World psychiatric association section of old age psychiatry consensus statement on ethics and capacity in older people with mental disorders.

The World Psychiatric Association (WPA) Section of Old Age Psychiatry, since 1997, has developed Consensus Statements relevant to the practice of Old Age Psychiatry. Since 2006 the Section has worked to develop a Consensus Statement on Ethics and Capacity in older people with mental disorders, which was completed in Prague, September 2008, prior to the World Congress in Psychiatry. This Consensus meets one of the goals of the WPA Action Plan 2008-2011, "to promote the highest ethical standards in psychiatric practice and advocate the rights of persons with mental disorders in all regions of the world". This Consensus Statement offers to mental health clinicians caring for older people with mental disorders, caregivers, other health professionals and the general public the setting out of and discourse in ethical principles which can often be complex and challenging, supported by practical guidance in meeting such ethical needs and standards, and to encouraged good clinical practice.

The wills of older people: risk factors for undue influence.

BACKGROUND: As people live longer, there is increasing potential for mental disorders to interfere with testamentary distribution and render older people more vulnerable to "undue influence" when they are making a will. Accordingly, clinicians dealing with the mental disorders of older people will be called upon increasingly to advise the courts about a person's vulnerability to undue influence. METHOD: A Subcommittee of the IPA Task Force on Testamentary Capacity and Undue Influence undertook to establish consensus on the definition of undue influence and the provision of guidelines for expert assessment of risk factors for undue influence. RESULTS: International jurisdictions differ in their approach to the notion of undue influence. Despite differences in legal systems, from a clinical perspective, the subcommittee identified some common "red flags" which might alert the expert to risk of undue influence. These include: (i) social or environmental risk factors such as dependency, isolation, family conflict and recent bereavement; (ii) psychological and physical risk factors such as physical disability, deathbed wills, sexual bargaining, personality disorders, substance abuse and mental disorders including dementia, delirium, mood and paranoid disorders; and (iii) legal risk factors such as unnatural provisions in a will, or provisions not in keeping with previous wishes of the person making the will, and the instigation or procurement of a will by a beneficiary. CONCLUSION: This review provides some guidance for experts who are requested by the courts to provide an opinion on the risk of undue influence. Whilst international jurisdictions require different thresholds of proof for a finding of undue influence, there is good international consensus on the clinical indicators for the concept.

Multicenter double-blind study of moclobemide and maprotiline.

A randomized double-blind, multicenter 6-week study was undertaken in 80 depressed patients to compare the effects of moclobemide, a selective and reversible monoamine oxidase-A inhibitor (300 mg daily), and maprotiline (75 mg daily). Efficacy was assessed by Hamilton Depression Rating Scale (HDRS) and Clinical Global Impression (CGI). Tolerability was assessed by adverse events reports. After 6 weeks of therapy, both groups of patients showed significant improvement in HDRS and CGI. Speed of onset of action was faster with moclobemide (significant difference at week 3, p = 0.025). There was a significant reduction of depression ratings (HDRS) in both the moclobemide and maprotiline group in all types of depression according to ICD-9 criteria (major depressive disorder, neurotic depression and adjustment-prolonged depressive reaction). Significantly fewer patients in the moclobemide group reported adverse events (28.9% compared with 70.2%) including weight gain (2.6% compared to 21.6%). Anticholinergic side effects were less frequent with moclobemide. It is concluded that both drugs are at least equivalent in terms of therapeutic efficacy, but moclobemide is better tolerated.

Estudo comparativo no uso de uma ou duas artérias torácicas internas na revascularizaçäo do miocárdio / Comparative study of the use of one or two internal thoracic arteries in myocardial revascularization

No Hospital da Beneficência Portuguesa, Serviço do Prof. Dr. Luís B. Puig, 30 pacientes foram submetidos a revascularizaçao do miocárdio, no período de novembrode 1991 a março de 1992. Quinze pacientes receberam uma artéria torácica interna (Grupo I) e complementaçao com pontes de veia safena e os outros l5 pacientes receberam duas artérias torácicas internas (Grupo II) e complementaçâo com pontes de veia safena. Nao havia diferenças nos dois grupos, quanto aos antecedentes patológicos e às condiçoes clínicas pré-operatórias. No Grupo I foi realizada uma média de 2,4 por cento enx./paciente e no Grupo II, 3,1 por cento. No período pós-operatório imediato, nao houve diferenças nos dois grupos, quanto a incidência de reoperaçoes por sangramento, infarto trans-operatório, ou presença de atelectasia pulmonar. Houve um óbito (3,3 por cento) no Grupo I, devido a acidente vascular cerebral. Treze pacientes foram submetidos a estudo hemodinâmico pós-operatório antes da alta hospitalar, sendo seis no Grupo I e sete no Grupo II. As 13(1OO por cento) artérias torácicas internas esquerdas e as 7(1OO por cento) artérias direitas estavam pérvias. No Grupo II a artéria direita foi utilizada para revascularizar a artéria marginal esquerda em cinco pacientes e o ramo dialgonalis em dois. OS resultados sugerem que a artéria torácica interna direita deve ser usada mais freqüentemente e talvez tenha sua melhor aplicaçao por via retro-aórtica direcionada para o ramo marginal esquerdo.