Suspected clozapine poisoning in the UK/Eire, 1992-2003

OBJECTIVE: Toxicological analyses are often performed to investigate suspected poisoning, but the interpretation of results may not be straightforward. We studied suspected poisoning cases 1992-2003 where blood clozapine and N-desmethylclozapine (norclozapine) were measured in order to assess the relationship of these parameters to outcome. METHODS: Samples were referred from clinicians, pathologists/coroners, or via the Clozaril Patient Monitoring Service (CPMS, Novartis). Information was gathered from clinical, post-mortem, or coroners' reports. RESULTS: There were seven fatal [five male, two female; median (range) age 28 (24-41) year] and five non-fatal [four male, one female; median age 35 (26-41) year] clozapine overdoses. The median post-mortem blood clozapine and norclozapine concentrations were 8.2 (3.7-12) and 1.9 (1.4-2.4)mg/L, respectively [median clozapine:norclozapine ratio 4.4 (2.9-5.1)]. The median plasma clozapine and norclozapine concentrations (first or only sample) were 3.9 (1.7-7.0) and 0.40 (0.30-0.70)mg/L, respectively [median clozapine:norclozapine ratio 7.6 (5.3-18)] in the remainder. These overdoses were in patients who were poorly or non-adherent to clozapine, or who had taken tablets prescribed for someone else. In 54 further people who died whilst receiving clozapine [38 male, 16 female; median age 41 (22-70) year], the median post-mortem blood clozapine and norclozapine concentrations were 1.9 (0-7.7, n = 43) and 1.4 (0-6.0, n = 39)mg/L, respectively [median clozapine:norclozapine ratio 1.5 (0.4-7.6, n = 38)]. The median post-mortem increase in blood clozapine and norclozapine as compared to the most recent ante-mortem measurement was 489 (98-5,350)% and 371 (139-831)%, respectively [median sample time before death 14 (0-30, n = 21) days]. CONCLUSION: Clozapine poisoning cannot be diagnosed on the basis of blood clozapine and norclozapine concentrations alone. The analysis of ante-mortem blood specimens collected originally for white cell count monitoring and the blood clozapine:norclozapine ratio may provide additional interpretative information.     

Interpersonal process-oriented group psychotherapy with offender populations

This article discusses the application of interpersonal process-oriented group psychotherapy to offender populations. Group psychotherapy with offenders presents problems not encountered with other populations; thus, applying the group method requires special considerations. The particular focus of this article is on the relevance of therapeutic factors in group work with offenders, group process as it applies to work with offenders, and work with difficult clients.     

State Aid To Cities: A Causal Inquiry

Path analysis is employed to identify major influences on twoforms of state aid to cities—financial and programmatic.Considerable support is found for a sequential model in whichstate resources and city need are modified by the politicalclimate and the legal/structural characteristics of the state.For financial aid, the most powerful influences are a professionalizedlegislature and a legal system under which cities are responsiblefor schools and welfare. Program support is more affected bystate resources and municipal need. In all, those states mostlikely to provide generous support have cities in need, ampleresources, professionalized legislatures, and a decentralizedstate-local structural relationship.     

Victims' Responses to traumatic life events: An unjust world or an uncaring world?

Although the psychological literature has generally equated deservingness and justice, victims' responses suggest the need to disentangle the two concepts. Victims usually feel their traumatic experience was undeserved but typically do not consider the outcome in terms of justice or fairness. Rather, their feelings about not deserving the victimization derive from a second type of moral judgment involving caring rather than justice. These two orientations are discussed in light of recent developments in work on moral reasoning. A framework for understanding the trauma of victimization is presented; the shattering of assumptions related to a caring world—in which people are protected from harm—is highlighted in this model. The crucialrole of social support and specific cognitive strategies used by victims in the aftermath of their victimization are discussed in terms of survivors' efforts to rebuild their assumptions about a caring world. Although concerns about justice are less common among survivors, an effort is made to discuss when these isues are most apt to arise.     

Sequential Contests

We compare expected rent-seeking expenditures and efficiencyof simultaneous versus sequential rent-seeking contests. We find that when two risk neutral ex ante identical agents are competing,sequential contests are ex ante Pareto superior tosimultaneous contests. We then endogenize the timing decisionof rent-seeking expenditures and show that with ex anteidentical contestants, all subgame perfect equilibria of thisgame are sequential contests.