Impact of changes in psychiatric practice on psychiatric education in the USA.

The evidence base for the field of psychiatry is rapidly changing in the twenty-first century due to advances in neuroscience that are in the process of being translated into clinical interventions. The delivery systems for mental healthcare are simultaneously undergoing dramatic transformations as the field attempts to meet population needs effectively and efficiently. These changes demand a reconsideration of the content and priorities of psychiatric training programmes for both medical students and residents. This article examines the current state of psychiatric practice, as well as future challenges and potential models of practice, and discusses how these changes are impacting the present needs of trainees. Preparing today's medical students and residents to be active participants in the creation of the mental healthcare delivery system of the future is the key to the success of the specialism and to the welfare of tomorrow's patients.

Obesity does not alter the pharmacokinetics of drotrecogin alfa (activated) in severe sepsis.

BACKGROUND: Drotrecogin alfa (activated) [DrotAA] is approved for the reduction of mortality in adults with severe sepsis (sepsis with acute organ dysfunction) and high risk of death. Patients whose actual body weight was >135 kg were excluded from the Phase III PROWESS trial. OBJECTIVE: To compare exposure to DrotAA in patients with severe sepsis weighing >135 kg with those weighing < or =135 kg in an open-label, Phase IV trial, and quantify the elimination half-life (t1/2) of DrotAA in these patients. METHODS: PROWESS inclusion/exclusion criteria were used, except that patients >135 kg were enrolled. Blood samples were collected for steady-state plasma concentration (Css) analysis of activated protein C once each day and for t1/2 analysis after infusion. Weight-normalized clearance (Clp) and t1/2 estimates for DrotAA were calculated and compared between weight groups. RESULTS: Patient weight range was 59-227 kg. There were 32 patients < or =135 kg and 20 patients >135 kg enrolled. Median Clp was 0.45 L/h/kg (interquartile range [IQR] 0.37-0.54) for patients < or =135 kg and 0.42 L/h/kg (IQR 0.33-0.54) for patients >135 kg (p = 0.692). Median estimates of Css were 51.9 ng/mL (IQR 43.4-62.0) and 56.5 ng/mL (IQR 44.9-71.1; p = 0.570). In patients < or =135 kg, DrotAA had a median t1/2 of 16.7 minutes (IQR 13.9-20.0) compared with 16.0 minutes (IQR 12.9-19.8) in patients >135 kg (p = 0.767), for a composite median t1/2 of 16.3 minutes (IQR 14.2-18.8). CONCLUSIONS: There is no statistically significant difference in Css concentrations or t1/2 of DrotAA between patients weighing < or =135 kg and >135 kg. DrotAA should be dosed by actual body weight.