Comparing neighborhoods of adults with serious mental illness and of the general population: research implications

OBJECTIVE

The International Classification of Functioning, Disability and Health emphasizes the importance of assessing the impact of environmental factors on functioning and disability. Drawing on this emphasis, this study used a set of objective measures to compare the characteristics of neighborhoods of adults with serious mental illness and of the general population. It also examined the relationship between neighborhood characteristics and neighborhood concentration of persons with serious mental illness.

METHODS

The sample comprised 15,246 adults who were treated for serious mental illness in Philadelphia between 1997 and 2000. Principal-components analysis of 22 neighborhood characteristics resulted in an ideal-factor solution of six components. The mean values of each component in neighborhoods of persons with serious mental illness were compared with values in an equally sized group of neighborhoods created by randomly generated addresses representative of the city's general population. Ordinary least-squares regression was used to assess the association between neighborhood characteristics and neighborhood concentration of persons with serious mental illness.

RESULTS

Neighborhoods in which adults with serious mental illness resided had higher levels of physical and structural inadequacy, drug-related activity, and crime than comparison neighborhoods. Higher levels of physical and structural inadequacy, crime, drug-related activity, social instability, and social isolation were associated with higher concentration of persons with serious mental illness in the neighborhood's adult population.

CONCLUSIONS

The differences in neighborhood characteristics identified in this study point to factors that merit closer attention as potential barriers or facilitators in the functioning, participation, and community integration of persons with serious mental illness.

Prevalence and risk of homelessness among US veterans

INTRODUCTION

Understanding the prevalence of and risk for homelessness among veterans is prerequisite to preventing and ending homelessness among this population. Homeless veterans are at higher risk for chronic disease; understanding the dynamics of homelessness among veterans can contribute to our understanding of their health needs.

METHODS

We obtained data on demographic characteristics and veteran status for 130,554 homeless people from 7 jurisdictions that provide homelessness services, and for the population living in poverty and the general population from the American Community Survey for those same jurisdictions. We calculated prevalence of veterans in the homeless, poverty, and general populations, and risk ratios (RR) for veteran status in these populations. Risk for homelessness, as a function of demographic characteristics and veteran status, was estimated by using multivariate regression models.

RESULTS

Veterans were overrepresented in the homeless population, compared with both the general and poverty populations, among both men (RR, 1.3 and 2.1, respectively) and women (RR, 2.1 and 3.0, respectively). Veteran status and black race significantly increased the risk for homelessness for both men and women. Men in the 45- to 54-year-old age group and women in the 18- to 29-year-old age group were at higher risk compared with other ages.

CONCLUSION

Our findings confirm previous research associating veteran status with higher risk for homelessness and imply that there will be specific health needs among the aging homeless population. This study is a basis for understanding variation in rates of, and risks for, homelessness in general population groups, and inclusion of health data from US Department of Veterans Affairs records can extend these results to identifying links between homelessness and health risks.

Inherited chondrodysplasia in Texel sheep

CASE HISTORY

A skeletal disease characterised by dwarfism, limb deformity and sometimes sudden death occurred over a period of 5 years in lambs born on a commercial sheep farm in Southland. The disease showed variable expression and occurred in crossbred sheep. A genetic aetiology was supported by the birth of affected lambs over two seasons in a flock of putative carrier and affected sheep transported to Massey University.

CLINICAL FINDINGS

Affected lambs appeared normal at birth but showed evidence of dwarfism, wide-based stance and exercise intolerance as early as 1 week of age. Most died within the first 3 months of life, often after developing bilateral varus deformity of the forelimbs. Some severely-affected lambs died suddenly of respiratory embarrassment, probably due to tracheal collapse. Mildly-affected individuals had a short, blocky stature and some survived to breeding age.

PATHOLOGICAL FINDINGS

Gross and microscopic lesions of variable severity were present in the tracheal, articular, epiphyseal and physeal cartilages. In severe cases, articular cartilage in major joints was eroded from weight-bearing surfaces. The trachea was flaccid, abnormally kinked, and had thickened cartilaginous rings and a narrow lumen. Affected sheep that survived to breeding age eventually developed severe degenerative joint disease. Histologically, chondrocytes were disorganised, surrounded by concentric rings of abnormal fibrillar material, and the matrix often contained focal to coalescing areas of chondrolysis.

DIAGNOSIS

Inherited chondrodysplasia of Texel sheep. CLINICAL RELEVANCE AND CONCLUSIONS: This chondrodysplasia differs from those previously described in sheep and is considered to be a newly-recognised, recessively-inherited genetic disease of the Texel breed. A defect in the synthesis of glycosaminoglycans in cartilage matrix is suspected. This disease of sheep may provide a suitable model for studying various forms of therapy for human chondrodysplasias.

Image-guided helical tomotherapy for localized prostate cancer: technique and initial clinical observations

The purpose of the present study was to implement a technique for daily computed tomography (CT)-based image-guided radiation therapy and to report observations on treatment planning, imaging, and delivery based on the first 2 years of clinical experience. Patients with previously untreated stage T1-T3 biopsy-proven adenocarcinoma of the prostate were considered eligible for treatment with daily CT-guided helical tomotherapy. The prostate was targeted daily using megavoltage CT (MVCT) images that were fused with treatment-planning CT images based on anatomic alignments. All patients were treated at 2 Gy per fraction to 76-78 Gy (mean: 76.7 Gy). As part of this study, 33 prostate patients were planned, imaged, and treated with a total of 1266 CT-guided fractions. The prostate, rectum, bladder, femoral heads, and pubis symphysis were visible in one or more slices for all 1266 MVCT image sets. The typical range of measured prostate displacement relative to a 3-point external laser setup in this study was 2-10 mm [3.4 mm standard deviation (SD)] in the anterior-posterior direction, 2-8 mm (3.7 mm SD) in the lateral direction, and 1-6 mm (2.4 mm SD) in the superior-inferior direction. The obese patients in this study had a substantially larger lateral variation (8.2 mm SD) attributable to mobility of skin marks. The prostate, seminal vesicles, rectum, and bladder anatomy were used to position the patient relative to the desired treatment position without the use of implanted markers. Acute toxicities were within the expected range given the number of patients treated and the dose level.

Vitamin A toxicity: when one a day doesn't keep the doctor away

Vitamin A toxicity has been reported to cause severe liver disease and, occasionally, liver failure. Herein we present the case of a 60-year-old male with symptoms of muscle soreness, alopecia, nail dystrophy, and ascites. He continued to deteriorate with the development of refractory ascites, renal insufficiency, encephalopathy, and failure to thrive. A liver biopsy demonstrated presence of Ito cells and vacuolated Kupffer cells without the presence of cirrhosis. His clinical history revealed ingestion of large doses of vitamin A. His worsening clinical situation ruled out the possibility of a transjugular intrahepatic portosystemic shunt. The patient underwent orthotopic liver transplantation with resolution of symptoms. Vitamin A toxicity should be considered in the differential diagnosis of noncirrhotic portal hypertension. In conclusion, liver transplantation is a valid option if no improvement occurs in spite of cessation of the medication.

Liver transplantation in the MELD era: a single-center experience

Model for Endstage Liver Disease (MELD) score has been used to allocate organs since February 2002. This policy allocates organs to candidates with regard to severity of their underlying liver disease except in the case of hepatocellular carcinoma (HCC) patients. The purpose of this study was to determine the impact of MELD on waiting times, dropout rates, and transplantation rates in all patients awaiting liver transplantation at our center. The records of all patients listed for liver transplantation between May 28, 1999, and February 27, 2004, at the Mayo Clinic, Scottsdale, Arizona, were reviewed. Candidates were grouped by two time periods as pre-MELD or post-MELD based on date of MELD implementation (February 27, 2002). The incidence of deceased donor liver transplantation (DDLT), waiting time to DDLT, dropout rate from the waiting list because of clinical deterioration or death, and survival while waiting for or after DDLT were determined for each group. Three hundred fifty-one patients were listed for liver transplantation (195 pre-MELD, 156 post-MELD) during the study period. HCC patients had an improved rate of transplantation after MELD (pre-MELD, 1.39 persons per year; post-MELD, 3.48 persons per year). In all groups, with the exception of hepatitis C virus, the transplantation rates were the same for both categories. The hepatitis C virus group also had improved transplantation rates in the post-MELD period. HCC candidates under the new allocation policy have an increased incidence of DDLT in our institution. However, this has not disadvantaged patients with non-HCC diagnoses. Thus, the new MELD-based allocation policy has benefited all candidates by allowing more timely transplants.

Living donor liver transplantation for hepatitis C-related cirrhosis: no difference in histological recurrence when compared to deceased donor liver transplantation recipients

The question of possible earlier and more aggressive recurrence of hepatitis C virus (HCV) infection after living donor liver transplantation (LDLT) compared to deceased donor liver transplantation (DDLT) remains unanswered. To address this issue we retrospectively reviewed virological, histological, and clinical data in 67 patients (52 DDLT and 15 LDLT) who underwent liver transplant for their HCV-related cirrhosis since April 2001. Our data indicate that there is no statistical difference between LDLT and DDLT groups in mean age, Child-Turcotte-Pugh score, model for end-stage liver disease score, and gender distribution. The mean follow-up was 749 +/- 371 days in LDLT and 692 +/- 347 days in DDLT. The predominant genotype in the LDLT and DDLT are genotype 1 (LDLT, 91%; DDLT, 70%). All patients with histologically confirmed recurrent HCV had detectable HCV-RNA in serum. The histological recurrence rate of hepatitis C was 58% at 4 months, 90% at 1 year, and 100% at 2 years in LDLT patients vs. 71% at 4 months, 94% at 1 year, and 95% at 2 years in DDLT patients (not significant) Comparison of the activity of inflammation and fibrosis score at all time points failed to show a statistical difference. Kaplan-Meier survival analysis showed similar patient and graft survival rates between the 2 groups. Our data indicate that histological recurrence of HCV is an early event and virtually universal 2 years' posttransplantation, regardless of modality of donor procurement.

Artificial neural network and tissue genotyping of hepatocellular carcinoma in liver-transplant recipients: prediction of recurrence

BACKGROUND

Liver transplantation (LT) is the treatment of choice for early stage hepatocellular carcinoma (HCC) with excellent 5-year survival, with a recurrence rate after LT of 3.4%. An artificial neural network (ANN), combined with genotyping for microsatellite mutations/deletions (TM-GTP), was designed at the University of Pittsburgh to predict tumor recurrence with a discriminatory power of 85%. This study aims to validate the ANN/TM-GTP model on patients receiving transplants in a single center.

METHODS

Nineteen patients with HCC underwent LT at our center between 1999 and 2002 (mean follow-up of 49.3 months). The ANN/TM-GTP analysis was performed blindly to prognosticate the risk of HCC recurrence, which was then validated against the actual clinical outcomes.

RESULTS

Nineteen patients received transplants. The primary diagnosis was hepatitis C (n=16), cryptogenic cirrhosis (n=2), and autoimmune hepatitis (n=1). ANN/TM-GTP was applied to all patients. The combination of ANN/TM-GTP predicted three patients to suffer recurrence of HCC. All three had HCC recurrence within 39 months (11, 23, and 39 months) postLT and died. Fourteen patients were predicted not to have HCC recurrence, and none did. Two patients could not be classified and were termed indeterminate for recurrence.

CONCLUSION

ANN/TM-GTP had a high discriminatory power (17/19, 89.5%) in our cohort, accurately predicting HCC recurrence.

Hepatic B-cell non-Hodgkin's lymphoma of MALT type in the liver explant of a patient with chronic hepatitis C infection

B-cell non-Hodgkin's lymphoma (B-NHL) is a well-documented complication of hepatitis C virus (HCV) infection. Marginal zone (mucosa-associated lymphoid tissue; MALT) lymphomas constitute a less common type of B-NHL. In this article, we report a case of liver MALT in a cirrhotic patient, incidentally discovered after liver transplantation (LT). We discuss pertinent diagnostic and management strategies in this clinical setting.

Hepatitis C virus infection with hepatocellular carcinoma: not a controversial indication for liver transplantation

BACKGROUND

The association of hepatocellular carcinoma (HCC) and chronic hepatitis C virus (HCV) infection has been identified as a potential contraindication for orthotopic liver transplantation (LT) because of lower survival rate compared with other indications.

AIM

Evaluate the outcome of patients with and without HCC and cirrhosis with and without chronic HCV infection undergoing transplantation. Determine the postLT HCC recurrence rate and frequency of de novo postLT HCC.

PATIENTS AND METHODS

United Network for Organ Sharing (UNOS) data was collected from January 1998 to December 2002. Cohort included 17,968 patients (11,552 M; 6,416 F) with a mean age of 51 (18-87) years. Four groups were established: HCV (n = 7,079), HCC (n = 611), HCV+HCC (n = 1,078), and no HCV/no HCC (n = 9,200). The overall survival rate was calculated at 24 and 48 months postLT.

RESULTS

Patient survival at 24 months and 48 months was 84% and 75% for HCV, 84% and 68% for HCC, 78% and 72% for HCV+HCC, and 85% and 80% for no HCV/no HCC, respectively. Survival at 48 months among the two groups was not significantly different (NS). Further analysis of these groups revealed a statistically significant advantage in survival at 48 months postLT for the no HCV/no HCC group when compared with the HCV group.(P < 0.05) The reported rate of postLT HCC recurrence and de novo postLT HCC was 3.3% and 0.05%, respectively.

CONCLUSION

In this large cohort of U.S. patients, HCC does not have an impact on the survival of LT patients infected with HCV.

Hepatic steatosis in hepatitis C virus genotype 3 infection: does it correlate with body mass index, fibrosis, and HCV risk factors?

Hepatic steatosis is a recognized feature of hepatitis C viral infection, particularly in genotype 3. The demographics and the associations contributing to moderate to severe steatosis in genotype 3 are not very well studied. The aim of this study is to determine the demographics and association of steatosis with fibrosis, obesity, diabetes, lipid levels, and risk factors among patients with hepatitis C virus (HCV) genotype 3. Two hundred ninety-three consecutive HCV patients (genotype 1, n = 218; genotype 2, n = 43; genotype 3, n = 32) at our institution were studied retrospectively. Demographic information such as height, weight, genotype, risk factors, serum cholesterol and triglyceride, and liver biopsy was collected. Steatosis was graded using the Brunt classification. HCV genotype 3-infected patients were younger (P < 0.04) and had lower serum cholesterol levels (P < 0.02) compared to nongenotype 3 patients. Moderate to severe steatosis was more prevalent in HCV genotype 3 patients (P < 0.001) with intravenous drug abuse as a risk factor (P = 0.04). Genotype 3 was the independent predictor of steatosis in all patients. There was no statistical association between grade of steatosis and body mass index, fibrosis, necroinflammation, or hyperlipidemia when only HCV genotype 3 patients were included in the multivariate logistic model. Hepatic steatosis is a feature of genotype 3. Patients with HCV genotype 3 are younger and have lower serum cholesterol levels. Genotype 3 is the independent predictor for steatosis in HCV patients. HCV genotype 3 patients with moderate to severe steatosis are more likely to have intravenous drug use as a risk factor.

Hepatitis C virus recurrence in living donor liver transplant recipients

Recurrence of hepatitis C virus (HCV) after liver transplantation (LT) is a universal phenomenon. Recent reports have suggested an earlier and more aggressive recurrence in the living donor liver transplant (LDLT) population. The aim of this study was to compare the histological recurrence of HCV after LDLT versus deceased donor transplantation (DDT). Twenty-nine patients underwent LT for HCV-related end-stage liver disease at our institution between April 2001 and March 2003 (42 months). Twenty patients underwent DDT, and nine patients LDLT. Laboratory data were collected on a weekly to biweekly basis and HCV PCR was performed before LT and 3-4 months and yearly post-LT. Liver biopsies were performed as needed and per institutional protocol at 7 days, at 4 months, and yearly thereafter. All biopsies were evaluated by a single pathologist and scored for rejection (Banff score) and chronic hepatitis (Ishak score system). The predominant genotype in the DDT and LDLT groups was genotype 1 (DDT = 70%, LDLT = 79%). HCV RNA titers pre-LT and 3-4 months after LT did not differ. The incidence of rejection was higher in the DDT group (P < 0.05). There was a trend toward improved Ishak stage and grade in the LDLT group at 4 and 12 months post-LT, however, this trend did not reach statistical significance. No histological difference in the recurrence or severity rate was observed at 4 or 12 months post-LT in the DDT group vs. the LDLT group.

Liver transplantation for hepatocellular carcinoma: the MELD impact

The new allocation policy of the United Network of Organ Sharing (UNOS) based on the model for end-stage liver disease (MELD) gives candidates with stage T1 or stage T2 hepatocellular carcinoma (HCC) a priority MELD score beyond their degree of hepatic decompensation. The aim of this study was to determine the impact of the new allocation policy on HCC candidates before and after the institution of MELD. The UNOS database was reviewed for all HCC candidates listed between July 1999 and July 2002. The candidates were grouped by two time periods, based on the date of implementation of new allocation policy of February 27, 2002. Pre-MELD candidates were listed for deceased donor liver transplantation (DDLT) before February 27,2002, and post-MELD candidates were listed after February 27, 2002. Candidates were compared by incidence of DDLT, time to DDLT, and dropout rate from the waiting list because of clinical deterioration or death, and survival while waiting and after DDLT. Incidence rates calculated for pre-MELD and post-MELD periods were expressed in person years. During the study, 2,074 HCC candidates were listed for DDLT in the UNOS database. The DDLT incidence rate was 0.439 transplant/person years pre-MELD and 1.454 transplant/person years post-MELD (P < 0.001). The time to DDLT was 2.28 years pre-MELD and 0.69 years post-MELD (P < 0.001). The 5-month dropout rate was 16.5% pre-MELD and 8.5% post-MELD (P < 0.001). The 5-month waiting-list survival was 90.3% pre-MELD and 95.7% post-MELD (P < 0.001). The 5-month survival after DDLT was similar for both time periods. The new allocation policy has led to an increased incidence rate of DDLT in HCC candidates. Furthermore, the 5-month dropout rate has decreased significantly. In addition, 5-month survival while waiting has increased in the post-MELD period. Thus, the new MELD-based allocation policy has benefited HCC candidates.

Utility of paired BACTEC MYCO/F LYTIC blood culture vials for detection of bacteremia, mycobacteremia, and fungemia

In previous bloodstream infection studies in Malawi, we inoculated blood from a single venesection into a single BACTEC MYCO/F LYTIC (MFL) vial. Inoculation of one vial, however, would be expected to reduce the sensitivity of bloodstream pathogen detection with MFL vials. To ascertain the degree of this loss of sensitivity, blood was drawn from each of 228 febrile, adult inpatients in Malawi and 5 ml of each blood sample was inoculated into each of two MFL vials. Of 228 paired vials, 51 (22%) were both positive, 172 (75%) were both negative, and 5 (3%) had discordant results. Bloodstream infection would have been detected in 11 (92%) of 12 patients with mycobacteremia and 38 (92%) of 41 patients with bacteremia had only one MFL vial been inoculated. Our study shows that a second MFL vial does not significantly increase diagnostic sensitivity.

Student perceptions of methylphenidate abuse at a public liberal arts college

With the ever-increasing diagnosis of attention deficit hyperactivity disorder, methylphenidate has become readily accessible in the college environment. Several properties of methylphenidate indicate abuse liability. A survey regarding the recreational use of methylphenidate was distributed to the student body at a public, liberal arts college. More than 16% of the students reported they had tried methylphenidate recreationally, and 12.7% reported they had taken the drug intranasally. Use of the drug was more common among traditional students than among nontraditional students. Among traditional-age students, reports of methylphenidate use were roughly equivalent to reports of cocaine and amphetamine use. Environmental conditions characteristic of college student life may influence the recreational use of the drug.

Comparison of BACTEC MYCO/F LYTIC and WAMPOLE ISOLATOR 10 (lysis-centrifugation) systems for detection of bacteremia, mycobacteremia, and fungemia in a developing country

In less-developed countries, studies of bloodstream infections (BSI) have been hindered because of the difficulty and costs of culturing blood for bacteria, mycobacteria, and fungi. During two study periods (study period I [1997] and study period II [1998]), we cultured blood from patients in Malawi by using the BACTEC MYCO/F LYTIC (MFL), ISOLATOR 10 (Isolator), Septi-Chek AFB (SC-AFB), and Septi-Chek bacterial (SC-B) systems. During study period I, blood was inoculated at 5 ml into an MFL bottle, 10 ml into an Isolator tube for lysis and centrifugation, and 10 ml into an SC-B bottle. Next, 0.5-ml aliquots of Isolator concentrate were inoculated into an SC-AFB bottle and onto Middlebrook 7H11 agar slants, chocolate agar slants, and Inhibitory Mold Agar (IMA) slants. During study period II, the SC-B and chocolate agar cultures were discontinued. MFL growth was detected by fluorescence caused by shining UV light (lambda = 365 nm) onto the indicator on the bottom of the bottle. During study period I, 251 blood cultures yielded 44 bacterial isolates. For bacteremia, the MFL was similar to the Isolator concentrate on chocolate agar (34 of 44 versus 27 of 44; P, not significant [NS]), but more sensitive than the SC-B bottle (34 of 44 versus 24 of 44; P = 0.05). For both study periods combined, 486 blood cultures yielded 37 mycobacterial and 13 fungal isolates. For mycobacteremia, the sensitivities of the MFL and Isolator concentrate in the SC-AFB bottle were similar (30 of 37 versus 29 of 37; P, NS); the MFL bottle was more sensitive than the concentrate on Middlebrook agar (30 of 37 versus 15 of 37; P = 0.002). For fungemia, the MFL bottle was as sensitive as the SC-B bottle or Isolator concentrate on chocolate agar or IMA slants. We conclude that the MFL bottle, inoculated with just 5 ml of blood and examined under UV light, provides a sensitive and uncomplicated method for comprehensive detection of BSI in less-developed countries.

MDMA and learning: effects of acute and neurotoxic exposure in the rat

In two experiments, the effects of MDMA on the acquisition of lever-press responding of rats were examined under procedures in which water delivery was delayed by 0, 10, or 20 s relative to the response that produced it. In the first study, experimentally naive, water-deprived rats received an intraperitoneal injection of MDMA (0, 1.0, 3.2, or 5.6 mg/kg) prior to one 8-h experimental session. Response acquisition was observed under all conditions at all drug doses. MDMA increased the total number of responses emitted and the total number of water deliveries earned in dose-dependent fashion, but only when reinforcement was immediate. Under conditions of delay, MDMA had no effect on either measure. Under all reinforcement conditions, higher doses of MDMA typically produced an initial reduction in lever pressing, and in that sense interfered with learning. In the second study, rats received an MDMA injection regimen previously shown to be neurotoxic. Control rats received saline solution according to the same injection schedule. Two weeks after completing the regimen, rats were water deprived and exposed to behavioral procedures as described for the first experiment. Although MDMA significantly reduced 5-HT and 5-HIAA levels in the striatum and prefrontal cortex, mean performance of rats exposed to MDMA did not differ from that of rats exposed to vehicle. Twenty-five percent of the rats exposed to MDMA and delayed reinforcement did fail to acquire responding, which suggests that further study of the effects of neurotoxic doses of MDMA on initial response acquisition is warranted.