Patients experiencing a first psychotic episode have high rates of extrapyramidal symptoms (EPSs) when treated with the doses of neuroleptics used in multiepisode or chronic schizophrenia. There is some evidence that lower doses may be equally, if not more, effective but less toxic in this population. Here, we report the results of a biphasic open label trial designed to assess the efficacy, safety, and tolerability of low-dose (2–4 mg/day) risperidone treatment in a group of 96 first-episode nonaffective psychosis patients. At the end of the trial, 62% of patients met the response criteria although approximately 80% had achieved a response at some time during the study. Reports of EPS remained low, and there were no dystonic reactions. We conclude that even at a dose of 2 mg/day, risperidone was highly effective in reducing acute symptomatology in a real world sample of young first-episode psychosis patients.

Introduction by the column editor: The period around the onset of the first psychotic episode and the first years after the start of treatment provide pivotal opportunities to affect the course of schizophrenia. Early intervention in schizophrenia is receiving increasing interest, and a number of specialized centers are focusing on treating young people to secure better outcomes and prevent the accrual of disabilities. For example, the Early Psychosis Prevention and Intervention Centre (EPPIC) is a comprehensive treatment service for individuals experiencing their first psychotic episode who live in the western metropolitan region of Melbourne. Readers can learn more at EPPIC's Web site, www.eppic.org.au. About a fifth of persons with recent-onset schizophrenia have persistent psychotic symptoms that translate into disability, suffering, and family burden. Since 1994, a subprogram of EPPIC, the Treatment Resistance Early Assessment Team (TREAT), has been developing a framework for the management of patients experiencing prolonged recovery in early psychosis. Below, Edwards and her colleagues outline the rationale and operation of the consultation service provided by TREAT to the clinicians working at EPPIC.

Objectives. Cognitively oriented psychotherapy for early psychosis (COPE) is aimed at facilitating the adjustment of the person, and at preventing or alleviating secondary morbidity in the wake of the first psychotic episode. Design. A total of 80 people participated in the initial trial and completed assessments on a range of outcome measures. Post-treatment assessment results from a non-randomized controlled trial of COPE have been previously reported. The present paper describes the results obtained from 51 patients who attended a follow-up assessment 1 year subsequent to the end-of-treatment assessment. Method. The 51 patients formed three groups: (1) those who were offered and accepted COPE; (2) those who were offered COPE but refused it, and continued to receive other services from the Early Psychosis Prevention and Intervention Centre (EPPIC) (refusal subjects); and (3) those who were offered neither COPE nor any other continuing treatment from EPPIC (control subjects). Results. At 1-year follow-up, there was only one significant difference and this was between the COPE and refusal groups on the Integration/Sealing Over (I/SO) measure ( p = .008). End-of-treatment differences were mostly sustained over the 1-year follow-up period. When the complete sample of 80 was considered, there were no differences between the three groups in terms of hospital admissions, community episodes, or time taken to first in-patient re-admission. Conclusions. The study was weakened by the poor follow-up rates in the two control groups. This reduced power to detect differences between groups on the seven major measures. However, the relapse data gathered on the complete set of 80 patients were discouraging and suggest that the present formulation of COPE does not confer any advantage to those patients receiving the therapy over those not receiving the therapy.

BACKGROUND:An ageing population will increase the need for resources to treat patients with a fractured neck of femur (DRG 210/211). Provision of these resources will be helped by a better understanding of current practices.METHODS:A prospective study of outcome at discharge for 100 consecutive patients with DRG 210/211 was conducted at five Victorian metropolitan teaching hospitals to assess length of stay and the reasons for any variations.RESULTS:The major influences on timing of discharge were: delayed availability of rehabilitation beds; the timing of referral and assessment by the Geriatric Assessment Team; delay in surgery more than 24 h after admission; and development of postoperative complications.CONCLUSION:The efficient management of patients with DRG 210/211 requires a strong protocol of treatment and referral strategies with adequate resources.

A survey of Victorian surgeons performing laparoscopic cholecystectomy was carried out. This report discusses the bile duct injuries identified in the survey. Twelve injuries were recorded, a rate of 0.2%. Three of the 12 required formal repair, the other 9 being treated by T-tube alone. Possible mechanisms of these injuries, the experience of the surgeon, the role of operative cholangiography and delays in recognition of the injury are discussed.

Until recent years it has been thought prudent to reoperate for high‐output enterocutaneous fistula complicating abdominal surgery. With the advent of adequate parenteral nutrition, however, providing calories and balanced intake, this concept is challenged. Three case reports describe spontaneous closure of high‐output fistula over three to four months, in patients in whom surgical reintervention had proved, or would have proved, technically extremely difficult. In the first patient, a fistula had been resected once with recurrence; in the second, a fistula had been resected once, with recurrence, and at a further operation it was found technically impossible to appose the bowel ends for anastomosis; the third patient demonstrates the success of a conservative approach from the outset. A suggested regime for long‐term parenteral therapy is outlined. Some complications of such long‐term intravenous therapy and patient care arc mentioned.