found to discriminate between the two samples at the 5% level of significance. A factor analysis of these items indicated that a general delinquency behavior factor and three family background factors accounted for most of the variance in the data.

Drinking and drug taking patterns of 8,516 adults in Sydney

Data on the drinking and drug taking patterns of 8,516 adults who had been through a Medicheck screening were analysed. This is the largest sample studied in Australia to date. The alcohol intake pattern of at least 29% of males and 9% of females puts them "at risk" of physical and/or psychosocial complications; 11% of males and 2% of females were considered to be at high risk. Very few heavy drinkers considered themselves to have a drinking problem and even fewer had been told by their doctor that they were problem drinkers. One-quarter of all the women took either psychotropic drugs or analgesics regularly; 19% of females, compared with 7% of males, took one or more of the psychotropic drugs (mainly tranquillizers) regularly, and 9% of females compared with 3% of males took analgesics regularly. Approximately one-third of both males and females were current smokers, but more males than females had given up smoking. The important role to be played by general practioners in the prevention and early treatment of drug dependence is highlighted by these findings.

The use of methadone as a treatment tool for opiate addicts: A two-year follow-up study

Eighty-three per cent of a sample of 116 drug addicts in a Sydney methadone treatment programme were successfully followed up. Methadone was not found to be "the quick cure" for opiate addiction. More than two-thirds were still taking methadone, only 3% had not taken any opiates for six months or longer, and a further 5% had not taken any opiates for less than six months. The remainder (22%) were using illegal opiates either regularly or intermittently, or were in gaol. However, from the employment, crime and social-emotional stability data, it may be concluded that the methadone programme, particularly if adhered to continuously, is "successful". These findings generally support the findings of overseas studies. The clients, especially those who were still adhering to the programme, felt that methadone was helpful, although there was concern about still being drug-dependent and about side effects.

Random urine analyses from drug addicts in a methadone treatment programme

Random testing of urine from opiate addicts in the methadone treatment programme at the Drug Dependency Service, Brisbane Street, Sydney, was carried out for 18 months. Six samples from each of approximately 100 clients (that is, 580 specimens) have been analysed. It was found that clients receiving high methadone dosages (80 mg and over) used illegal opiates significantly less frequently than those on lower dosages. Furthermore, a decline in the use of illegal opiates and an increase in the proportion of "clear" urine specimens (that is, clear of all drugs except methadone) were indicators of the effectiveness of the methadone programme. It was concluded that urine testing was a useful and objective means of evaluating methadone or any other drug addiction treatment programme, and of monitoring what other drugs were being taken, both consciously or inadvertently in combinations. The results of urine testing can also be of value to counsellors in the therapeutic situation.