By F. Agenak. Champlain College.

J Child Psychol Psychiatr Disord 1991;32: morphometric analysis of the corpus callosum purchase 100 mg aurogra visa. Outcome discount aurogra express, prognosis size in attention-deficit hyperactivity disorder generic aurogra 100mg mastercard. J Child Neurol and risk in a longitudinal follow-up study buy aurogra 100mg otc. The emergence of may be similar in children with ADHD and siblings of children attention deficits in early childhood: a prospective study. Impact of exposure nance imaging measurement of the caudate nucleus in adoles- to parental psychopathology and conflict on adaptive function- cents with attention-deficit hyperactivity disorder and its rela- ing and comorbidity in children with attention deficit hyperac- tionship with neuropsychological and behavioral measures. J Am Acad Child Adolesc Psychiatry 1995;34: Neurol 1997;54:963–968. Research on children and adolescents with phology of the corpus callosum in children with neurofibro- mental, behavioral and developmental disorders. Washington, matosis and attention-deficit hyperactivity disorder. Hills- tion-deficit hyperactivity disorder: a morphometric MRI study. Implication of right tion deficit hyperactivity disorder during higher-order motor frontostriatal circuitry in response inhibition and attention-defi- control: a study with functional MRI. Volumetric functional anatomy of working memory in adult attention defi- MRI analysis: comparing subjects having attention-deficit hy- cit hyperactivity disorder. Focal cerebral dysfunction in functional magnetic resonance study. Proc Natl Acad Sci USA developmental learning disabilities. SCHULTE NOSOLOGY AND CLASSIFICATION Thus, reading at the word level may involve visual, lexical, or semantic processes (2,3), with correspondingly different Current conceptualizations of learning disorders (LDs), for- neuroanatomic circuitry and computational mechanisms merly referred to as 'academic skills disorders' (1), follow within the brain. There are subtypes characterized both by the traditional approach of classifying learning by specific the pattern of skills deficits (e. These skills include reading, mathematics, no mathematics disorder) and by different patterns of and written expression. In each case, the skills are measured neuropsychological function, such as the relative strength by standardized tests whose scores must fall substantially of verbal and nonverbal factors on intelligence tests (4). The deficits must signifi- such that variables characterizing the disorder at earlier ages cantly interfere with academic or daily living activities re- may be different from those seen in older patients (5). When LDs result from sensory, medical, vances in the genetics and neuroimaging of LDs will depend or neurologic conditions, they are coded on Axis III (medi- on more homogeneous clinical definitions at the symptom- cal conditions) within the DSM-IV nomenclature. Commonly associated features of LDs include low self- esteem and demoralization, social skills deficits, school dropout, and difficulties in employment or social adjust- PREVALENCE ment. Patients with conduct disorder, oppositional disor- der, attention-deficit/hyperactivity disorder (ADHD), The DSM-IV reports prevalence estimates of 2% to 10% major depression, dysthymic disorder, and Tourette syn- for LDs, depending on the nature of ascertainment and drome all have substantially elevated rates of LD. In most prevalence studies, a skills in pervasive developmental disorders are often not dis- diagnosis of LD has been made on the basis of a significant crepant from the measured intelligence and language abili- discrepancy between IQ and achievement in one or more ties associated with the pervasive development disorder. Spelling disorders the prevalence of regression-based ability/achievement dis- are usually not considered separate from other reading- and crepancies using the co-norming sample from the Wechsler writing-related deficits. Intelligence Scale for Children III and the Wechsler Individ- Although this approach to classification of LDs is useful ual Achievement Scales found that 17% of the norming in a practical context and allows for an operational defini- group had ability/achievement discrepancies at the. Reading, math- figure can probably be considered the upper limit for LD ematics, and writing comprise many processing skills, giving prevalence estimates based on ability/achievement discrep- rise to subtypes with different underlying mechanisms. Several researchers have questioned the conceptual and C. Keith Conners: Behavioral Neurology Department, Durham, North empiric basis for the use of ability/achievement discrepan- Carolina. Schulte: Department of Psychology, North Carolina State Uni- cies in the diagnosis of LDs, as well as current operationali- versity, Raleigh, North Carolina. Reasons for concern on 598 Neuropsychopharmacology: The Fifth Generation of Progress the use of ability/achievement discrepancies are (a) findings each are found, whereas in LDs alone, only symptoms of that the cognitive profiles of children with low achievement LD, not those of ADHD, are present, and vice versa (14). Alternate proposals for identification include simply using a low achievement criterion (e. In general, these alternate classification system will eventually be replaced by one that procedures are likely to raise prevalence rates. Vellutino and his colleagues used daily tutoring as a 'first The greatest progress in specifying the cognitive and cut' diagnostic criterion to distinguish between children neuropsychological dysfunctions underlying LDs has oc- who had reading difficulties caused by cognitive deficits and curred in reading. Numerous investigations using longitudi- those whose deficits were the result of poor instruction, they nal, intervention, genetic, and neuroimaging methods have found that two thirds of their sample scored within the produced strong and converging evidence that deficits in average range in reading (thirtieth percentile and higher) phonologic processing are the proximal cause of reading after one semester of one-to-one tutoring (12). This rela- difficulties in a large proportion of children with RDs (see tively stringent criterion for establishing an 'adequate edu- refs. Deficits in phonologic process- cational environment' resulted in a drop in the prevalence ing also appear to affect spelling, written expression, and rate of reading disorders (RDs) from 9% to 3%. Clearly, Although conceptualizations of phonologic processing and the definition of caseness in these studies has implications its components vary, within the Wagner and Torgesen for how phenotypes are characterized in genetic and neuro- model of phonologic processing, it consists of three related biological investigations. The use of the more conservative abilities: phonologic awareness, phonologic memory, and methods of case definition are clearly more costly for select- rapid naming (18,19). Phonologic awareness refers to the ing subjects, but they may prove more valid and useful in understanding that words can be broken down into pho- finding biological markers of LD. Phonemes are the smallest sound unit that changes the meaning of a word (e. Phonologic awareness is a critical ability in learning to read because it allows beginning readers to Many psychiatric and medical conditions include LD as an link letters and letter combinations in text to sound strings associated deficit. The most common childhood condition in oral language (20). Knowledge of these links allows read- comorbid with LD is ADHD. Estimates of comorbidity ers to discover the regularities in written text so written range from 20% to 90%, with the lower figures appearing words can be rapidly translated into their spoken equiva- in epidemiologic samples and the higher figures appearing lents. Such recoding allows the reader to access the semantic in clinically referred samples. The high degree of overlap in code (or meaning) for the letter string. The repeated pairing clinical samples suggests that common mechanisms may be of the visual letter string and its spoken equivalent is thought at work in the neurologic basis for both disorders. LDs eventually to allow the reader to develop direct visual word were once considered a necessary criterion for minimal brain recognition strategies that bypass the phonologic code (10, dysfunction. When children have additional interventions targeted toward increasing lan- difficulty with phonologic coding, reading acquisition is im- guage and reading fluency. Difficulties in verbal short-term memory are also example, Berninger et al. Geary proposed that there are three subtypes of (20). MDs, with corresponding deficits in semantic memory, pro- Rapid naming is the ability to access phonologic informa- cedural knowledge of mathematics, and visuospatial pro- tion that is stored in long-term memory rapidly. Such tasks are thought to tap many of the same cognitive processes required in skilled reading, such It has been known for decades that LDs run in families. There is debate about fluences on RD and MD (Table 44. The genetic studies whether the difficulty with rapid naming tasks observed in also confirm the heterogeneity of the phenotype, with both many children with RDs is a reflection of a core deficit in orthographic and phonologic traits implicated but not hav- phonologic processing or whether it represents a deficit in ing identical sources of genetic influence. A genetic link a second set of processes that impairs reading. If this is the between RD and MD was confirmed in several studies. A case, there may be 'double-deficit' readers who are im- strong link of Tourette syndrome, ADHD, and LD has paired in both phonologic and rapid naming processes (23). Evidence has accumu- tions that address phonologic processing and would require lated that locations on the short arm of chromosome 6 TABLE 44.

Can be given once daily purchase aurogra canada, but is given in divided doses when using large doses discount aurogra 100mg on line. Clonazepam is a long acting drug; usual daily dose 1 cheap aurogra 100 mg on-line. Oxazepam is an intermediate acting drug; usual daily dose 30-60 mg order aurogra 100mg on-line. Temazepam is an intermediate acting drug which is exclusively marketed as an hypnotic. The usual nocte dose is 10 mg, but 20 mg is also used. Alprazolam, which is structurally distinct from all other benzodiazepines, is given a separate paragraph because it has a relatively high potential for abuse. In many jurisdictions it is listed along with the highly restricted drugs (narcotics). An inhaled form is being developed which will have quicker onset but may increase addiction potential (Reissig et al, 2014). It suppresses activity in presynaptic serotonergic neurons, leading to diminished serotonin activity and down-regulation of some serotonin receptors. It has no muscle relaxant properties, no psychomotor or cognitive impairment, and is less sedating than the benzodiazepines. It does not potentiate the effects of alcohol (as can the benzodiazepines) and there is no withdrawal. The side-effects include headache, dizziness and nausea. In formal clinical trials, buspirone is as effective as diazepam (Fulton & Brogden, 1997). The main clinical disadvantage is that the anxiolytic effect does not appear immediately, and may be delayed for at lest 2 weeks. The benzodiazepines, on the other hand have an immediate effect. A second disadvantage is that buspirone is much Pridmore S. In clinical practice, and certainly when a rapid response is required, buspirone is rarely used in the treatment of anxiety (Hodge et al, 2012). BETA-ADRENERGIC ANTAGONISTS Where the symptoms are predominantly somatic and mediated by the sympathetic nervous system (palpitations, tremor and gastrointestinal overactivity), beta-blockade has been suggested. However, there is no evidence of efficacy and plenty of evidence of troublesome side effects; hypotension, bradycardia, excessive dreaming, bronchospasm, skin reactions and gastrointestinal upset. Most authorities no longer recommend the use of beta-blockers in the treatment of anxiety. In states of high arousal, when an individual who needs steady hands (for example, a concert pianist about to go on stage) a single dose of a beta-blocker (propranolol, 40 mg) may have the desired effect. SEROTONIN REUPTAKE INHIBITION (SSRI & SNRI) These drugs have been described in Chapter 16: Antidepressant drugs. Most now regard these agents as first-line therapies for anxiety disorders (Lecrubier et al, 1997; Davis et al, 2014, Mohatt et al, 2014; Bandelow, 2014). Their effect is independent of the presence of depression. The effective dose in anxiety treatment is frequently higher than used in the treatment of depression. The antidepressants have the advantage of not being of interest to drug traffickers. A recent meta-analysis of generalized anxiety treatments (Baldwin et al, 2011) found that fluoxetine was superior to various other drugs (including a benzodiazepine) in both response and remission; and that sertraline was the best tolerated. The disadvantage relative to the benzodiazepines in the management of anxiety is that the onset of beneficial effect may take some weeks. In addition, there may be an initial, temporary worsening of anxiety. It has been stated that the SSRIs are associated with increased suicidality; this has not been properly substantiated and may be a confound of the occasional, initial worsening of anxiety symptoms, just mentioned. Venlafaxine (SNRI) is effective in the treatment of anxiety (Davis et al, 2014; Bandelow et al, 2014). It is not without side-effects and withdrawal symptoms, but like the SSRIs, is of no interest to drug traffickers. It is believed to inhibit calcium channel activity, leading to reduced neurotransmitter release, which in turn leads to reduced postsynaptic neuron excitability. Studies (Lydiard et al, 2009) have indicated anxiolytic effects comparable to the benzodiazepines. It appears to be effective in the treatment of social anxiety disorder and is recommended when other agents are ineffective or bring troublesome side-effects (Kawalec et al, 2014). There is much interest in pregabalin because small abuse potential and it represents a new approach. It was recently approved as a treatment of anxiety in Europe (Bandelow 2013). It is currently marketed around the world as a treatment of neuropathic pain and fibromyalgia. PSYCHOTHERAPY Psychotherapy, of which cognitive behaviour therapy (CBT) is a current leading example, is effective in the treatment of anxiety (Allgulander et al, 2003). Claims have been made that CBT is superior to pharmacotherapy in the treatment of anxiety disorders (Bandelow et al, 2014). Evidence is stronger for CBT than other forms of psychotherapy. Claims have been made that CBT has a long lasting effect, persisting well beyond the treatment period. However, literature reviews have found no such evidence (Brandelow, et al, 2008). It has been stated that the combination of CBT and pharmacotherapy provides a better outcome than either treatment alone. But this has not been supported by one literature reviews (Davidson et al, 2010) or a recent Cochrane Review (at least with respect to panic disorder; Watanabe et al, 2009). However, general practitioners lack confidence in the use of in the use of psychological therapies such at CBT in the treatment of insomnia (Everitt et al, 2014). HYPNOTICS Benzodiazepines Temazepam and nitrazepam continue to be marketed as hypnotics Benzodiazepine-like hypnotic Zolpidem is a non-benzodiazepine hypnotic which potentiates GABA by binding to the benzodiazepine receptor. It is effective in sleep initiation, but less effective in sleep maintenance. Transient memory problems and, in depressed individuals, worsening of suicidal thinking, has been reported. A study at the Mayo Clinic showed zolpidem significantly increases the risk of falls, and it is being discontinued at that hospital (Voelker, 2012). Initially, marketed as an immediate release agent, for short-term treatment (7-10 days) of insomnia. A controlled release form (CR) is now available, which is not restricted to short-term treatment. ANTIPSYCHOTICS Antipsychotic medications (quetiapine etc) have been used in the treatment of anxiety disorders (Hershenberg et al, 2014). However, due to potential serious side effects, this practice is strongly discouraged. THE FUTURE The search continues for an anxiolytic with the effects, but not the side-effects of the benzodiazepines (Skolnick, 2013). A recent report (Herring et al, 2012) indicates a new direction. Orexin is a neurotransmitter which regulates arousal; and lack of it has been identified in cataplexy. Suvorexant is an orexin receptor antagonist, which appears useful in the treatment of primary insomnia.

Still cheap aurogra 100 mg free shipping, the high frequency of mood tant to emphasize that treatment in structured settings aurogra 100 mg generic, such disturbances associated with this disorder resulted in trials as inpatient units buy discount aurogra 100 mg on-line, even without medication buy generic aurogra, succeeds in of drugs such as amitriptyline (41–43), and lithium (44). Thus, it may be difficult to prove that an active medi- compared with the effects of placebo. However, relapse within For more that 50 years (45), investigators have suggested 1 year after successful inpatient weight restoration is very that AN shares similarities with obsessive-compulsive disor- common (25). In fact, patients with AN have a high prevalence ported that only 23% of the patients had a good outcome of obsessive-compulsive symptoms or disorders (46–48), as at 1 year after discharge despite intensive outpatient individ- well other anxiety disorders (49). Controlled trials of the neuroleptics pimozide (27) and Individuals with a past history of AN display evidence of sulpiride (28) have suggested limited effects in accelerating increased serotonin (51) activity that persists after long-term weight gain or altering anorectic attitudes for some patients weight recovery. In addition, women who recover from AN for part of the study, but overall drug effect was marginal. Similarly (10), personality characteris- a good outcome on placebo (P. Aside tics associated with AN, such as introversion, self-denial, from improved outcome, fluoxetine administration was as- limited spontaneity, and a stereotyped thinking style, may sociated with a significant reduction in obsessions and com- also persist after weight recovery. Studies in humans and pulsions and a trend toward a reduction in depression. Together, these data raise the possibility in some patients with AN. Women plicated in OCD (52) and only serotonin-specific medica- with AN, when malnourished and underweight, have re- tion has been found to be useful in treating OCD. In addition, low estrogen values during the malnour- patients with AN. Initial reports on cyproheptadine, a drug ished state may reduce serotonin activity by effects on gene that is thought to act on the serotonergic and histaminergic expression for serotonin receptors (64) or the serotonin system (53), indicated that it might have beneficial effects transporter (65). SSRIs are dependent on neuronal release on weight gain, mood, and attitude in some patients (54, of serotonin for their action. Cyproheptadine data from comparison trials with ami- compromised release of serotonin from presynaptic neu- triptyline and placebo found cyproheptadine to significantly ronal storage sites and reduced synaptic serotonin concen- improve weight gain in the restricting subtype of AN, trations, then a clinically meaningful response to an SSRI whereas amitriptyline was more effective in those patients might not occur (66). The possibility that fluoxetine is only with bulimic behavior (56). For example, CSF 5-HIAA levels are low might help patients with AN gain and/or maintain a healthy in underweight anorexics, normal in short-term weight-re- body weight. Recently, the Pittsburgh group reported a dou- stored anorexics, and elevated in long-term weight-restored ble-blind placebo-controlled trial of fluoxetine in 35 pa- anorexics (67). If CSF 5-HIAA levels accurately reflect CNS tients with restrictor-type AN (59). Subjects were started serotonin activity, then these data imply that a substantial on fluoxetine after they achieved weight restoration (approx- increase in serotonin activity occurs after weight gain. The use of serotonin-specific medications in the treat- Patients were randomly assigned to fluoxetine (N 16) ment of AN is promising but many questions remain. First, or placebo (N 19) after inpatient weight-restoration and only one double-blind placebo-controlled study has been then were followed as outpatients for 1 year. After 1 year completed in a relatively small number of restrictor-type of outpatient follow-up, 10 of 16 (63%) subjects had a good patients. Thus, it will be important to replicate this work FIGURE 116. Survival of subjects with anorexia ner- vosa treated with fluoxetine or placebo. Chapter 116: Psychopharmacology of Eating Disorders 1679 in a larger group of patients. Second, more data are needed to determine if there are differential effects in the restricting of binge eating/purging subtypes of AN. Third, it needs to be determined whether certain features are especially re- sponsive to serotonin-specific medications: core anorexic symptoms, depression, anxiety, obsessionality, or eating be- havior. Guidelines for Clinical Treatment The first line of treatment for underweight patients with AN should be refeeding and weight restoration. As noted, although difficult, most patients will gain weight in a struc- tured eating disorders treatment program without the use of medication. Weight gain alone tends to reduce exaggerated obsessionality and dysphoric mood in many patients (68). Median percentage change in the number of binge-eating episodes among patients with bulimia nervosa re- There is limited evidence that fluoxetine and possibly other ceiving fluoxetine or placebo. It is important to emphasize that some physio- logic and cognitive alterations persist for months after achieving goal weight, including increased energy needs, menstrual disturbances, several neurotransmitter distur- of benefit from antidepressant treatment typically is quite bances, urges to engage in disordered eating patterns, and rapid (Fig. Thus, treatment should continue No trials have been published in which the efficacy of for at least 3 to 6 months after achieving goal weight, prefer- one antidepressant is compared directly to that of another. We strongly support use of the recent American oxetine, only fluvoxamine has been formally examined in Psychiatric Association (APA) guidelines for eating disor- BN. Fichter and colleagues reported a study of novel design ders (69), which describe comprehensive treatment of AN. Although fluvoxamine was associated with PHARMACOLOGIC TREATMENT OF BN a dropout rate of 38% over 19 weeks compared to 14% on placebo, the active drug was superior to placebo in reducing As summarized in Neuropsychopharmacology, the Fourth the re-emergence of bulimic behaviors and attitudes. In light Generation of Progress, a substantial body of work was pub- of these results, it is surprising that a large European trial lished during the 1980s and early 1990s demonstrating that has been reported to find no difference between the response antidepressants are more effective than placebo in the treat- to fluvoxamine and placebo in the initial treatment of out- ment of BN (70). In 1996, the FDA approved the use of patients with bulimia (Freeman, personal communication, fluoxetine (71,72) for this disorder, the only medication to 1999). Thus, although most clinicians expect sertraline, pa- receive such an official indication to date. Although the roxetine, citalopram, and venlafaxine to be useful, the effi- notion of using antidepressants for BN emerged because of cacy and ideal dose of SSRIs other than fluoxetine for the the high frequency of symptoms of depression and anxiety, treatment of BN have not been established. CBT is generally believed to be more effec- of appetite. The notion that antidepressants may be useful tive than a single course of an antidepressant medication in BN via mechanisms other than those that are responsible (69). This fact, coupled with reasonable evidence of sus- for their antidepressant activity is also suggested by the ob- tained benefit following CBT and the reluctance of many servations that a higher daily dose of fluoxetine (60 mg per patients to take psychotropic medications, has led to CBTs day) appears superior to the standard antidepressant dose being generally considered the treatment of first choice for (20 mg per day) in the treatment of BN and that the onset BN. Several studies have examined whether it is beneficial 1680 Neuropsychopharmacology: The Fifth Generation of Progress to combine psychological treatment with antidepressant from one treatment approach or another would be ex- medication. Unfortunately, attempts to identify such The earliest studies of the combination of medication predictors of treatment response have been impressively un- and psychotherapy utilized tricyclic antidepressants. Because those patients who derive the greatest ell and associates (74) found that imipramine was associated benefit from treatment typically exhibit an early response with a greater reduction in measures of anxiety and depres- (80), it may useful to initiate treatment with CBT, for exam- sion than was placebo when combined with an intensive ple, and to add another intervention such as medication if group psychotherapy program; however, imipramine did the initial response is not satisfactory. Recent data demon- not augment the impact of the psychological treatment on strate that medication can be useful for patients who do the salient behavioral symptom, binge eating. Agras and not respond adequately to psychological treatment or who colleagues (75) compared five treatments for BN: individual relapse following the end of treatment (18). CBT alone, desipramine alone for 16 or 24 weeks, and CBT Despite the progress in developing treatment approaches plus desipramine for either 16 or 24 weeks. As was also for bulimia in the last 20 years, a major current problem is true of the study of Mitchell and colleagues, Agras and co- the absence of treatments of established efficacy other than workers reported that the outcome of psychological treat- CBT and antidepressant medication. Even in the best ment alone was clearly superior to that of a course of tricyclic hands, only about 50% of patients achieve remission with antidepressant. There were a few hints of a small advantage these treatments, and a significant number relapse following for the combination of medication and CBT, but these were the conclusion of the initial intervention. Leitenberg and co-workers (76) attempted investigators have considered the use of other psychotropic to compare CBT to a course of desipramine and to a combi- medications that are believed to reduce appetite, such as nation, but terminated the study prematurely because of topiramate, but no controlled data are available to date about its utility in BN. Recently, Faris and associates (82) a high dropout rate, primarily caused by medication side have reported that the antiemetic medication ondansetron, effects. The Columbia group has reported the results of data regarding the side effects of ondansetron and its impact a study that compared two forms of individual psychological on psychological features of the disorder are required to treatment (CBT and supportive psychotherapy) combined assess the clinical utility of this agent, but the exploration either with placebo or a two-stage medication intervention of novel medication interventions for BN is overdue. Patients assigned to receive active medication received desipramine; if desipramine was either ineffective or intoler- able, the medication was changed to fluoxetine under dou- ble-blind conditions. In this study, CBT was clearly superior PHARMACOLOGIC TREATMENT OF BINGE to supportive psychotherapy in reducing the key behavioral EATING DISORDER symptoms of BN. In addition, compared to placebo, active medication added modestly but significantly to improve- During the development of DSM-IV, interest grew in defin- ment in binge eating and depression. Unfor- pensatory behavior required for the diagnosis of BN. Out tunately, interpretation of the results is limited by a high of these discussions, criteria for binge eating disorder (BED) dropout rate, which resulted in few significant differences evolved, and were included in an appendix of DSM-IV as among the three treatments.

The editor is not only there to organise and delegate: the third duty of the editor is to bear a part of the work on his own shoulders cheap aurogra 100mg without a prescription. The more the editors write buy aurogra mastercard, the better they understand their authors and the more qualified they are to give advice order aurogra online. Mentor A young editor profits from discussing his textbook project with an experienced colleague; an older editor should seek the advice of a good friend and colleague buy discount aurogra 100mg. It is possible to publish a book as a lone wolf, but it is easier to lose your way alone than in pairs. It is not only the younger colleagues who refuse the help of the older ones; sometimes the older ones no longer possess the mellow goodwill to watch their younger colleagues working on projects for which they themselves are too old. Medical Readers In the section on editors, we saw that medical readers may be needed to help with the stylistic and didactic finishing of a book. Medical readers are often doctors themselves, and a proof-reader with 20 years experience can be a valuable addition to an editorial team. The additional financial burden should be allowed for in the budget, but it is worth every penny when editors are unable to perfect texts for the final print version due to lack of time. Proofreaders There is no such thing as an error-free book, but you should make every effort to produce as perfect a text as possible – gifted proofreaders can help you. Proofreaders are the last ones to work on the chapters before they are put together as a whole. It is not easy to 30 Time frame find good proofreaders. Secretariat A text passes through several stages before it is published. The stages which it must complete before it is incorporated in HIV Medicine are shown in Table 2. For each text, a careful account is kept of the stage it has reached. In the production of HIV Medicine, this task is performed by the editors; other projects have a project secretariat. If all the authors get to work straight away, a textbook project can theoretically be completed in 6 months. For the first edition, this can be anything from 100 to 400 hours. However you organise it: the first edition means work and stress. The world needs one hundred doctors and more so in the subsequent ones, that the workload is reduced to between a third and a quarter of the initial number of hours. Deadline The co-authors have to read up on their subject, structure the material, write and correct the text. This needs to be organised and fitted in to the full schedule of a busy hospital doctor. If the circumstances are good – the colleague is highly motivated, happens to be on holiday and throws himself enthusiastically into his work – it is realistic that a chapter of 20 pages can be written in 6 weeks. So do not be afraid to ask your co-authors if they can submit their text “at the end of next month”. In other cases, more time may be required, but it does not make sense to set a deadline too far in the future. If you give someone 12 months, he will rarely start work before the last four weeks. Therefore, a deadline of four months should only be extended to six months in justified exceptions (post-doctoral lecture qualification, work on an important publication, etc. Perhaps you should give your co-authors the option of choosing a deadline of between six weeks and four months. Make sure that the deadlines are spread evenly over this period, so that the texts do not all arrive at the editorial office at the same time. If you sense that this unsettles your author, you can always modify the date for text submission, but insist that a deadline is deadline, and that means the new deadline too. Printing costs The printing costs for a book comparable in size (24 cm x 15 cm) and length (800 pages) with HIV Medicine 2005 are listed in Table 2. The relatively high costs for small editions are due to the fact that print preparation (construction and setting up of printing plates, 32 Budget adjustment of the printing machine, test printing, etc. Once the printing machine is up and running, the costs are reduced dramatically. While for an edition of 500 copies each print costs 14 Euro, every book over th and above the 1000 costs only 3. In chapter 4, we have to make sure that we recover this money. Webhosting Compared with the printing costs, the cost of placing your text on a computer with internet access is relatively low, at between 10 and 30 Euro a month. The editors have certain financial reserves and can finance the project from their nest egg. In this case, they can offer their authors a fixed fee. For example, the authors are guaranteed 13 Euro per page, plus a further 13 Euro per page if book sales cover the printing costs. The editors have no financial reserves and cannot offer their authors a fee. In this case, it is a good idea to form a financial partnership. If book sales and entries from company logos displayed on the internet site generate a profit, this will be split 33 2. The world needs one hundred doctors according to the number of pages written. The authors bear the whole risk – for the whole profit. Team of authors Concept, structuring, editorial team and scheduling make up the framework of a project. What is missing now are the people you need to press ahead with the project. It is not easy to find them, especially as you have to acquire between 15 and 30 co-authors for a large medical textbook. What are the criteria for assembling a team of authors? They should also enjoy imparting their knowledge to other people. This is usually only possible via friendship or authority. You must decide whether at least one of these conditions is fulfilled. E-mail is the modern method, but the telephone is better. Call your preferred candidates and explain your project. Emphasise the fact that it is an Flying Publisher project and that you could publish the individual chapters on the internet within a few weeks. If the candidates are not familiar with the principle, refer to this book. Discuss the following items: ƒ Subject and title of their contribution ƒ Length ƒ Fee ƒ Deadline ƒ Word processing software (mostly Word) The most important message to put across to your authors during this discussion is: “You will be No. The authors need to know that they are not working on just any old project, but on an adventure with exciting and successful years ahead. Summary Editor/Publisher ƒ Only write if you want your book to be No. Those who cannot perform this task themselves should delegate the job to a professional reader. Calculate printing costs and think about whether foundations or sponsors might be interested in taking on part of the edition. Author ƒ Books which are not freely available on the internet are like cars without wheels. Doctor ƒ As you can see, publishers who take their task seriously and want to be more than just a figurehead have plenty to do. The world needs one hundred doctors Student ƒ If you have heard of Flying Publisher projects and have basic skills in the management of HTML sites, go ahead and offer your services.