Clozapine is an atypical antipsychotic used in the management of Treatment-Resistant Schizophrenia (TRS). Despite its efficacy, Clozapine is associated with rare but clinically important haematological side effects of neutropenia and agranulocytosis, thus warranting regular monitoring of full blood count (FBC) white blood count (WBC) and neutrophil count (NC).

Clozaril Patient Monitoring service (CPMS) supervises the prescribing of Clozapine and haematological testing for patients. Amber and Red alerts are issued by the CPMS when WBC and NC values fall below specified levels, Clozapine treatment is either suspended or discontinued completely.

We present a case of 35-year-old Caucasian lady with a history of schizophrenia who was maintained on Clozapine treatment for 10 years and whose Clozapine was necessarily stopped because of red alerts. This lead to a significant deterioration in her mental state and level of functioning necessitating a prolonged hospital admission.

• • Detailed retrospective review of this patient's CPMS results over a 2-year period identified consistently higher levels of WBC and NC, when the blood tests were conducted in the afternoon compared to mornings.

• • Literature review supported the phenomenon of a diurnal variation of WBC and NC levels in a proportion of patients prescribed Clozapine.

• • With clear knowledge of this patient's diurnal trends in WBC and NC count, it was possible to liaise with CPMS and restart her Clozapine treatment, leading to a significant improvement in her mental state and level of functioning.

• • We recommend that clinicians consider this phenomenon of diurnal variation in blood parameters in patients with frequent amber and red alert results who are at risk of having their Clozapine medication discontinued.

• • Close collaboration with CPMS and haematological advice may lead to a more nuanced approach to blood sampling, whereby afternoon samples are used in certain at-risk patients.

Our principle objective was to examine the personal and professional impact of service user (SU) suicide on mental health professionals (MHPs). We also wished to explore putative demographic or clinical factors relating to SUs or MPHs that could influence the impact of SU suicide for MHPs and explore factors MHPs report as helpful in reducing distress following SU suicide.

A mixed-method questionnaire with quantitative and thematic analysis was utilised.

Quantitative data indicated SU suicide was associated with personal and professional distress with sadness (79.5%), shock (74.5%) and surprise (68.7%) particularly evident with these phenomena lasting less than a year for more than 90% of MHPs. MHPs also reported guilt, reduced self-confidence and a fear of negative publicity. Thematic analysis indicated that some MHPs had greater expertise when addressing SU suicidal ideation and in supporting colleagues after experiencing a SU suicide. Only 17.7% of MHPs were offered formal support following SU suicide.

SU suicide impacts MHPs personally and professionally in both a positive and negative fashion. A culture and clear pathway of formal support for MHPs to ascertain the most appropriate individualised support dependent on the distress they experience following SU suicide would be optimal.

The early and effective detection of neurocognitive disorders poses a key diagnostic challenge. We examined performance on common cognitive bedside tests according to differing delirium syndromal status and clinical (motor) subtypes in hospitalized elderly medical inpatients.

A battery of nine bedside cognitive tests was performed on elderly medical inpatients with DSM-IV delirium, subsyndromal delirium (SSD), and no delirium (ND). Patients with delirium were compared according to clinical (motor) subtypes.

A total of 198 patients (mean age 79.14 ± 8.26) were assessed with full syndromal delirium (FSD: n = 110), SSD (n = 45), and ND (n = 43). Delirium status was not associated with differences in terms of gender distribution, age, or overall medication use. Dementia burden increased with greater delirium status. Overall, the ability to meaningfully engage with the tests varied from 59% for the Vigilance B test to 85% for Spatial Span Forward test and was lowest in patients with FSD, where engagement ranged from 32% for the Vigilance B test to 77% for the Spatial Span Forwards test. The ND group was distinguished from SSD group for the Months of the year backwards, Vigilance B, global VSP, Clock Drawing test, and Interlocking Pentagons test. The SSD group was distinguished from the FSD group by Vigilance A, Spatial Span Forward, and Spatial Span Backwards. Regarding differences among motor subtypes in terms of percentage engagement and performance, the No subtype group had higher ratings across all tests. Delirious patients with no subtype had significantly lower scores on the DRS-R98 than for the other three subtype categories.

Simple bedside tests of attention, vigilance, and visuospatial ability are useful in distinguishing neurocognitive disorders, including SSD from other presentations.

1. • Understand the concept of cognitive friendliness and how addressing the problem of delirium can contribute to this in our healthcare system.

2. • Become more aware of specific aspects of a cognitive-friendly programme and how these can be implemented in practice.

3. • Explore the key outstanding issues for research that can further enhance our awareness of cognitive-friendly practices.