Preliminary experiences with a single-patient trials service in general practice

Objective: To pilot a single-patient trials (SPTs) service in general practice, designed to improve decision-making about long-term medications for chronic conditions. Design: 12-week within-patient, randomised, double-blind, placebo-controlled, crossover comparison of ibuprofen with paracetamol for osteoarthritis, involving three pairs of two-week treatment periods for each participating patient. Setting and patients: Patients attending an academic general practice with a clinical diagnosis of osteoarthritis, with pain of at least a month's duration severe enough to warrant consideration of long-term non-steroidal anti-inflammatory drug (NSAID) use. Main outcome measures: Pain and stiffness; measures of overall arthritis compared with previous fortnight; preference for NSAID at the end of each two-week treatment period; use of escape analgesia; side effects; and management changes as a result of the SPTs. Results: Eight of 14 patients completed SPTs. One was a clear responder to NSAIDs, five were non-responders, and two were indefinite. Of the five who were using NSAIDs before the SPT, two continued and three ceased using them. Clinically useful information assisted decision-making for all eight participants. Medication management changed for six. Conclusions: Single-patient trials can be successfully implemented in general practice and might be a valuable method for GPs to identify patients who respond to medication for chronic stable conditions such as osteoarthritis, in which individual response to medication is variable.

Olanzapine vs risperidone in the management of schizophrenia: a randomized double-blind trial in Australia and New Zealand

Improved drug therapy for schizophrenia may represent the best strategy for reducing the costs of schizophrenia and the recurrent chronic course of the disease. Olanzapine and risperidone are atypical antipsychotic agents developed to meet this need. We report a multicenter, double-blind, parallel, 30-week study designed to compare the efficacy, safety, and associated resource use for olanzapine and risperidone in Australia and New Zealand. The study sample consisted of 65 patients who met DSM-IV criteria for schizophrenia, schizoaffective disorder, or schizophreniform disorder. Olanzapine-treated patients showed a significantly greater reduction in Positive and Negative Syndrome Scale (PANSS) total, Brief Psychiatric Rating Scale (BPRS) total, and PANSS General Psychopathology scores at endpoint compared to the risperidone-treated patients. Response rates through 30 weeks showed a significantly greater proportion of olanzapine-treated patients had achieved a 20% or greater improvement in their PANSS total score compared to risperidone-treated patients. Olanzapine and risperidone were equivalent in their improvement of PANSS positive and negative scores and Clinical Global Impression-Severity of Illness scale (CGI-S) at endpoint. Using generic and disease-specific measures of quality of life, olanzapine-treated patients showed significant within-group improvement in most measures, and significant differences were observed in favor of olanzapine over risperidone in Quality of Life Scale (QLS) Intrapsychic Foundation and Medical Outcomes Study Short Form 36-item instrument (SF-36) Role Functioning Limitations-Emotional subscale scores. Despite the relatively small sample size, our study suggests that olanzapine has a superior risk:benefit profile compared to risperidone. (C) 2002 Elsevier Science B.V. All rights reserved.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders

Background: The Royal Australian and New Zealand College of Psychiatrists is co-ordinating the development of clinical practice guidelines (CPGs) in psychiatry, funded under the National Mental Health Strategy (Australia) and the New Zealand Health Funding Authority. This paper presents CPGs for schizophrenia and related disorders. Over the past decade schizophrenia has become more treatable than ever before. A new generation of drug therapies, a renaissance of psychological and psychosocial interventions and a first generation of reform within the specialist mental health system have combined to create an evidence-based climate of realistic optimism. Progressive neuroscientific advances hold out the strong possibility of more definitive biological treatments in the near future. However, this improved potential for better outcomes and quality of life for people with schizophrenia has not been translated into reality in Australia. The efficacy-effectiveness gap is wider for schizophrenia than any other serious medical disorder. Therapeutic nihilism, under-resourcing of services and a stalling of the service reform process, poor morale within specialist mental health services, a lack of broad-based recovery and life support programs, and a climate of tenacious stigma and consequent lack of concern for people with schizophrenia are the contributory causes for this failure to effectively treat. These guidelines therefore tackle only one element in the endeavour to reduce the impact of schizophrenia. They distil the current evidence-base and make recommendations based on the best available knowledge. Method: A comprehensive literature review (1990-2003) was conducted, including all Cochrane schizophrenia reviews and all relevant meta-analyses, and a number of recent international clinical practice guidelines were consulted. A series of drafts were refined by the expert committee and enhanced through a bi-national consultation process. Treatment recommendations: This guideline provides evidence-based recommendations for the management of schizophrenia by treatment type and by phase of illness. The essential features of the guidelines are: (i) Early detection and comprehensive treatment of first episode cases is a priority since the psychosocial and possibly the biological impact of illness can be minimized and outcome improved. An optimistic attitude on the part of health professionals is an essential ingredient from the outset and across all phases of illness. (ii) Comprehensive and sustained intervention should be assured during the initial 3-5 years following diagnosis since course of illness is strongly influenced by what occurs in this 'critical period'. Patients should not have to 'prove chronicity' before they gain consistent access and tenure to specialist mental health services. (iii) Antipsychotic medication is the cornerstone of treatment. These medicines have improved in quality and tolerability, yet should be used cautiously and in a more targeted manner than in the past. The treatment of choice for most patients is now the novel antipsychotic medications because of their superior tolerability and, in particular, the reduced risk of tardive dyskinesia. This is particularly so for the first episode patient where, due to superior tolerability, novel agents are the first, second and third line choice. These novel agents are nevertheless associated with potentially serious medium to long-term side-effects of their own for which patients must be carefully monitored. Conventional antipsychotic medications in low dosage may still have a role in a small proportion of patients, where there has been full remission and good tolerability; however, the indications are shrinking progressively. These principles are now accepted in most developed countries. (vi) Clozapine should be used early in the course, as soon as treatment resistance to at least two antipsychotics has been demonstrated. This usually means incomplete remission of positive symptomatology, but clozapine may also be considered where there are pervasive negative symptoms or significant or persistent suicidal risk is present. (v) Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for comorbid conditions, such as substance abuse, depression and anxiety. (vi) The social and cultural environment of people with schizophrenia is an essential arena for intervention. Adequate shelter, financial security, access to meaningful social roles and availability of social support are essential components of recovery and quality of life. (vii) Interventions should be carefully tailored to phase and stage of illness, and to gender and cultural background. (viii) Genuine involvement of consumers and relatives in service development and provision should be standard. (ix) Maintenance of good physical health and prevention and early treatment of serious medical illness has been seriously neglected in the management of schizophrenia, and results in premature death and widespread morbidity. Quality of medical care for people with schizophrenia should be equivalent to the general community standard. (x) General practitioners (GPs)s should always be closely involved in the care of people with schizophrenia. However, this should be truly shared care, and sole care by a GP with minimal or no special Optimal treatment of schizophrenia requires a multidisciplinary team approach with a consultant psychiatrist centrally involved.

Organizational Learning in the Context of an Agri-Food Chain

This paper reports on the outcomes of the first stage of a longitudinal study that focused on the transformational change process being undertaken within the Supply Chain and Operations Area of a major Australian food manufacturing company. Organizational learning is an essential prerequisite for any successful change process and an organization's ability to learn is dependent on the existence of an environment within the organization that nurtures learning and the presence of key enablers that facilitate the learning process. An organization's capacity to learn can be enhanced through its ability to form and sustain collaborative relationships with its chain partners. The results show that an environment that supports organizational learning is being developed through consultative leadership and the empowerment of individuals within a culture that supports innovation and cross-functional teamwork but demands responsibility and accountability. The impact of these changes within the Supply Chain and Operations Area is evident in the significant improvement in the Area's productivity and efficiency levels over the past twelve months. The company's endeavours to engage its major supply chain partners in the learning process have been limited by the turmoil within the company. However the company has involved its supply chain partners in a series of mutually beneficial projects that have improved communication and built trust thereby laying the foundations for more collaborative chain relationships.

(Book review) Neuropsychotherapy and Community Integration: Brain Illness, Emotions, and Behavior. T. Judd. 1999. New York: Kluwer Academic/Plenum Publishers

As individuals gain expertise in a chosen field they can begin to conceptualize how what they know can be applied more broadly, to new populations and situations, or to increase desirable outcomes. Judd's book does just this. It takes our current understanding of the etiology, course, and sequelae of brain injuries, combines this with established psychotherapy and rehabilitation techniques, and expands these into a cogent model of what Judd calls “neuropsychotherapy.” Simply put, neuropsychotherapy attempts to address the cognitive, emotional and behavioral changes in brain-injured persons, changes that may go undiagnosed, misdiagnosed, or untreated.

The anammox case - A new experimental manifesto for microbiological eco-physiology

The anaerobic ammonium oxidation process is a new process for ammonia removal from wastewater. It is also a new microbial physiology that was previously believed to be impossible. The identification of Candidatus Brocadia anammoxidans and its relatives as the responsible bacteria was only possible with the development of a new experimental approach. That approach is the focus of this paper. The approach is a modernisation of the Winogradsky/Beyerinck strategy of selective enrichment and is based on the introduction of the molecular toolbox and modern bioreactor engineering to microbial ecology. It consists of five steps: (1) postulation of an ecological niche based on thermodynamic considerations and macro-ecological field data; (2) engineering of this niche into a laboratory bioreactor for enrichment culture; (3) black-box physiological characterisation of the enrichment culture as a whole; (4) phylogenetic characterisation of the enriched community using molecular tools; (5) physical separation of the dominant members of the enrichment culture using gradient centrifugation and the identification of the species of interest in accordance with Koch's postulates; (6) verification of the in situ importance of these species in the actual ecosystems. The power of this approach is illustrated with a case study: the identification of the planctomycetes responsible for anaerobic ammonium oxidation. We argue that this was impossible using molecular ecology or conventional 'cultivation based techniques' alone. We suggest that the approach might also be used for the microbiological study of many interesting microbes such as anaerobic methane oxidisers.

Observations of foehn onset in the Southern Alps, New Zealand

Local scale windfield and air mass characteristics during the onset of two foehn wind events in an alpine hydro-catchment are presented. Grounding of the topographically modified foehn was found to be dependent on daytime surface heating and topographic channelling of flow. The foehn front was observed to advance down-valley until the valley widened significantly. The foehn wind appeared to decouple from the surface downstream of the accelerated flow associated with the valley constriction. and to be lifted above local thermally generated circulations including a lake breeze. Towards evening. the foehn front retreated up valley in response to reduced surface heating and the intrusion into the study area of a deep and cool air mass associated with a regional scale mountain-plain circulation. Differences in the local windfield observed during both case study events reflect the importance of different thermal and dynamic forcings on airflow in complex terrain. These are the result of variation in surface energy exchanges, channelling and blocking of airflow. Observations presented here have both theoretical and applied implications with regard to forecasting foehn onset, wind hazard management, recreational activities and air quality management in alpine settings.

Differences in benthic fauna and sediment among mangrove (Avicennia marina var. australasica) stands of different ages in New Zealand

Management of coastal environments requires understanding of ecological relationships among different habitats and their biotas. Changes in abundance and distribution of mangroves, like those of other coastal habitats, have generally been interpreted in terms of changes in biodiversity or fisheries resources within individual stands. In several parts of their range, anthropogenically increased inputs of sediment to estuaries have led to the spread of mangroves. There is, however, little information on the relative ecological properties, or conservational values, of stands of different ages. The faunal, floral and sedimentological properties of mangrove (Avicennia marina var. australasica) stands of two different ages in New Zealand has been compared. Older (>60 years) and younger (3-12 years) stands showed clear separation on the basis of environmental characteristics and benthic macrofauna. Numbers of faunal taxa were generally larger at younger sites, and numbers of individuals of several taxa were also larger at these sites. The total number of individuals was not different between the two age-classes, largely due to the presence of large numbers of the surface-living gastropod Potamopyrgus antipodarum at the older sites. It is hypothesized that as mangrove stands mature, the focus of faunal diversity may shift from the benthos to animals living on the mangrove plants themselves, such as insects and spiders, though these were not included in the present study. Differences in the faunas were coincident with differences in the nature of the sediment. Sediments in older stands were more compacted and contained more organic matter and leaf litter. Measurement of leaf chemistry suggested that mangrove plants in the younger stands were able to take up more N and P than those in the older stands. (C) 2003 Elsevier Science B.V. All rights reserved.