Bipolar missed states : the diagnosis and clinical salience of bipolar mixed states

Objective: To explore diagnostic and treatment issues concerning bipolar mixed states.

Method: Bipolar mixed states are described and concerns about diagnostic and treatment difficulties are summarized and discussed.

Result: Mixed states can present with equal admixtures of depressive or manic symptoms, or more commonly one component predominates. There is fair consensus, although little data, regarding the management of manic mixed states. However depressive mixed states are far more complex both in terms of recognition and management. People suffering from mixed states characteristically present with complaints of depression.

Conclusions: The boundaries between depressive mixed states and agitated depression are vague, yet carry substantial therapeutic implications. Bipolar mixed states are often difficult to treat, and tend to take much longer to settle than either pure mania or depression.  Furthermore there is data that treatment with antidepressants can worsen the course of mixed states. Hence missed diagnoses can potentially have negative clinical implications.  Therefore in this paper the clinical presentation, diagnosis and therapy of mixed states is reviewed with a view to improving management.

Clinical characteristics and management of bipolar disorder in women across the life span

Though prevalent in both genders, specific consideration needs to be given when treating a woman suffering from bipolar disorder over her lifetime. Bipolar disorder is a serious and incapacitating illness affecting an estimated 5% of women. The first episode of illness in women is usually a depressive episode. Female gender has been associated with greater axis-one comorbidity, more depressive episodes, rapid cycling and mixed affective states. Special consideration is required for the treatment of bipolar disorder during reproductive events. More studies are required to better understand the course, outcome and gender-specific treatment strategies of this disorder.

Combination antidepressants : use by GPs and psychiatrists

Background : Current treatment of depression fails to achieve remission in 50% of patients. Combinations of two antidepressants are used by some Australian psychiatrists.

Objective : This article investigates the pros and cons of combination antidepressant therapy and provides suggestions for when to consider their use, which combinations to choose, and how to introduce combination antidepressant therapies.

Discussion : Combining two antidepressants is a controversial strategy, with supporters and critics arguing its efficacy and safety from opposing perspectives. The use of combination antidepressant therapies may facilitate remission from depression. However, there is limited evidence supporting these treatments, and safety concerns are often cited. There is some support for combination therapies in selected cases from international bodies. After considering risks and benefits on a case-by-case basis, careful use of selected combination antidepressant therapy may be one of a range of effective treatments for some individuals suffering from depression.

An audit of clinical outcomes and client and referrer satisfaction with a mood and anxiety Disorders unit

Objective To evaluate outcome and client and referrer satisfaction with the service provided by a Mood and Anxiety Disorders Unit (MADU).

Method MADU was a specialized clinical service for the assessment and management of individuals suffering with affective and anxiety disorders. Clients were referred to MADU from a variety of health service providers. A telephone survey of 30 clients and 20 referrers who have used the services of MADU was conducted, investigating outcome satisfaction with the service provided by MADU.

Results Clients and referrers reported a high level of satisfaction with the service provided by MADU. There was a high degree of adherence to treatment recommendations. The mean Patient Global Impression of Improvement (PGI) rating by the clients before the MADU assessment was 2.74 (SD = 1.27). In comparison the mean PGI rating at the time of follow-up was 6.64 (SD = 1.91).

Conclusions Specialist mood disorders units are a useful and potentially cost-effective additional service included as a part of a mental health service.

East and West, past and present : rekindle old principles for new management practices

This paper explores the sayings and stories of the ancient Chinese philosophers Guanzi, Hanfeizi, Xunzi and Yanzi. Their way of ruling the state and managing the people are analysed and discussed in line with thoughts from the mainstream and modern Western management gurus, such as Warren Bennis, Peter Drucker, Mary Parker Follett, Douglas McGregor, Rosabeth Moss Kanter, Elton Mayo, and Jeffrey Pfeffer. Striking similarities call for addressing key issues in human resource management. East and west thinkers across 3000 years are identified. The principles-based ruling and management were found difficult to be taken seriously in ancient times as it is today. However, these principles must be rekindled to protect organisations and the world from mischievous behaviour that has caused much human suffering.

Accounting education at a crossroad in 2010 and challenges facing accounting education in Australia

Of the various reports released in 2010, two purport to examine the state of accounting education in Australia. These are Accounting Education at a Crossroad in 2010 and Challenges Facing Accounting Education in Australia. Both were released as collaborations of the leading academic organisation, the Accounting and Finance Association of Australia and New Zealand (AFAANZ) or professional accounting bodies in Australia including the Institute of Chartered Accountants in Australia (ICAA), the Institute of Public Accountants (IPA),1 and Certified Practising Accountants of Australia (CPA Australia). As their titles imply, the main thrust of these reports is to examine the challenges facing accounting education in Australian universities and, as such, they act as the input for this AE Briefing. The main challenges articulated in these reports portray a sector suffering from the combined pressure of a large international student enrolment, high student-to-staff ratios, an inadequate funding model, and an ageing academic staff profile. By way of commentary, we suggest that, if these gloomy circumstances continue to develop unabated, then the future for the sector will play out as a ‘perfect storm’2 with the sector suffering on-going troubled development.

Humanity or justice?

This paper reflects on a critique of cosmopolitanism mounted by Tom Campbell, who argues that cosmopolitans place undue stress on the issue of global justice. Campbell argues that aid for the impoverished needy in the third world, for example, should be given on the Principle of Humanity rather than on the Principle of Justice. This line of thought is also pursued by ‘Liberal Nationalists’ like Yael Tamir and David Miller. Thomas Nagel makes a similar distinction and questions whether the ideal of justice can even be meaningfully applied on a global scale. The paper explores whether the distinction between the Principle of Humanity and the Principle of Justice might be a false dichotomy in that both principles could be involved in humanitarian assistance. It will suggest that both principles might be grounded in an ethics of caring and that the ethics of caring cannot be so sharply distinguished from the discourse of justice and of rights. As a result, the Principle of Humanity and the Principle of Justice cannot be so sharply distinguished either. It is because we care about others as human beings (Principle of Humanity) that we pursue justice for them (Principle of Justice) and the alleviation of their avoidable suffering.

A combined strength and balance exercise program to decrease falls risk in dialysis patients : a feasibility study

People suffering end-stage kidney disease receiving hemodialysis have a greater risk of falling and suffering debilitating injuries. The purpose of this study was to examine the feasibility and impact of a combined strength and balance exercise intervention on falls risk in hemodialysis patients. Twenty-four adults (mean age = 67.8 yrs) from two Australian outpatient hemodialysis clinics completed the intervention. Falls risk was measured using the Physiological Profile Assessment (PPA). There was a significant reduction in the median overall falls risk z-score from 1.67 to .52 (z = -3.11, P<.008; r = .45). Median reaction time improved from .30 to .26 sec (z = -2.86, P<.008; r = .41). A strength and balance intervention to reduce the falls risk for dialysis patients is feasible and may reduce falls risk for at risk patients.

Robust finite-horizon Kalman filtering for uncertain discrete-time systems

In this note, we propose a design for a robust finite-horizon Kalman filtering for discrete-time systems suffering from uncertainties in the modeling parameters and uncertainties in the observations process (missing measurements). The system parameter uncertainties are expected in the state, output and white noise covariance matrices. We find the upper-bound on the estimation error covariance and we minimize the proposed upper-bound.

Duration and persistence in multidimensional deprivation : methodology and Australian application

This article extends the recent literature on static multidimensional deprivation to propose dynamic deprivation measures that incorporate both the persistence and duration of deprivation across multiple dimensions. The article then illustrates the usefulness of the extension by applying it to Australian panel data for the recent period, 2001–2008. The empirical application exploits the subgroup decomposability of the deprivation measures to identify the subgroups that are more deprived than others. The proposed measure is also decomposable by dimensions and is used to identify the dimensions where deprivation is more persistent. The comparison between the subgroups shows that the divide between homeowners and non-homeowners is one of the sharpest, with the latter suffering much more deprivation than the former. The results are robust to alternative schemes for weighting and aggregating the dimensions as well as to the choice of model parameters.

Gatekeeping parenthood : should the state play a role in determining eligibility criteria for assisted reproductive treatment?

The use of assisted reproductive treatment to conceive a child provides the opportunity for the state and/or medical practitioners to play a role in deciding who should or should not become a parent. This article explores the primary criteria used to "screen" people wishing to use assisted reproductive treatment and to exclude them from treatment in some circumstances. It argues that idiosyncratic judgment or general legal presumptions against treatment are not satisfactory, as they are unlikely to predict whether the best interests of a child born as a result of assisted reproductive treatment will be compromised. Rather, such judgments may serve to be discriminatory, and are often misinformed. The author suggests that the law and society should rather serve to support children and parents in need, and to protect existing children from actual suffering or risks of harm.

The health loss from ischemic stroke and intracerebral hemorrhage : evidence from the North East Melbourne Stroke Incidence Study (NEMESIS)

Background People suffering different types of stroke have differing demographic characteristics and survival. However, current estimates of disease burden are based on the same underlying assumptions irrespective of stroke type. We hypothesized that average Quality Adjusted Life Years (QALYs) lost from stroke would be different for ischemic stroke and intracerebral hemorrhage (ICH).

Methods We used 1 and 5-year data collected from patients with first-ever stroke participating in the North East Melbourne Stroke Incidence Study (NEMESIS). We calculated case fatality rates, health-adjusted life expectancy, and quality-of-life (QoL) weights specific to each age and gender category. Lifetime 'health loss' for first-ever ischemic stroke and ICH surviving 28-days for the 2004 Australian population cohort was then estimated. Multivariable uncertainty analyses and sensitivity analyses (SA) were used to assess the impact of varying input parameters e.g. case fatality and QoL weights.

Results Paired QoL data at 1 and 5 years were available for 237 NEMESIS participants. Extrapolating NEMESIS rates, 31,539 first-ever strokes were expected for Australia in 2004. Average discounted (3%) QALYs lost per first-ever stroke were estimated to be 5.09 (SD 0.20; SA 5.49) for ischemic stroke (n = 27,660) and 6.17 (SD 0.26; SA 6.45) for ICH (n = 4,291; p < 0.001). QALYs lost also differed according to gender for both subtypes (ischemic stroke: males 4.69 SD 0.38, females 5.51 SD 0.46; ICH: males 5.82 SD 0.67, females 6.50 SD 0.40).

Discussion People with ICH incurred greater loss of health over a lifetime than people with ischemic stroke. This is explained by greater stroke related case fatality at a younger age, but longer life expectancy with disability after the first 12 months for people with ICH. Thus, studies of disease burden in stroke should account for these differences between subtype and gender. Otherwise, in countries where ICH is more common, health loss for stroke may be underestimated. Similar to other studies of this type, the generalisability of the results may be limited. Sensitivity and uncertainty analyses were used to provide a plausible range of variation for Australia. In countries with demographic and life expectancy characteristics comparable to Australia, our QoL weights may be reasonably applicable.

A neuro-immune model of myalgic encephalomyelitis/chronic fatigue syndrome

This paper proposes a neuro-immune model for Myalgic Encephalomyelitis/Chronic fatigue syndrome (ME/CFS). A wide range of immunological and neurological abnormalities have been reported in people suffering from ME/CFS. They include abnormalities in proinflammatory cytokines, raised production of nuclear factor-κB, mitochondrial dysfunctions, autoimmune responses, autonomic disturbances and brain pathology. Raised levels of oxidative and nitrosative stress (O&NS), together with reduced levels of antioxidants are indicative of an immuno-inflammatory pathology. A number of different pathogens have been reported either as triggering or maintaining factors. Our model proposes that initial infection and immune activation caused by a number of possible pathogens leads to a state of chronic peripheral immune activation driven by activated O&NS pathways that lead to progressive damage of self epitopes even when the initial infection has been cleared. Subsequent activation of autoreactive T cells conspiring with O&NS pathways cause further damage and provoke chronic activation of immuno-inflammatory pathways. The subsequent upregulation of proinflammatory compounds may activate microglia via the vagus nerve. Elevated proinflammatory cytokines together with raised O&NS conspire to produce mitochondrial damage. The subsequent ATP deficit together with inflammation and O&NS are responsible for the landmark symptoms of ME/CFS, including post-exertional malaise. Raised levels of O&NS subsequently cause progressive elevation of autoimmune activity facilitated by molecular mimicry, bystander activation or epitope spreading. These processes provoke central nervous system (CNS) activation in an attempt to restore immune homeostatsis. This model proposes that the antagonistic activities of the CNS response to peripheral inflammation, O&NS and chronic immune activation are responsible for the remitting-relapsing nature of ME/CFS. Leads for future research are suggested based on this neuro-immune model.

An experimental study of original and ordered fuzzy ARTMAP neural networks in pattern classification tasks

This paper investigates the effectiveness of an ordering algorithm applied to the supervised Fuzzy ARTMAP (FAM) neural network in pattern classification tasks. Before presenting the input patterns to the FAM network (known as ordered FAM), a fixed order of input patterns is first identified using the ordering algorithm. An experimental study is conducted to compare the results from ordered FAM with the average and voting results from original FAM. In the study, a pool of the original FAM networks is trained using different sequences of input patterns, and the results are averaged. Outputs from various original FAM networks can also be combined using a majority voting strategy to reach a final result. A database comprising various symptoms and measurements of patients suffering from heart attack is used to evaluate the various schemes of the FAM network in medical pattern classification tasks. The results are compared, analyzed, and discussed.

Religion as a source of resilience for elderly Greeks in Melbourne, Australia

This paper discusses the role of religion in creating resilience among elderly individuals of Greek background in melbourne, Australia, who are suffering from chronic disease. The role of religion in forming their conceptualization of health is analyzed in the context of their linguistic and cultural background as well as in relation to how they view their heritage and cultural identity.