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Integrated care systems join up health and care services, so that people have the support they need, in the right place, at the right time. The aims include improving outcomes in healthcare, tackling inequalities in access and enhancing productivity and value for money. This is needed for neuroscience care as the traditional delivery of neuroscience care is inefficient, outdated and expensive, and can involve complex referral pathways and long waiting times. In preparation for the formation of the integrated care system (ICS), a novel innovative collaboration across multiple NHS trusts developed across North Central London in 2021. We developed a model where neuroscience specialists engage in collaborative care with clinicians outside the specialist hospital setting. Pivotal to the pathway is a multidisciplinary meeting, and collaborative working enables joint clinical reviews, diagnostics and medication initiation. This innovative collaboration has already significantly improved access, addressed inequalities due to borough variation and enhanced the delivery and quality of neuroscience care in our ICS. It is a translatable model that can be adapted to suit other regions in the UK. It fulfils many of the objectives of the integrated care system and these benefits are seen without the need for significantly more resource., Competing Interests: Declaration of competing interest There are no competing interests related to this piece of work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: Although early palliative care (EPC) is beneficial in acute myeloid leukaemia, little is known about EPC value in multiple myeloma (MM). We compared quality indicators for palliative and end-of-life (EOL) care in patients with MM receiving EPC with those of patients who received usual haematological care (UHC)., Methods: This observational, retrospective study was based on 290 consecutive patients with MM. The following indicators were abstracted: providing psychological support, assessing/managing pain, discussing goals of care, promoting advance care plan, accessing home care services; no anti-MM treatment within 14 and 30 days and hospice length of stay >7 days before death; no cardiopulmonary resuscitation, no intubation, <2 hospitalisations and emergency department visits within 30 days before death. Comparisons were performed using unadjusted and confounder-adjusted regression models., Results: 55 patients received EPC and 231 UHC. Compared with UHC patients, EPC patients had a significantly higher number of quality indicators of care (mean 2.62±1.25 vs 1.12±0.95; p<0.0001)); a significant reduction of pain intensity over time (p<0.01) and a trend towards reduced aggressiveness at EOL, with the same survival (5.3 vs 5.46 years; p=0.74))., Conclusions: Our data support the value of integrating EPC into MM routine practice and lay the groundwork for future prospective comparative studies., Competing Interests: Competing interests: FF: advisory boards for Jannsen and Novartis and travel grants from Jazz Pharmaceuticals outside the submitted work. RM: honoraria from AbbVie, Roche, Janssen, and Shire, outside the submitted work. FE: consultancy for Abbvie, Amgen, Janssen, Orsenix, Takeda, and grants from Amgen (to his Institution), outside the submitted work. EB: grants from Helsinn Healthcare, outside of the submitted work. ML: advisory board Abbvie, Novartis, Gilead science, Jazz Pharmaceuticals, Sanofi, MSD, Daiichi-Sankyo, Travel grant Gilead science., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This article reports on the results of an analysis of metaphorical language used by patients diagnosed with advanced cancer and their caregivers receiving early palliative care (EPC)., Methods: Data were collected through a pen-and-paper questionnaire on respondents' perceptions of the disease, its treatment and their idea of death, before and after receiving EPC. The data were analysed by identifying all metaphorical uses of language, following the 'metaphor identification procedure' proposed by the Praggjelaz Group., Results: Metaphors were used from a variety of semantic fields. EPC was described using spiritual terms, to indicate that this approach was instrumental in 'restoring life', 'producing hope' and making patients feel 'accompanied'. The most recurrent metaphors were those referring to light and salvation; spatial metaphors were used to describe the treatment and the hospital as a 'safe haven' and 'an oasis of peace'. Patients and caregivers were overall consistent in the aforementioned ways of referring to illness and treatment; caregivers were more likely than patients to use war metaphors, although their use overall was rare., Conclusions: Our results suggest that EPC is perceived positively by patients and their caregivers and provide insights regarding the manner in which EPC could be presented to patients, caregivers and the public., Competing Interests: Competing interests: EBa—consultancy for Sandoz and Viatris, outside the submitted work. SB—consultancy for Biomarin, Roche and Viatris, outside the submitted work. FE—consultancy or advisory role for AbbVie, Incyte, Syros and Novartis, outside the submitted work. EBr—grants from Helsinn Healthcare, outside the submitted work. ML—advisory board of AbbVie, Novartis, Gilead Science, Jazz Pharmaceuticals, Sanofi, MSD, Daiichi-Sankyo, Grifols and Incyte; and travel grant from Gilead Science, outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Oncologists are often concerned that talking about death with patients may hinder their relationship. However, the views of death held by patients have not been thoroughly investigated. This study aimed to describe the perception of death among patients with advanced cancer receiving early palliative care (EPC) and their caregivers., Material and Methods: Qualitative and quantitative analyses were performed on 2 databases: (a) transcripts of open-ended questionnaires administered to 130 cancer patients receiving EPC with a mean age of 68.4 years and to 115 primary caregivers of patients on EPC with a mean age of 56.8; (b) texts collected from an Italian forum, containing instances of web-mediated interactions between patients and their caregivers., Results: Quantitative analysis shows that: (a) patients and caregivers are not afraid of speaking about death; (b) patients and caregivers on EPC use the word "death" significantly more than patients on standard oncology care (SOC) and their caregivers (P < .0001). For both participants on EPC and SOC, the adjectives and verbs associated with the word "death" have positive connotations; however, these associations are significantly more frequent for participants on EPC (verbs, Ps < .0001; adjectives, Ps < .003). Qualitative analysis reveals that these positive connotations refer to an actual, positive experience of the end of life in the EPC group and a wish or a negated event in the SOC group., Conclusions: EPC interventions, along with proper physician-patient communication, may be associated with an increased acceptance of death in patients with advanced cancer and their caregivers., (© The Author(s) 2022. Published by Oxford University Press.)

Background: Oncologists' fear of taking away hope from patients when proposing early palliative care (EPC) is a barrier to the implementation of this model. This study explores hope perceptions among bereaved caregivers of onco-hematologic patients who received EPC., Materials and Methods: Open-ended questionnaires were administered to 36 primary caregivers of patients who received EPC (26 solid and 10 hematologic cancer patients; mean age: 51.4 years, range age: 20-74), at 2 cancer centers, 2 months to 3 years after a patient death. Definitions of hope in the caregivers' narratives were analyzed through a directed approach to content analysis. Results were complemented with automated lexicographic analysis., Results: Caregivers perceived hope mainly as resilience and as expectations based on what they were told about the patients' clinical conditions. Their hope was bolstered by trusting relationships with the healthcare teams. EPC interventions were recalled as the major support for hope, both during the illness and after the death of the patient. The automated quantitative lexical analysis provided deeper insights into the links between hope, truth, and trust., Conclusions: Our findings suggest that telling the truth about an incurable onco-hematologic disease and beginning EPC might be the combination of factors triggering hope in the setting of incurable cancer., (© The Author(s) 2022. Published by Oxford University Press.)

Several PI3Kδ inhibitors are approved for the therapy of B cell malignancies, but their clinical use has been limited by unpredictable autoimmune toxicity. We have recently reported promising efficacy results in treating chronic lymphocytic leukemia (CLL) patients with combination therapy with the PI3Kδγ inhibitor duvelisib and fludarabine cyclophosphamide rituximab (FCR) chemoimmunotherapy, but approximately one-third of patients develop autoimmune toxicity. We show here that duvelisib FCR treatment in an upfront setting modulates both CD4 and CD8 T cell subsets as well as pro-inflammatory cytokines. Decreases in naive and central memory CD4 T cells and naive CD8 T cells occur with treatment, while activated CD8 T cells, granzyme positive Tregs, and Th17 CD4 and CD8 T cells all increase with treatment, particularly in patients with toxicity. Cytokines associated with Th17 activation (IL-17A and IL-21) are also relatively elevated in patients with toxicity. The only CLL feature associated with toxicity was increased priming for apoptosis at baseline, with a significant decrease during the first week of duvelisib. We conclude that an increase in activated CD8 T cells with activation of Th17 T cells, in the context of lower baseline Tregs and greater CLL resistance to duvelisib, is associated with duvelisib-related autoimmune toxicity., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Background: Several novel targeted therapies seem to improve the outcome of acute myeloid leukemia (AML) patients. Nonetheless, the 5-year survival rate remains below 40%, and the trajectory of the disease remains physically and emotionally challenging, with little time to make relevant decisions. For patients with advanced solid tumors, the integration of early palliative care (EPC) with standard oncologic care a few weeks after diagnosis has demonstrated several benefits. However, this model is underutilized in patients with hematologic malignancies., Methods: In this article, we analyze the palliative care (PC) needs of AML patients, examine the operational aspects of an integrated model, and review the evidence in favor of EPC integration in the AML course., Results: AML patients have a high burden of physical and psychological symptoms and high use of avoidant coping strategies. Emerging studies, including a phase III randomized controlled trial, have reported that EPC is feasible for inpatients and outpatients, improves quality of life (QoL), promotes adaptive coping, reduces psychological symptoms, and enhances the quality of end-of-life care., Conclusions: EPC should become the new standard of care for AML patients. However, this raises issues about the urgent development of adequate programs of education to increase timely access to PC.

Background: Little is known about the underlying mechanisms through which early palliative care (EPC) improves multiple outcomes in patients with cancer and their caregivers. The aim of this study was to qualitatively and quantitatively analyze patients' and caregivers' thoughts and emotional and cognitive perceptions about the disease prior to and during the EPC intervention, and in the end of life, following the exposure to EPC., Materials and Methods: Seventy-seven patients with advanced cancer and 48 caregivers from two cancer centers participated in semistructured interviews. Their reports were qualitatively and quantitatively analyzed by the means of the grounded theory and a text-analysis program., Results: Participants reported their past as overwhelmed by unmanaged symptoms, with detrimental physical and psychosocial consequences. The EPC intervention allowed a prompt resolution of symptoms and of their consequences and empowerment, an appreciation of its multidimensional approach, its focus on the person and its environment, and the need for EPC for oncologic populations. Patients reported that conversations with the EPC team increased their acceptance of end of life and their expectation of a painless future. Quantitative analysis revealed higher use of Negative Affects (p < .001) and Biological Processes words (p < .001) when discussing the past; Agency words when discussing the present (p < .001); Positive Affects (p < .001), Optimism (p = .002), and Insight Thinking words (p < .001) when discussing the present and the future; and Anxiety (p = .002) and Sadness words (p = .003) when discussing the future., Conclusion: Overall, participants perceived EPC to be beneficial. Our findings suggest that emotional and cognitive processes centered on communication underlie the benefits experienced by participants on EPC., Implications for Practice: By qualitative and quantitative analyses of the emotional and cognitive perceptions of cancer patients and their caregivers about their experiences before and during EPC interventions, this study may help physicians/nurses to focus on the disease perception by patients/caregivers and the benefits of EPC, as a standard practice. The analysis of words used by patients/caregivers provides a proxy for their psychological condition and support in tailoring an EPC intervention, based on individual needs. This study highlights that the relationship of the triad EPC team/patients/caregivers may rise as a therapeutic tool, allowing increasing awareness and progressive acceptance of the idea of death., (© 2021 The Authors. The Oncologist published by Wiley Periodicals LLC on behalf of AlphaMed Press.)

We undertook a cross-sectional survey of a random sample of thoracic oncologists from the American Society of Clinical Oncology clinical directory to characterize whether prognostic uncertainty has increased and if tolerance of uncertainty is associated with prognostic discussion practices. We also assessed the Physicians' Reactions to Uncertainty Scale and presented a vignette about an incurable patient with uncertain life expectancy. One hundred and ninety-two of 438 surveys (43.8%) were received. Of the respondents, 52.1% agreed "there is more prognostic uncertainty in the management of lung cancer now than 10 years ago," and 37.4% noted difficulty "staying up-to-date." In multivariable analyses, physician-reported anxiety about uncertainty (p = .05) and reluctance to disclose uncertainty (p = .04) were inversely associated with reporting having prognostic discussions with most patients. For the vignette, 92.1% reported they would discuss incurability, but only 76.3% said they would discuss the patient's life expectancy. Our data suggest prognostic uncertainty has increased in thoracic oncology and oncologists' tolerance of uncertainty may affect discussion practices., (© 2021 AlphaMed Press.)

Fludarabine, cyclophosphamide, and rituximab (FCR) is highly effective initial therapy for younger patients with chronic lymphocytic leukemia (CLL); however, most eventually relapse. Duvelisib is a delta/gamma PI3K inhibitor approved for relapsed/refractory CLL. We conducted an investigator-initiated, phase 1b/2 study of duvelisib + FCR (DFCR) as initial treatment for CLL patients aged ≤65. A standard 3 + 3 design included two dose levels of duvelisib (25 mg qd and 25 mg bid). Duvelisib was given for 1 week, then with standard FCR added for up to six 28-day cycles, then up to 2 years of duvelisib maintenance. Thirty-two patients were enrolled. The phase 2 dose of duvelisib was identified as 25 mg bid. Hematologic toxicity was common, and all-grade non-hematologic toxicities included transaminitis (28%), febrile neutropenia (22%), pneumonia (19%), and colitis (6%). The best overall response rate by ITT was 88% (56% CR/CRi and 32% PR). The best rate of bone marrow undetectable minimal residual disease (BM-uMRD) by ITT was 66%. The rate of CR with BM-uMRD at end of combination treatment (primary endpoint) was 25%. Three-year PFS and OS are 73 and 93%, respectively. DFCR is active as initial therapy of younger CLL patients. Immune-mediated and infectious toxicities occurred and required active management.

The addition of high-dose cytarabine to rituximab/bendamustine (RB) induction could improve outcomes for transplant-eligible patients with mantle cell lymphoma (MCL). We conducted a pooled analysis of 2 phase 2 trials and an off-trial cohort each testing 3 cycles of RB and 3 cycles of rituximab/high-dose cytarabine (RC) followed by autologous stem cell transplantation (ASCT) among untreated, transplant-eligible patients with MCL. Dana-Farber Cancer Institute (DFCI) and Washington University in St. Louis (WUSTL) led separate phase 2 trials testing sequential and alternating cycles of RB/RC, respectively. Patients treated at DFCI with sequential RB/RC off trial were retrospectively identified. Minimal residual disease (MRD) was assessed in the DFCI trial. A total of 88 patients (23 DFCI trial, 18 WUSTL trial, and 47 off trial) received RB/RC; 92% of patients completed induction, and 84% underwent planned consolidative ASCT. Grade 3 or 4 adverse events among trial patients included lymphopenia (88%), thrombocytopenia (85%), neutropenia (83%), and febrile neutropenia (15%). There were no treatment-related deaths during induction and 2 following ASCT. Among 87 response-evaluable patients, the end-of-induction overall and complete response rates were 97% and 90%, respectively. After a median follow-up of 33 months, 3-year progression-free survival and overall survival were 83% and 92%, respectively. Patients undergoing MRD testing experienced prolonged MRD negativity after ASCT with emergence of MRD occurring in only 1 patient who subsequently relapsed. RB/RC followed by ASCT achieves high rates of durable remissions in transplant-eligible patients with MCL. These trials were registered at www.clinicaltrials.gov as #NCT01661881 (DFCI trial) and #NCT02728531 (WUSTL trial)., (© 2020 by The American Society of Hematology.)

The excitement about immunotherapy is justified. Patients with advanced disease and limited life expectancy before immune checkpoint inhibitors are now having prolonged and sometimes complete responses to treatment; however, most patients do not respond to checkpoint inhibitors. The hope for a meaningful response with only a limited risk of high-grade toxicity generated a prognostic dilemma for patients with advanced cancers and their treating oncologists. Older adults with advanced cancers are at the intersection of multiple biologic and clinical factors that can influence the efficacy of immunotherapy. Treating physicians should take all of these elements into account when considering treatment options for an older adult with advanced disease. Oncologists should have an honest conversation with their patients regarding the uncertainty around the clinical profile of checkpoint inhibitors. Early high-quality goals of care discussions can help manage expectations of older adults with advanced cancer treated with immunotherapy. We review in this paper select clinical characteristics that are important to consider when evaluating an older adult for checkpoint inhibitor therapy. In addition, we discuss strategies to optimize goals of care discussion given the increasing complexity of prognostication in the immunotherapy era.

Rituximab is an increasingly used immunotherapeutic agent for women of reproductive age for treatment of autoimmune diseases, leukemias, and lymphomas. Rituximab is a chimeric monoclonal antibody that targets B-cell surface antigen CD20 and can cross the placenta. Current evidence of the impact of this medication on the developing fetus is limited, but there is little to suggest that fetal exposure to this medication places an infant at increased risk of immunosuppression and subsequent infection. Here we report a case of in utero rituximab exposure that was associated with 2 severe septic episodes with Enterococcus faecalis , in a premature infant of 29 weeks' gestational age with a birth weight of 820 g. The patient had a critically depressed B-lymphocyte subset of 10% and undetectable immunoglobulin (Ig)G, IgM, and IgA levels at 37 weeks' postmenstrual age. Interestingly, both episodes of sepsis coincided with transition from donor human milk to formula feeds. She was treated with intravenous immunoglobulin, antibiotics, and donor human milk. We postulate that placental transfer of rituximab, prematurity, and the low levels of protective maternal antibodies increased the susceptibility of this patient to sepsis by E faecalis , a resident of the normal gut flora, whereas the secretory IgA in donor human milk may have played a protective role., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Context: Understanding end-of-life (EOL) care patterns is a prerequisite to improving the experience for cancer patients. EOL measures endorsed by the National Quality Forum (NQF) have been examined in older patients using Medicare claims., Objectives: To evaluate EOL care for patients treated at a comprehensive cancer center, using private payer claims data., Methods: A retrospective cohort study was conducted of Dana-Farber Cancer Institute (DFCI) patients who died between July 2010 and December 2012, and were insured by Blue Cross Blue Shield of Massachusetts. Primary data sources included Blue Cross Blue Shield of Massachusetts claims information and DFCI administrative data. We assessed NQF-endorsed measures of EOL care related to emergency department visits, hospitalizations, and intensive care unit admissions in the last 30 days, chemotherapy in the last 14 days, hospice stay, and death in an acute care setting. Patterns of care by cancer type and service location were determined., Results: Among 674 patients (mean age 58 years), event rates for NQF-endorsed EOL measures were similar to those reported using Medicare claims. Decedents with hematologic malignancies received significantly more intensive care and were less likely to have enrolled in hospice, compared to decedents with solid tumors. Thirty to 45% of EOL events occurred outside of DFCI and its affiliated hospitals., Conclusion: Data sharing between a private payer and a large cancer center proved feasible and informative. High rates of hospital service use outside of our sites of care were unexpected. The findings suggest opportunities to better manage care at the end of life., (Copyright © 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

The genetics of angioimmunoblastic T-cell lymphoma (AITL) are very poorly understood. We defined the mutational landscape of AITL across 219 genes in 85 cases from the United States and Europe. We identified ≥2 mutations in 34 genes, nearly all of which were not previously implicated in AITL. These included loss-of-function mutations in TP53 (n = 4), ETV6 (n = 3), CCND3 (n = 2), and EP300 (n = 5), as well as gain-of-function mutations in JAK2 (n = 2) and STAT3 (n = 4). TET2 was mutated in 65 (76%) AITLs, including 43 that harbored 2 or 3 TET2 mutations. DNMT3A mutations occurred in 28 (33%) AITLs; 100% of these also harbored TET2 mutations (P < .0001). Seventeen AITLs harbored IDH2 R172 substitutions, including 15 with TET2 mutations. In summary, AITL is characterized by high frequencies of overlapping mutations in epigenetic modifiers and targetable mutations in a subset of cases.

Unlabelled: Although the safety and efficacy of oxaliplatin-based chemotherapy regimens for colorectal cancer (CRC) have been demonstrated in adults > 75 years of age enrolled in clinical trials, safety and effectiveness outside the trial setting are less established. In this comparative effectiveness study, we note that older adults with stage III and metastatic CRC treated outside of a clinical trial experienced safety and effectiveness of oxaliplatin-based chemotherapy regimens comparable to that of younger adults., Background: Although the safety and efficacy of oxaliplatin-based chemotherapy regimens for colorectal cancer (CRC) have been demonstrated in adults ≥ 75 years of age who are enrolled in clinical trials, safety and effectiveness outside the trial setting are less established., Methods: We retrospectively collected cases of patients ≥ 75 years of age who were diagnosed with stage III and metastatic CRC and initiated treatment between January 2000 and January 2007 at 2 academic hospitals in Boston, MA. Cases were matched in a 1:2 ratio to controls who were < 75 years of age by hospital site, stage of disease (stage III vs. metastatic) and line of therapy (first- or second-line or beyond). The primary study endpoints were grade ≥ 3 treatment-associated toxicities and intolerance (number of dose delays/reductions and hospital/facility admissions during treatment). The secondary endpoint was overall survival., Results: We identified 84 patients ≥ 75 years of age (25% ≥ 80 years) and 168 controls. In the cohort, 77% had colon cancer, 75% had metastatic disease, and 60% were receiving oxaliplatin as first-line therapy. There was no significant difference in grade ≥ 3 treatment-associated toxicities between the patients and the controls (71.4% vs. 68.5%, respectively; P = .63). Further there was no statistically significant difference between patients and controls for combined endpoints of any grade ≥ 3 toxicity or hospital/facility admission (P = .92). With a median follow-up of 52 months, 2-year overall survival was similar between patients and controls (43% vs. 52%, respectively; P = .87)., Conclusion: Older adults with stage III and metastatic CRC treated outside of a clinical trial experienced safety and effectiveness of oxaliplatin-based chemotherapy regimens that was comparable to that of younger adults., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Objective: To determine the prevalence of pain and its psychological and physical effects on cancer patients., Method: We interviewed 210 consecutively admitted cancer patients in the University College Hospital, Ibadan between May 2006 and November, 2006 using the socio-demographic / clinical questionnaire with a section designed to measure psychological and physical symptoms. The screening modules of the depression and anxiety sections of the Structured Clinical Interview for DSM-IV diagnosis was used to screen for depression and anxiety., Results: There were 63 (30%) males and 147 (70%) females. Sixty-eight (32.4%) subjects had breast cancer, 59 (28.1%) had cervical cancer, 40 (19.0%) had colon / rectal cancer while the remaining 43 (20.5%) had prostate cancer. The prevalence of pain was found to be 73.8%. Presence of pain was significantly associated with depressive and anxiety symptoms, suicidal ideation, poor sleep, impaired concentration, lack of opportunity for leisure, dissatisfaction with health, poor overall quality of life, poor ability to get around and the need for extreme amount of medical treatment to function in the daily life., Conclusion: Pain is common among cancer patients and is associated with significant psychological and physical impairment. Therefore pain should be adequately assessed and managed.

This study focused on the psychosocial condition of a cohort of rural farmers, highlighting the social condition of their children, their life style, life events in the past year, the extent of their involvement in farming, the sufficiency of material sustenance from their products, their unmet needs and social aspirations, difficulties encountered in farm work, satisfaction with farming, and psychological distress. In 1992, 186 farmers were interviewed during health education visits at farm villages in Idere town, Oyo State. There were 161 (87%) males and 25 (13%) females mean age 49.9 (sd 11.7) years: who were illiterate, mainly polygamous, with 4-6 children per household. Only two families had a child each in institutions of higher learning. The general picture that emerged was that of a peasant, hardworking (six-day per week) farmer who relaxes with a game of cards in the evenings. His greatest problem is that of transportation and hiring extra hands for work. He is impressed by the yield from his farm. Compared with urban junior civil servants, the farmers had significantly lesser life events and GHQ-12 (psychological symptoms) scores. They had unmet social needs and were not satisfied with their condition of living. Meeting some of the basic needs of these farmers will boost their morale, enhance yield, and lower prices of food for the general population.

Pathways patients take to psychiatric care will reflect the nature of the services available and the popular beliefs about mental illness. Studying the pathways may help in the identification of sources of delay in the receipt of care and suggest possible improvements. By studying the pathways of 159 patients to a tertiary psychiatric service in Nigeria, we show that traditional and religious healers are consulted at some stage by many patients with mental illness. Such healers are the first carers to a large proportion of the patients. These patients are not different from those who consult orthodox medical practitioners either in demographic features, presenting complaints, or nearness to service. Patients who consult traditional healers first tended to arrive at a tertiary psychiatric service much later than those who consult other carers. Our observations suggest that attempts to incorporate traditional medical care into the health care system must seek to improve their referral skill.

Objective: The somatic presentation of psychic distress among Africans is different from that in the West, and the prevalence of somatization symptoms suggests that they could be usefully incorporated in screening instruments. This report examines the prevalence of somatization symptoms among users of health care facilities in a rural community in southwestern Nigeria. It also examines the correlation between the presence of these symptoms and scores on instruments that assess psychiatric morbidity., Method: Over a 5-month period in 1991, 865 adults using five primary health care facilities or seeking help from voluntary village health assistants were assessed with the 28-item General Health Questionnaire and two World Health Organization instruments, the Self-Reporting Questionnaire and the Brief Disability Questionnaire. The somatization symptoms investigated included feelings of heat, peppery and crawling sensations, and numbness., Results: About 20% of the subjects admitted experiencing at least one somatization symptom, while 8.2% fulfilled operational criteria for probable psychiatric "caseness" on the basis of somatization alone. The rate of caseness according to the General Health Questionnaire was 6.4%. The presence of any of the somatization symptoms was significantly correlated with scores on the other test instruments. There were no sex differences in the pattern of somatization., Conclusions: These symptoms are reliable indexes of psychic distress. In this culture, the sensitivity of standard screening instruments fashioned in the West can be improved by using these symptoms to replace the somatization symptoms contained in those instruments.

In a double-blind placebo substitution study, 27 chronic schizophrenic patients successfully treated for more than 2 years with fluphenazine decanoate were withdrawn from the drug. These patients showed a significantly higher relapse rate than the matched control group of 26 patients who continued to receive fluphenazine (56% versus 19%, p less than .001). This high rate of relapse is viewed as indicating the need for continued medication in most chronic schizophrenic patients.

The reliability and validity of the World Health Organization student drug-use survey model questionnaire was tested among 96 senior secondary school students in the Abeokuta Local Government Area of Ogun State, Nigeria. The exercise was the major theme of a pilot study of a student drug-use survey carried out in this area. The test-retest interval was 4 weeks. The questionnaire was found to be reliable when group and individual (item by item) comparisons were made. The validity scores were also comparable to those of widely accepted previous studies. It was concluded that the questionnaire is reliable and valid enough for use in this environment to allow for comparisons. It can also yield better results if slightly modified and when respondents become more familiar with questionnaire surveys.

In a review of the studies on alcohol use in Nigeria, evidence shows that within the last decade there has been a rapid increase in alcohol availability (production/importation) and alcohol consumption. Similarly, the literature on the subject reveals an increasing trend in alcohol-related psychosocial and physical health hazards. This observation prompted a review of the existing alcohol treatment methods in Nigeria. These treatment methods include: traditional healers' approach, syncretic churches, government hospitals including a specialised drug addiction centre and voluntary agencies. Suggestions are made on how to improve alcohol treatment systems and data collection in Nigeria.