A model for pediatric neurocognitive interventions: considering the role of development and maturation in rehabilitation planning.

The need for post-acute neurorehabilitation after childhood acquired brain injury is increasingly recognized but recent reviews highlight the limited evidence-base and lack of a neuropsychological treatment model. Evidence from different fields was reviewed to inform the development of a pediatric neurocognitive interventions (PNI) model. The review included literature from child neuropsychology, adult neuropsychology, cognitive neuroscience, learning disabilities, education, and mental health. The resulting PNI model provides a systematic approach to delivering and evaluating appropriate care while minimizing the obstacles to successful outcomes. The model emphasizes the role of development and cognitive maturation in the planning of rehabilitation. Areas that represent significant gaps in our knowledge are discussed and future research directions are suggested based on predictions generated by the proposed model.

Euthanasia and assisted suicide in the post-Rodriguez era: lessons from foreign jurisdictions.

Euthanasia and assisted suicide are highly controversial subjects that have drawn much attention in Canada over the last two decades. This paper outlines how the Netherlands, the United States, Australia, and Canada have approached the practices. Jurisprudence, public opinion polls, legislative developments, and the positions of medical organizations and their members are included in the analysis. A number of arguments for and against the continued prohibition of the practices in Canada are evaluated. As well, information regarding the extent to which euthanasia and assisted suicide are performed in these countries is assessed. It will be shown that Canadians currently enjoy significant control over decisions concerning end of life. The principles of autonomy and beneficence provide the foundation necessary to justify lifting the prohibition of voluntary euthanasia and assisted suicide in Canada. With regard to the development of safeguards, the way in which foreign jurisdictions have dealt with both procedures is highly instructive. A qualified system of pre-authorization, unlike those adopted elsewhere, would prevent abuses from occurring and maintaining the prohibition of non-voluntary and involuntary euthanasia. Since legislators are in the best position to deal with the issues, change in the law should be made by the government, not the judiciary. Practical legislation is feasible and a proposal of what this should entail is presented.

The long-term use of benzodiazepines: patients' views, accounts and experiences.

BACKGROUND: Although a decrease in new prescribing has occurred for anxiolytic benzodiazepines, concerns have been raised that a 'core' of long-term users has been left behind. Typically, elderly people represent this 'core', using the benzodiazepines as hypnotics. OBJECTIVE: The present study focuses on the reasons why hypnotic benzodiazepines are used for protracted lengths of time. By examining patient experiences and cognitions, a deeper understanding may be gained of why patients continue to use benzodiazepines. METHODS: Elderly, long-term users of benzodiazepine hypnotics were interviewed using a semi-structured interview procedure. A comparison group of non-users of the drugs were given a brief interview to collect comparative data. Interview data were analysed from transcripts using qualitative methodology; statistical comparisons between the groups were made using non-parametric statistics. RESULTS: The long-term users had significantly fewer hours of sleep per night than the non-users. There was some evidence of tolerance and a suggestion that symptoms of withdrawal were maintaining continual use. None of the long-term users had clean knowledge of what their doctors thought of their use of benzodiazepines. CONCLUSIONS: The data suggest that the power of the doctor may not be utilized to its full potential in the prevention of long-term use, that at least 50% of elderly benzodiazepine users would like to discontinue use, and that patients need information and advice on how to discontinue these drugs.

Evaluation of an easy, cost-effective strategy for cutting benzodiazepine use in general practice.

AIM: This study set out to assess the effect of a letter from the general practitioner, suggesting a reduction in the use of benzodiazepines, and whether the impact of the letter could be increased by the addition of information on how to tackle drug reduction. METHOD: Two hundred and nine long-term users of benzodiazepines in general practice were divided into three groups: two intervention groups and a control group. The first intervention group received a letter from their general practitioner asking that benzodiazepine use be gradually reduced and perhaps, in time, stopped. The second intervention group received the same letter plus four information sheets at monthly intervals, designed to assist drug reduction: The mean age of the 209 people was 69 years (age range 34-102 years). RESULTS: After six months, both intervention groups had reduced their consumption to approximately two thirds of the original intake of benzodiazepines and there was a statistically significant difference between the intervention groups and the control group. Eighteen per cent of those receiving the interventions received no prescriptions at all during the six month monitoring period. CONCLUSION: The results indicate that a simple intervention can have a considerable effect on the use of hypnotic and anxiolytic drugs, even with a sample of elderly users.

Factors linked to the prescribing of benzodiazepines by general practice principals and trainees.

Principals and trainees in general practice attending training events were asked to give information about their prescribing of drugs, with a focus on the prescribing of benzodiazepines for psychological problems. High prescribers of benzodiazepines believed that a prescription saved consultation time, tended to be influenced by drug company information and believed that patients expected a prescription. Low prescribers of benzodiazepines did not prescribe for bereavement, wished to have more psychological expertise and offered treatments other than drugs. Doctors classified as empathic from their statements at interview found difficulty in ending consultations and thought that social problems should be part of the general practitioner's work, although there were no differences between empathic and unsympathetic doctors in overall prescribing rates of benzodiazepines. The data suggest that doctors who are emphatic towards their patients would prescribe less if they had training in psychological skills.

The effect of minimal interventions by general practitioners on long-term benzodiazepine use.

Seventy one long-term users of benzodiazepines were asked by their general practitioners in a letter or short interview to reduce their medication. Twenty two patients were successful in giving up or reducing their consumption to less than 100 tablets per annum. There were no clear predictors of success in terms of patient characteristics, duration of drug use, type of benzodiazepine, reason for drug use or strategy employed to reduce medication. However, patients who were successful at reducing their medication had a significantly lower mean baseline drug consumption than unsuccessful patients. The implications of this study are that a proportion of long-term users who are not in current crisis, especially those with relatively low consumption, can reduce or stop benzodiazepine treatment with minimal difficulty.

Psychological alternatives to long-term benzodiazepine use.

The aim of the study was to evaluate the effectiveness of psychological management of anxiety as an alternative to long-term benzodiazepine medication. Fifty patients were identified who had been taking benzodiazepines continuously for at least one year. No significant differences were found between patients who joined a treatment group and patients who were simply advised by letter to cut down their pills. Patients gave a variety of reasons for initially requiring medication and somewhat different reasons for needing to maintain chemotherapy, which suggested that pill-taking might be self-maintaining through withdrawal symptoms.

Dream recall and the contraceptive pill.

Data collected on women students at Edinburgh University allowed a comparison to be made between those who were taking a contraceptive pill and those who were not. The evidence suggests that women taking a contraceptive pill are more likely to recall dreaming, and that it is the progestagenic component that is the more active one. However, the data collected do not exclude the possibility that the differences observed are the consequence of other psychosocial variables; further research is recommended.

Variations in menstrual cycle symptom reporting.

PIP: The student population at Edinburgh University was surveyed in 1974 to collect data on women's menstrual cycles and to examine sources of individual differences in reporting symptoms associated with the cycle. 2542 non-oral contraceptive (OC) users and 756 OC users provided data. Both sets of respondents were questioned about the occurrence, both premenstrually and during menstruation, of 9 symptoms. The "physical" symptoms (stomachache, backache, nausea, fainting) were more often reported during menstruation, whereas the so-called "emotional" symptoms (lethargy, irritability, depression, tension, headache) had a greater prevalence premenstrually. When the 9 menstrual symptoms were broken down by students' fields of concentration, arts students were found to report more "emotional" symptoms than those in the sciences and professions (medicine and law). Further analysis showed that only and 1st born children were slightly less likely to report symptoms than those whose nearest sibling is 7 or more years older or younger or later born children. A similar trend was found for the reporting of illness in an earlier analysis of data from this sample. When cycle length and reqularity were analyzed together, women with long and regular cycles were found to have the lowest proportion reporting symptoms during menstruating with the exception of tension, nausea, and fainting, and women with short and irregular cycles had a correspondingly high incidence of all symptoms. In addition, women with more regular cycles were more likely to report infrequent recall of dreams than those with irregular cycles. Overall, the women who are most likely to report menstrual symptoms, especially those of an "emotional" character, are more likely to report other illnesses with emotional connotations, recall their dreams more frequently, show a preference for the arts, and tend to have been brought up with older siblings. This cluster of personality attributes defines an "expressive" personaltiy in contrast to the more "controlled" style of women at the other extreme.^ieng