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Clozapine remains the gold standard intervention for treatment-resistant schizophrenia; however, it remains underused, especially for some minority groups. A significant impediment is concern about propensity to neutropenia. The aim of this article is to provide an update on current knowledge relating to: the pattern and incidence of severe blood dyscrasias; the effectiveness of current monitoring regimes in reducing harm; the mechanisms of and the distinctions between clozapine-induced neutropenia and agranulocytosis; benign ethnic neutropenia; and changes to the monitoring thresholds in the USA and other international variations. These all have implications for the practical use of clozapine; specifically, how barriers to initiating, maintaining and restarting clozapine can be understood and in many cases overcome, especially for patients from minority groups, potentially with simpler approaches than the use of lithium or G-CSF.
Beginning in 1856 and ending in 1876, Portuguese colonial authorities in Mozambique registered almost 55,000 enslaved and freed Africans (libertos). The sources for these twinned registration processes are located in the national archives of Portugal and Mozambique. Fragments of the originals survive for only six of the ten districts of the colony, but contemporary copies exist for nearly all districts. Combined, they provide a unique opportunity to understand both the extent of slavery — as opposed to the export slave trade — and the process of abolition in late-nineteenth-century Mozambique. In this article we first describe the registers themselves, then focus on the registration of enslaved and freed Africans, the resistance of slaveholders, and the kinds of information that we can glean from the registers. We also explore the ways in which freed Africans were employed after registration and the extent to which being a liberto implied ‘freedom’. Finally, we consider how the registration led to new laws and policies in Portuguese Africa, opening a new era of European colonialism and imperial expansion.
The HCR-20 has taken on a life of its own. In forensic services it has been elevated from helpful aide-mémoire into a prophetic tool worthy of Nostradamus himself. Almost every outcome is interpreted through it. Despite the evidence of its limited utility, the difficulties of predicting rare events, the narrative fallacies and other heuristic biases it creates, and the massive opportunity costs it entails, commissioners and services alike mandate its use. Yet in routine practice the problems are not acknowledged, multiple conflicts of interest lie unobserved and other opportunities are neglected.
A series of eleven patients prescribed intramuscular clozapine at five UK sites is presented. Using routinely collected clinical data, we describe the use, efficacy and safety of this treatment modality.
Results
We administered 188 doses of intramuscular clozapine to eight patients. The remaining three patients accepted oral medication. With the exception of minor injection site pain and nodules, side-effects were as expected with oral clozapine, and there were no serious untoward events. Nine patients were successfully established on oral clozapine with significant improvement in their clinical presentations.
Clinical implications
Although a novel formulation in the UK, we have shown that intramuscular clozapine can be used safely and effectively when the oral route is initially refused.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
An ‘assertive approach’ to clozapine, where nasogastric administration is approved, is assessed through a case-load analysis to provide the first systematic description of its use and outcomes worldwide.
Results
Five of the most extremely ill patients with treatment-resistant schizophrenia were established and/or maintained on clozapine, resulting in improvements to their mental state; incidents were reduced, segregation was terminated and progression to less restrictive environments was achieved.
Clinical implications
Despite being underutilised and rarely enforced, in extreme circumstances, an assertive approach to clozapine can be justified. Nasogastric clozapine can be safely delivered and the approach itself, rather than actual nasogastric administration, may be enough to help establish and maintain patients with treatment-resistant schizophrenia on the most effective treatment.
Declaration of interest
E.S. has received speaker fees from Jansen Pharmaceuticals and Novartis.
We prove two main results on Denjoy–Carleman classes: (1) a composite function theorem which asserts that a function $f(x)$ in a quasianalytic Denjoy–Carleman class ${\mathcal{Q}}_{M}$, which is formally composite with a generically submersive mapping $y=\unicode[STIX]{x1D711}(x)$ of class ${\mathcal{Q}}_{M}$, at a single given point in the source (or in the target) of $\unicode[STIX]{x1D711}$ can be written locally as $f=g\circ \unicode[STIX]{x1D711}$, where $g(y)$ belongs to a shifted Denjoy–Carleman class ${\mathcal{Q}}_{M^{(p)}}$; (2) a statement on a similar loss of regularity for functions definable in the $o$-minimal structure given by expansion of the real field by restricted functions of quasianalytic class ${\mathcal{Q}}_{M}$. Both results depend on an estimate for the regularity of a ${\mathcal{C}}^{\infty }$ solution $g$ of the equation $f=g\circ \unicode[STIX]{x1D711}$, with $f$ and $\unicode[STIX]{x1D711}$ as above. The composite function result depends also on a quasianalytic continuation theorem, which shows that the formal assumption at a given point in (1) propagates to a formal composition condition at every point in a neighbourhood.
Many ethical dilemmas in medicine are associated with highly unusual clinical situations and are an almost daily challenge for mental health teams. We describe the ethical issues that arose in relation to a significant difference of opinion between team members about using nasogastric clozapine in the treatment of a severely ill patient. We discuss how conflicting emotions and perspectives within teams acquire ethical significance and how negotiation and reflection are essential for good-quality ethical reasoning to take place.
Learning Objectives
• Understand the different effects and importance of reasoning and emotions in moral decision-making
• Use a clinical scenario involving a difficult and controversial procedure to explore the impact of social persuasion in moral decision-making
• Consider the effects of heuristics against rational thinking
A peat core from southern Greenland provided a rare opportunity to investigate human-environment interactions, climate change and atmospheric pollution over the last ~ 700 years. X-ray fluorescence, gas chromatography-combustion, isotope ratio mass spectrometry, peat humification and fourier-transform infrared spectroscopy were applied and combined with palynological and archaeological evidence. Variations in peat mineral content seem to be related to soil erosion linked with human activity during the late Norse period (13th–14th centuries AD) and the modern era (20th century). Cooler conditions during the Little Ice Age (LIA) are reflected by both slow rates of peat growth and carbon accumulation, and by low bromine (Br) concentrations. Spörer and Maunder minima in solar activity may be indicated by further declines in Br and enrichment in easily degradable compounds such as polysaccharides. Peat organic matter composition was also influenced by vegetation changes at the end of the LIA when the expansion of oceanic heath was associated with polysaccharide enrichment. Atmospheric lead pollution was recorded in the peat after ~ AD 1845, and peak values occurred in the 1970s. There is indirect support for a predominantly North American lead source, but further Pb isotopic analysis would be needed to confirm this hypothesis.
The main purpose of this panel discussion was to encourage conversation around potential collaborations between the IAU Office of Astronomy for Development (OAD) and IAU Divisions. The discussion was facilitated by the OAD and the conversation revolved mainly around two questions: (i) What should the OAD be doing to enhance the work of the Divisions? (ii) What could the Divisions (both members and respective scientific discipline in general) contribute towards the implementation of the IAU strategic plan?
Congenital heart diseases are common in foetuses, with an incidence greater than six times that of chromosomal abnormalities; however, experts in cardiac anatomy have evaluated only the foetuses of pregnant women with increased risk for congenital heart disease. Over the years, it has become clear that congenital heart disease occur in foetuses of low-risk women. In the mid-1980s, a proposal to expand the assessment of cardiac anatomy was presented to obstetricians in order to improve prenatal screening. With the aim to systematise and improve the diagnosis of congenital heart disease in foetuses, the International Society of Ultrasound in Obstetrics and Gynecology established an ultrasound heart examination guideline. In this review, we have described the important features of this guideline and discussed the applications of this tool in clinical practice.
Methods
We performed a literature search of the National Library of Medicine for publications released between 2000 and 2012; we used search terms pertinent to congenital heart disease, such as foetal echocardiography, foetal heart and cardiac screening examination.
Results
The guidelines serve as a standard and help to systematise the screening for congenital heart diseases, but we think that some topics may be added to design the most appropriate screening method. However, we cannot expand the topics to be evaluated in this examination without good training of sonographers who undergo this screening.
Conclusion
Although the screening standardisation is a good tool to be used in day-to-day practice, the increment of aortic and ductal archs and colour Doppler to heart screening could be useful to detect further cardiac defects.
In Professional Ethics and Civic Morals, Emile Durkheim (1957: 50) explains that the state is the organ of a particular form of collective consciousness. This consciousness is not
so obscure and so indefinite as these collective representations that are spread throughout all societies-myths, religious or moral legends, and so on. … The representations that derive from the state are always more conscious of themselves, and of their causes and their aims. They have been concerted in a way that is less obscured. The collective agency which plans them realizes better what it is about.
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