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Focuses on the organization of community mental health care. Improvement of medical education in psychiatry; Encouragement of team work with general practitioners; Discussion on the treatment of doctors with the patients.

A response by W. C. Stewart, R. Feldman and M. A. Mychaskiw to a letter to the editor about their article regarding the evidence of ocular blood flow in the pathogenesis and treatment of glaucoma..

The authors discuss the article "Risk of Intracranial Haemorrhage in Anti-Depressant Users With Concurrent Use of Non-steroidal Anti-Inflammatory Drugs: Nationwide Propensity Score Matched Study," by Ju-Yong Shin and colleagues which appeared in the same issue. Topics include the relation between antidepressant drugs, non-steroidal anti-inflammatory drugs (NSAIDs), and intracranial hemorrhage, the risk of bleeds when the two classes of drugs are combined, and clinical implications.

The article highlights the problems associated with the management of multiple chronic conditions. Several strategies to deal with such combination of illness are highlighted. These include addressing multimorbidity by applying the idea of "no health without mental health;" shifting the design, funding, and outcomes of interest related to multimorbidity research; and developing new approaches of holistic care for all patients with mental-physical multimorbidity.

The article discusses the 'inverse care law' according to which the availability of good medical care tends to vary inversely with the need for it in the population served with exposure to market forces playing a major role. This has resulted in inadequate care of multimorbid populations in deprived regions compared to affluent ones. In order to restore the imbalances in the allocation of medical resources, they will have to meet the demands of younger multimorbid populations in deprived areas.

A letter to the editor is presented in response to the article "The future of primary care nurses and health visitors," by C. Derrett and L. Burke in the December 9, 2006 issue.

Compares the effectiveness of behavioral family counseling and taking naltrexone in the presence of a family member than individual-based treatment without family involvement. Prescription of naltrexone to the participants; Main outcome measures including abstinence from opioids assessed by Time Line Follow Back interview; Results showing that abstinence from opioids was greater in the behavior family counseling group than in the individual treatment group during treatment and at 12 months follow up; Conclusion that behavior family treatment improves outcomes better than individual treatment in men with opioid dependence.

The article discusses the medical examination of a 63-year-old man with a three-month history of non-specific generalized headache. He experienced episodes of odd behavior and forgetfulness. The patient was a non-smoker and had been in good health with no history of medical problems. He used to work as a secondary school teacher but had retired and opted to focus on horticulture.

The article presents a case study of a 58-year-old man who is experiencing a difficulty of finishing a round of golf due to an abnormal sensation around his abdomen and weakness of his legs. It says that the patient has showed an evidence of cerebral lymphoma five months after presenting with acute confusion and drowsiness. It adds that five cycles of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) chemotherapy was received by the patient.

An abstract of the article "A Diagnostic Dilemma: Rapid Cognitive Decline With White Matter Disease," by S. L. Miller, W. Stewart, C. Santosh, and colleagues is presented.

Background: In the USA, the lack of processes standardisation in histopathology laboratories leads to less than optimal quality, errors, inefficiency and increased costs. The effectiveness of large-scale quality improvement initiatives has been evaluated rarely. Aim: To measure the effect of implementation of a Lean quality improvement process on the efficiency and quality of a histopathology laboratory section. Methods: A non-concurrent interventional cohort study from 1 January 2003 to 31 December 2006 was performed, and the Lean process was implemented on 1 January 2004. Also compared was the productivity of the Lean histopathology section to a sister histopathology section that did not implement Lean processes. Pre- and post-Lean specimen turnaround time and productivity ratios (work units/full time equivalents) were measured. For 200 Lean interventions, a 5-part Likert scale was used to assess the impact on error, success and complexity. Results: In the Lean laboratory, the mean monthly productivity ratio increased from 3439 to 4074 work units/ full time equivalents (p

Objective: To evaluate open-angle glaucoma patients, who were insufficiently controlled on latanoprost mono- therapy, to determine the 24 h intraocular pressure (lOP) efficacy and safety when changing them to dorzolamide/timolol (DTFC) or latanoprost/timolol fixed combination (LTFC) or adding DTFC. Methods: A prospective, observer-masked, placebo-controlled, crossover, comparison. Consecutive adults with primary open-angle or exfoliative glaucoma who exhibit a mean baseline lOP >21 mm Hg on latanoprost monotherapy were randomised for 3 months to: OTFC, LTFC or DTFC and latanoprost. Patients were then crossed over to the next treatment for periods 2 and 3. At the end of the latanoprost run-in and after each 3-month treatment period, patients underwent 24 h lOP monitoring. Results: 31 patients completed this study. All three adjunctive therapies significantly reduced the lOP at each time point and for the mean 24 h curve, except at 18:00 and 02:00 with DTFC and 02:00 with LTFC. When the three treatments were compared directly, the DTFC and latanoprost therapy demonstrated lower lOPs versus the other treatment groups, including: the mean 24 h pressure, maximum as well as minimum levels and individual time points following a modified Bonferroni correction (p<0.0032). Conclusions: This study showed DTFC, LTFC and the addition of DTFC to latanoprost significantly decrease the lOP compared with latanoprost alone, but the latter therapy regime yields the greatest OP reduction. [ABSTRACT FROM AUTHOR]

Aim: To evaluate 24 h intraocular pressure (lOP) and blood pressure (BP) with bimatoprost or latanoprost in patients with normal-tension glaucoma. Design: Prospective, randomised, crossover, active-controlled, observer-masked study. Methods: After a 6-week medicine-free period, we randomised patients to either latanoprost or bimatoprost for 8 weeks and then to the opposite medicine for 8 weeks. At baseline, and at the end of each treatment period, we evaluated lOP and BP at 08:00 and then every 2 h over the 24 h day. Diastolic ocular perfusion pressure (DOPP) was calculated from the above parameters. Results: Forty completed patients had a 24 h untreated baseline lOP of 15.5 (2.3) mm Hg, and a DOPP of 59.2 (6.1) mm Hg. Both treatments lowered lOP at each time point (p<0.006), and over the 24 h curve (p<0.001, both medicines 13.1 mm Hg, 16% decrease). No difference existed between treatments in absolute lOP, at each time point, and over the 24 h curve (p⩾0.26). Additionally, no differences were found between treated 24 h systolic (p⩾0.29) and diastolic BP )p⩾0.12). The mean 24 h DOPP for latanoprost was increased from baseline (3%, p = 0.031) but not for bimatoprost (2%, p = 0.21). However, no difference in DOPP existed between treatments at any time point or over the 24 h curve (p⩾0.17). No difference was observed between treatments for any adverse event (p>0.05). Conclusions: In patients with normal-tension glaucoma, both bimatoprost and latanoprost reduce the 24 h intraocular pressure from untreated baseline to a similar extent. Latanoprost is associated with slightly improved ocular diastolic perfusion pressure over 24 h but similar absolute perfusion levels to that of bimatoprost. [ABSTRACT FROM AUTHOR]

Aims: To evaluate efficacy and safety in patients with ocular hypertension or open angle glaucoma changed to latanoprost/timolol fixed combination (LTFC). Methods: A prospective, multicentre, historical control in which qualified patients had their previous therapy substituted by LTFC and were followed for at least 2 months. Results: In 1676 patients LTFC was continued in 93% throughout the observation period. In all patients LTFC reduced the intraocular pressure (IOP) from 20.6 (SD 3.8) to 17.7 (3.0) mm Hg (p<0.001) compared to previous monotherapies including latanoprost, timolol, α agonists or carbonic anhydrase inhibitors (CAI). LTFC provided more efficacy after changing from adjunctive therapies including: a β blocker added to either CAI, α agonist, or pilocarpine, or CAI added to an α agonist, or latanoprost added to either CAI, α agonist, or β blocker (unfixed combination), and travoprost added to timolol (p<0.007). LTFC was as effective as latanoprost used with dorzolamide/timolol fixed combination (-0.9 mm Hg, p =0.1792). The most common reason to discontinue therapy was lack of efficacy (n = 70, 4%) and adverse event (n = 17, 1%). Conclusion: In a clinical selling, patients who have their monotherapy or adjunctive therapy substituted with LTFC may experience reduced IOP, good tolerability, and continuation of therapy for the first 2-3 months of treatment. [ABSTRACT FROM AUTHOR]

Background/aims: To evaluate the efficacy of brimonidine purite versus dorzolamide given twice daily in primary open angle glaucoma or ocular hypertensive subjects. Methods: In this double masked, multicentre, prospective, crossover comparison 33 subjects were randomised to brimonidine purite or dorzolamide for the first 4 week treatment period alter a 4 week washout. Subjects began the opposite treatment for the second 4 week period after another 4 week washout. Intraocular pressure (lOP) was measured at 08:00 (trough) and 10:00, 18:00, and 20:00 hours after dosing at each baseline and at the end of each treatment period. Results: The baseline diurnal lop was 22.9 (SD 2.8) for brimonidine purite and 22.2 (SD 2.4) mm Hg for dorzolomide. The trough lOP following 4 weeks of therapy was 21.0 (SD 3.7) for brimonidine purite and 21.0 (SD 3.1) mm Hg for dorzolamide (p = 0.90). The mean diurnal lOP was 19.3 (SD 3.1) for brimonidine purite and 19.8 (SD 2.4) mm Hg for dorzolamide (p=0.46). Dorzolomide caused more ocular stinging upon instillation (n = 8) than brimonidine purite (n = 1) (p = 0.02). No statistical differences existed between groups for systemic adverse events. Conclusions: This study suggests that brimonidine purite and dorzolamide each given twice daily have similar efficacy in primary open angle glaucoma or ocular hypertensive subjects. However, a trend was observed at 10:00 of greater brimonidine purite efficacy compared with dorzolamide. [ABSTRACT FROM AUTHOR]

The article presents case of a 50 year old woman who had history of end stage non-ischaemic cardiomyopathy. The patient was hypoxic, hypotensive, and tachycardic. Clinically, the patient was felt to have decompensated heart failure so she was admitted to the British Cardiac Society for haemodynamic monitoring and management. Invasive haemodynamic monitoring and intensive medical treatments were initiated. Despite medical treatment the patient did not improve, so a more strong medical treatment was pursued. The tracings depicted simultaneous EGG, radial arterial pressure tracing, pulmonary artery pressure tracing, and central venous pressure tracing being monitored in the cardiovascular intensive care unit.

Presents letters to the 'British Medical Journal' about a variety of topics. Length of patient consultations with doctors; Drawbacks of telephone consultations; Value of knee imaging by general practitioners; Hormone replacement therapy; Reducing unintended adolescent pregnancy; Others.

The article discusses how the care of patients with multimorbidities can be improved by use of a new technology. The new technology involves bringing together guidelines on individual conditions and tailoring the advice to each individual's personal condition. Some guidelines to help clinicians in treatment of these patients include cross reference guidelines using electronic delivery, provide guidance about treatments most likely to benefit and least likely to harm, and make better use of existing evidence. However, all guidelines do have their limitations, which is where physician experience comes into play. Patient circumstances and preferences should be paid heed to.

STUDY QUESTION: How often do clinical guidelines recommend drugs with potentially problematic interactions for people with more than one medical condition? SUMMARY ANSWER: In clinical guidelines, drug-disease interactions were uncommon except when patients also had chronic kidney disease, but potentially serious drug-drug interactions were common. WHAT IS KNOWN AND WHAT THIS PAPER ADDS: Clinical guidelines are almost all focused on single diseases and rarely account for comorbidity. This paper shows that in the presence of comorbidity, current guidelines often recommend drugs with potentially serious interactions with other diseases or with other recommended drugs. [ABSTRACT FROM AUTHOR]