Dual Diagnosis and Treatment: The Experience of a Multiprofessional Team in Mental Health

Introduction

The work was developed with the people hospitalized in the period of 1 year in a psychiatric clinic in Rio de Janeiro city, Brazil. 175 patients who presented dual diagnosis were evaluated.

Objectives

The research aims to know the distribution of the most frequent psychiatric diagnosis associated with the disorders for the use of psychoactive substances. The work also has as objective to assess the treatment of patients carrying these disorders so that there is a better efficiency of the individual treatment plan.

Methods

The work consisted of the evaluation of all patients who were admitted to the clinic in the period of 1 year, using the ICD-10 for the diagnosis of dual pathologies. All the patients were assessed by the multiprofessional team, composed by general practicioner, psychiatrist, psychologist, pharmaceutic, therapist in chemical dependence, family therapist and physiotherapist. The patients were treated with the use of psychopharms, cognitive behavioral psychotherapy, 12-step program, art therapy and moderate physical activity. Family members of all patients were also interviewed.

Results

In the evaluation conducted by the team, it was found the following distribution of the most frequent diagnosis associated to disorder for the use of psychoactive substances: depression (26.3%), personality disorder (22.9%), bipolar disorder (22.3%), non-schizophrenic psychosis (12.6%), schizophrenia (9.1%), and other diagnosis (6.8%).

Conclusions

The formulation of the dual diagnosis provided a better approach of the patients on the part of the team, promoting the strengthening of the therapeutic bond and causing positive impact on the evolution of these disorders.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Performance of the clinical index of stable febrile neutropenia (CISNE) in different types of infections and tumors

PURPOSE

The clinical index of stable febrile neutropenia (CISNE) can contribute to patient safety without increasing the complexity of decision-making. However, febrile neutropenia (FN) is a diverse syndrome. The aim of this analysis is to assess the performance of CISNE according to the type of tumor and infection and to characterize these patients.

METHODS

We prospectively recruited 1383 FN episodes in situations of apparent clinical stability. Bonferroni-adjusted z tests of proportions were used to assess the association between the infections suspected at the time of onset and the type of tumor with the risk of serious complications and mortality. The performance of CISNE was appraised in each category using the Breslow-Day test for homogeneity of odds ratios and Forest Plots.

RESULTS

171 patients had a serious complication (12.3 %, 95 % confidence interval 10.7-14.2 %). The most common initial assumptive diagnoses were: fever without focus (34.5 %), upper respiratory infection (14.9 %), enteritis (12.7 %), stomatitis (11.8 %), and acute bronchitis (10.7 %). Lung and breast were the most common tumors, accounting for approximately 56 % of the series. The distribution of complications, mortality, and bacteremia varies for each of these categories. However, Breslow-Day tests indicate homogeneity of the odds ratio of the dichotomized CISNE score to predict complications in all infection and tumor subtypes.

CONCLUSION

Despite FN's clinical and microbiological heterogeneity, the CISNE score was seen to be consistent and robust in spite of these variations. Hence, it appears to be a safe tool in seemingly stable FN.

Very low level viraemia and risk of virological failure in treated HIV-1-infected patients

OBJECTIVES

The aim of the study was to investigate whether very low level viraemia (VLLV) (20-50 HIV-1 RNA copies/mL) was associated with increased risk of virological failure (VF) as compared with persistent full suppression (< 20 copies/mL).

METHODS

From the VACH Cohort database, we selected those patients who started antiretroviral therapy (ART) after January 1997 and who achieved effective viral suppression [two consecutive viral loads (VLs) < 50 copies/mL] followed by full suppression (at least one VL <20 copies/mL). We carried out survival analyses to investigate whether the occurrence of VLLV rather than maintaining full suppression at < 20 copies/mL was associated with virological failure (two consecutive VLs > 200 copies/mL or one VL > 200 copies/mL followed by a change of ART regimen, administrative censoring or loss to follow-up), adjusted for nadir CD4 cell count, sex, age, ethnicity, transmission group, type of ART and time on effective suppression at < 50 copies/mL.

RESULTS

Of 21 480 patients who started ART, 13 674 (63.7%) achieved effective suppression at < 50 copies/mL, of whom 4289 (31.4%) further achieved full suppression at < 20 copies/mL after May 2009. A total of 2623 patients (61.1%) remained fully suppressed thereafter, while 1666 had one or more episodes of VL detection > 20 copies/mL (excluding virological failure). A total of 824 patients had VLLV after suppression at < 20 copies/mL. VLLV was not associated with virological failure as compared with persistent full suppression [hazard ratio (HR) 0.67; 95% confidence interval (CI) 0.44-1.00], independently of the number of blips recorded (from one to 18).

CONCLUSIONS

In our population of HIV-infected patients on ART who achieved viral suppression at < 20 copies/mL, the risk of virological failure was no different for patients who remained fully suppressed compared with those who experienced subsequent episodes of VLLV.

Water flux management and phytoplankton communities in a Mediterranean coastal lagoon. Part II: Mixotrophy of dinoflagellates as an adaptive strategy?

Dinoflagellate proliferation is common in coastal waters, and trophic strategies are often advanced to explain the success of these organisms. The Biguglia lagoon is a Mediterranean brackish ecosystem where eutrophication has long been an issue, and where dominance of dinoflagellates has persisted for several years. Monthly monitoring of fluorescence-based properties of phytoplankton communities carried out in 2010 suggested that photosynthesis alone could not support the observed situation all year round. Contrasting food webs developed depending on the hydrological season, with a gradual shift from autotrophy to heterotrophy. Progressively, microphytoplankton assemblages became unequivocally dominated by a Prorocentrum minimum bloom, which exhibited very weak effective photosynthetic performance, whereas paradoxically its theoretical capacities remained fully operational. Different environmental hypotheses explaining this discrepancy were examined, but rejected. We conclude that P. minimum bloom persistence is sustained by mixotrophic strategies, with complex compromises between phototrophy and phagotrophy, as evidenced by fluorescence-based observations.

Water flux management and phytoplankton communities in a Mediterranean coastal lagoon. Part I: How to promote dinoflagellate dominance?

The Biguglia lagoon is a shallow Mediterranean coastal ecosystem where eutrophication is increasing for years. A channel supplying freshwater was cleared in 2009 to enhance lagoon water circulation and alleviate dystrophic crises. Monthly monitoring was started in 2010 to document the impacts of this action on abiotic characteristics and phytoplankton communities. Three stations were surveyed (by microscopy and HPLC). Evidence suggests that this operation had an unexpected outcome. Salinity footprints indicated the succession of three main hydrological sequences that depended on rainfall and circulation pattern. Diatoms and dinoflagellates dominated the first sequence, characterized by heavy rainfall, while Prorocentrum minimum became progressively the dominant species in the second period (increasing salinities) with extensive bloom over the whole lagoon (5.93×10-(5) cells·L(-1)) during the third period. These phytoplankton successions and community structures underline the risk of pernicious effects arising from remediation efforts, in the present case based on increasing freshwater inputs.

Naltrexone but Not Ketanserin Antagonizes the Subjective, Cardiovascular, and Neuroendocrine Effects of Salvinorin-A in Humans

BACKGROUND

Salvinorin-A is a terpene found in the leaves of the plant Salvia divinorum. When administered to humans, salvinorin-A induces an intense but short-lasting modified state of awareness, sharing features with those induced by the classical serotonin-2A receptor agonist psychedelics. However, unlike substances such as psilocybin or mescaline, salvinorin-A shows agonist activity at the kappa-opioid receptor rather than at the serotonin-2A receptor. Here, we assessed the involvement of kappa-opioid receptor and serotonin-2A agonism in the subjective, cardiovascular, and neuroendocrine effects of salvinorin-A in humans.

METHODS

We conducted a placebo-controlled, randomized, double-blind study with 2 groups of 12 healthy volunteers with experience with psychedelic drugs. There were 4 experimental sessions. In group 1, participants received the following treatment combinations: placebo+placebo, placebo+salvinorin-A, naltrexone+placebo, and naltrexone+salvinorin-A. Naltrexone, a nonspecific opioid receptor antagonist, was administered at a dose of 50mg orally. In group 2, participants received the treatment combinations: placebo+placebo, placebo+salvinorin-A, ketanserin+placebo, and ketanserin+salvinorin-A. Ketanserin, a selective serotonin-2A antagonist, was administered at a dose of 40mg orally.

RESULTS

Inhalation of 1mg of vaporized salvinorin-A led to maximum plasma concentrations at 1 and 2 minutes after dosing. When administered alone, salvinorin-A severely reduced external sensory perception and induced intense visual and auditory modifications, increased systolic blood pressure, and cortisol and prolactin release. These effects were effectively blocked by naltrexone, but not by ketanserin.

CONCLUSIONS

Results support kappa opioid receptor agonism as the mechanism of action underlying the subjective and physiological effects of salvinorin-A in humans and rule out the involvement of a serotonin-2A-mediated mechanism.

A UASB reactor coupled to a hybrid aerobic MBR as innovative plant configuration to enhance the removal of organic micropollutants

An innovative plant configuration based in an UASB reactor coupled to a hybrid aerobic membrane bioreactor designed for sustainable treatment of municipal wastewater at ambient temperatures and low hydraulic retention time was studied in terms of organic micropollutants (OMPs) removal. OMPs removal mechanisms, as well as the potential influence of biomass activity and physical conformation were assessed. Throughout all periods of operation (150 days) high organic matter removals were maintained (>95%) and, regarding OMPs removal, this innovative system has shown to be more efficient than conventional technologies for those OMPs which are prone to be biotransformed under anaerobic conditions. For instance, sulfamethoxazole and trimethoprim have both shown to be biodegradable under anaerobic conditions with similar efficiencies (removal efficiencies above 84%). OMPs main removal mechanism was found to be biotransformation, except in the case of musk fragrances which showed medium sorption onto sludge. OMPs removal was strongly dependent on the efficiency of the primary metabolism (organic matter degradation and nitrification) and the type of biomass.

Simultaneous bilateral atypical femoral fracture in a patient receiving denosumab: case report and literature review

Osteoporosis remains a chronic and common disease associated with high medical costs. Pharmacological therapy has shown to be a good strategy to significantly reduce fracture risk. While literary evidence for bone protection in the short and medium term is strongly in it's favor, there are concerns about long-term treatment with antiresorptive drugs. Increased risk of atypical femoral fractures (AFFs) have been demonstrated in several studies following the long-term use of bisphosphonate. Denosumab offers an alternative approach to the treatment of osteoporosis, however, it is also an antiresorptive drug. We present a case of simultaneous bilateral atypical femoral fractures in a patient with denosumab treatment. These findings highlight the need to reevaluate the optimal antiresorptive therapy duration, as well as the safety of transition from bisphosphonates to denosumab and the need for continued monitoring in the prevention of AFFs.

Th-17 Alloimmune Responses in Renal Allograft Biopsies From Recipients of Kidney Transplants Using Extended Criteria Donors During Acute T Cell-Mediated Rejection

Although renal transplantation using expanded criteria donors has become a common practice, immune responses related to immunosenescence in those kidney allografts have not been studied yet in humans. We performed a retrospective molecular analysis of the T cell immune response in 43 kidney biopsies from patients with acute T cell-mediated rejection including 25 from recipients engrafted with a kidney from expanded criteria donor and 18 from recipients grafted with optimal kidney allograft. The clinical, transplant and acute T cell-mediated rejection characteristics of both groups were similar at baseline. The expression of RORγt, Il-17 and T-bet mRNA was significantly higher in the elderly than in the optimal group (p = 0.02, p = 0.036, and p = 0.01, respectively). Foxp3 mRNA levels were significantly higher in elderly patients experiencing successful acute T cell-mediated rejection reversal (p = 0.03). The presence of IL-17 mRNA was strongly associated with nonsuccessful reversal in elderly patients (p = 0.008). Patients with mRNA IL17 expression detection and low mRNA Foxp3 expression experienced significantly more treatment failure (87.5%) than patients with no mRNA IL17 expression and/or high mRNA Foxp3 expression (26.7%; p = 0.017). Our study suggests that the Th17 pathway is involved in pathogenesis and prognosis of acute T cell-mediated rejection in recipients of expanded criteria allograft.

Salvinorin-A Induces Intense Dissociative Effects, Blocking External Sensory Perception and Modulating Interoception and Sense of Body Ownership in Humans

BACKGROUND

Salvinorin-A is a terpene with agonist properties at the kappa-opioid receptor, the binding site of endogenous dynorphins. Salvinorin-A is found in Salvia divinorum, a psychoactive plant traditionally used by the Mazatec people of Oaxaca, Mexico, for medicinal and spiritual purposes. Previous studies with the plant and salvinorin-A have reported psychedelic-like changes in perception, but also unusual changes in body awareness and detachment from external reality. Here we comprehensively studied the profiles of subjective effects of increasing doses of salvinorin-A in healthy volunteers, with a special emphasis on interoception.

METHODS

A placebo and three increasing doses of vaporized salvinorin-A (0.25, 0.50, and 1mg) were administered to eight healthy volunteers with previous experience in the use of psychedelics. Drug effects were assessed using a battery of questionnaires that included, among others, the Hallucinogen Rating Scale, the Altered States of Consciousness, and a new instrument that evaluates different aspects of body awareness: the Multidimensional Assessment for Interoceptive Awareness.

RESULTS

Salvinorin-A led to a disconnection from external reality, induced elaborate visions and auditory phenomena, and modified interoception. The lower doses increased somatic sensations, but the highest dose led to a sense of a complete loss of contact with the body.

CONCLUSIONS

Salvinorin-A induced intense psychotropic effects characterized by a dose-dependent gating of external audio-visual information and an inverted-U dose-response effect on body awareness. These results suggest a prominent role for the kappa opioid receptor in the regulation of sensory perception, interoception, and the sense of body ownership in humans.

Volatile profile of breast milk subjected to high-pressure processing or thermal treatment

The effect of Holder pasteurisation (HoP) (62.5°C for 30 min) or high-pressure treatments (400 or 600 MPa for 3 or 6 min) on the volatile compound profile of human breast milk was evaluated, in order to compare both preservation technologies. A total of 46 different volatile compounds was found in milk samples. The most abundant compounds detected were aliphatic hydrocarbons. In general, the effect of some high-pressure treatments on the volatile profile of human milk was less intense than that caused by HoP. The treatments at 400 and 600 MPa for 3 min maintained the volatile compounds at similar levels to those found in control milk samples. However, the application of 600 MPa for 6 min changed the original volatile compounds of human milk, even more than HoP. Since, HPP at 400 or 600 MPa for 3 min preserved the original volatile compounds of human milk, this novel process may be an alternative to thermal pasteurisation.

Gemcitabine plus capecitabine (Gem-Cape) biweekly in chemorefractory metastatic colorectal cancer

Purpose

A proportion of patients with metastatic colorectal cancer (mCRC) are still able to continue with active therapy after their progression to fluoropyrimidines, oxaliplatin, and irinotecan regimens. Studies suggest that gemcitabine and fluoropyrimidines are synergic antimetabolites. The purpose was to evaluate gemcitabine–capecitabine (Gem–Cape) in heavily pretreated mCRC and to thus assess possible predictive factors for progression-free survival (PFS) and overall survival (OS).

Patients and methods

This analysis was performed on 119 evaluable patients pretreated with fluoropyrimidines, oxaliplatin, irinotecan, and biological agents between June 2001 and July 2011. Patients received gemcitabine 1,000 mg/m² day 1 and capecitabine 1,000 mg/m²bid for 7 days every 2 weeks.

Results

The general characteristics were ECOG 0–1, 89 %; male, 68 %, and median age 63 years. In total, 61 % had received two chemotherapy lines, while 39 % had received three or more. Objective response rates and stable disease rates at 3 months were 6.72 and 37.81 %, equalling a clinical benefit of 44.53 %. The median PFS and OS were 2.87 months [95 % confidence interval (CI) 2.53–3.17 months] and 6.53 months (95 % CI 5.33–8.77), respectively. The most frequent toxicities were grades 1–2, anemia (22 %), thrombocytopenia (10 %), and hand–foot syndrome (9 %); grade ≥3, diarrhea (2 %), with no treatment-related discontinuations. No treatment-related deaths were reported. Statistical significance was obtained by subgroups, assessing clinical benefits and objective responses for PFS and OS. Moreover, patients under 65 tended to have a better PFS.

Conclusion

These data suggest that Gem–Cape is a tolerable and feasible regimen, associated with clinical benefit in non-selected, heavily pretreated, mCRC patients.