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Ronaldson KJ, Fitzgerald PB, McNeil JJ. Clozapine-induced myocarditis, a widely overlooked adverse reaction. Acta Psychiatr Scand 2015; 132:231-40. [PMID: 25865238 DOI: 10.1111/acps.12416] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2015] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We review the published cases of clozapine-induced myocarditis and describe reasons for the higher incidence in Australia (>1%) than elsewhere (<0.1%). METHOD Medline was searched to September 2014 using 'clozapine' as the sole term. RESULTS A total of around 250 cases of clozapine-induced myocarditis have been published. Fever among patients commencing clozapine has been reported internationally, and very few of these cases were investigated for myocarditis. The time to onset of fever is consistent with its being part of a prodrome of undiagnosed myocarditis, and the risk factors are similar to those for myocarditis. In more severe cases, clozapine is discontinued, avoiding fatalities which may occur with myocarditis. Furthermore, cases of sudden death and respiratory illness may well have been undiagnosed myocarditis. The diagnosis of myocarditis is confounded by the non-specific nature of the signs and symptoms, and it depends on appropriate investigations being conducted at the time of myocardial involvement or, for fatal cases, the affected area of the myocardium being sampled for histology. CONCLUSION It is likely that the incidence of myocarditis is around 3%. Implementation of monitoring procedures will increase case ascertainment and result in more patients benefiting from this valuable medication.
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Affiliation(s)
- K J Ronaldson
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - P B Fitzgerald
- Monash Alfred Psychiatry Research Centre, Monash University Central Clinical School and The Alfred Hospital, Melbourne, VIC, Australia
| | - J J McNeil
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abstract
In-custody deaths are typically investigated by a medical examiner or coroner (ME/C) and include those that occur while in the custody of the police or in a government detention facility (e.g., prison). The potential manners of death are natural, homicide, suicide, accident, therapeutic complication, and undetermined. Once the cause of death is determined, the manner of death is certified based upon the cause and the circumstances of death. Deaths in custody may be challenging due to the potential for death at the hand of another (e.g., inmate, corrections officer, or law enforcement agent) or due to neglect. When a government takes a person's liberty, they have a duty to ensure safe and adequate housing, food, and medical care. Failure of a responsible party to exercise proper care of a person in-custody, may affect the manner of death. Since in-custody deaths at the hand of a government agent can be challenging to certify, we will focus on these manners of death including those associated with excited delirium (ED). Although manners are easily and consistently applied in most deaths, there are nuances in some instances which may result in jurisdictional variations in the determination of the manner of death. We will discuss these variations as the determination made by the ME/C is an opinion based upon his/her particular training, experience, and judgment.
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Affiliation(s)
| | - Eloy Girela-López
- University of Córdoba Faculty of Medicine and Nursing - Section of Forensic and Legal Medicine
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Cheng KY, Lin CY, Chang TK, Lin CCH, Lu TH, Chen SY. Mortality among long-stay patients with schizophrenia during the setting-up of community facilities under the Yuli model. Health Psychol Behav Med 2014; 2:602-612. [PMID: 25750804 PMCID: PMC4346082 DOI: 10.1080/21642850.2014.908717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Accepted: 03/18/2014] [Indexed: 11/12/2022] Open
Abstract
Objective: Over the past 15 years, Yuli Veterans Hospital (YVH) in Taiwan has developed the Yuli model to reform long-stay care for psychiatric patients. The development of the Yuli model could be divided into pre-early (1998–1999), early (2000–2006) and late (2007–2008) periods according to the setting-up of the community facilities. In the pre-early period, a vocational rehabilitation program was established for psychiatric patients in YVH. In the later periods, the independent living skills training and the program for social reintegration were instituted in the community facilities. This study aimed to evaluate mortality among the long-stay patients with schizophrenia during the three periods. Methods: In all, 2457 patients with schizophrenia who had been hospitalized for at least one year initially were retrospectively followed from 1 January 1998 to 31 December 2008. Compared with the general population in Taiwan, we calculated the age- and sex-specific standardized mortality ratios (SMRs) of those patients by cause of death during the three periods. Results: Most of the patients were male (81.3%). The mean ± SD age of the patients was 57.83 ± 16.95 years. The all-, natural- and unnatural-cause mortalities of the patients were nearly two times greater than those of the general population during the whole study period. Compared with those in the pre-early and early periods, all patients in the late period had the lowest mortality gaps. In the pre-early, early and late periods, the all-cause SMR were 5.40 (95% confidence interval (CI) = 4.27–6.81), 2.90 (95% CI = 2.20–3.79) and 1.17 (95% CI = 0.54–2.22), respectively, for the 50–69-year-old male patients. Nearly half of all the patients who participated the whole comprehensive rehabilitation program belonged to this sex and age group (N = 156, 46.6%). Conclusions: With the setting-up of community facilities for the comprehensive rehabilitation program, the mortality gaps among the 50–69-year-old male patients apparently decreased using the Yuli model.
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Affiliation(s)
- Kan-Yuan Cheng
- Department of Psychiatry, Yuli Veterans Hospital , Yuli , Taiwan, Republic of China
| | - Chih-Yuan Lin
- Department of Psychiatry, Yuli Veterans Hospital , Yuli , Taiwan, Republic of China
| | - Tzu-Kuei Chang
- Department of Public Health, Tzu Chi University , Hualien , Taiwan, Republic of China
| | - Chaucer C H Lin
- Medical Division, Eli Lilly and Company , Taipei , Taiwan, Republic of China ; Department of Psychiatry and Institute of Human Development, Tzu Chi University , Hualien , Taiwan, Republic of China
| | - Tsung-Hsueh Lu
- Department of Public Health, College of Medicine, National Chen Kung University , Tainan , Taiwan, Republic of China
| | - Shu-Yuan Chen
- Department of Public Health, Tzu Chi University , Hualien , Taiwan, Republic of China
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Pilgrim JL, Drummer OH. The toxicology and comorbidities of fatal cases involving quetiapine. Forensic Sci Med Pathol 2013; 9:170-6. [PMID: 23397562 DOI: 10.1007/s12024-012-9404-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2012] [Indexed: 11/26/2022]
Abstract
The use of quetiapine in Australia has increased rapidly in recent years. Anecdotal and post-marketing surveillance reports indicate an increase in quetiapine misuse in prisons as well as an increase in its availability on the black-market. This study examined a cohort of quetiapine-associated deaths occurring in Victoria, Australia, between 2001 and 2009, to determine the prevalence of deaths associated with this drug and to determine whether misuse represents a legitimate concern. Case details were extracted from the National Coronial Information System. There were 224 cases with an average age of 43 years of age (range 15-87 years). The cause of death was mostly drug toxicity (n = 114, 51 %), followed by natural disease (n = 60, 27 %), external injury (n = 31, 14 %) and unascertained causes (n = 19, 8 %). Depression and/or anxiety were common, observed in over a third of the cohort (80 cases, 36 %). About 20 % of cases did not mention a psychiatric diagnosis at all which raises the question of whether quetiapine had been prescribed correctly in these cases. Cardiovascular disease was the most commonly reported illness after mental disease. Quetiapine ranged in concentration from the limit of reporting (0.01 mg/L) to 110 mg/L. The median concentration of quetiapine was much lower in the natural disease deaths (0.25 mg/L) compared with drug caused deaths (0.7 mg/L). The most commonly co-administered drug was diazepam in 81 (36 %) cases. There were a small number of cases where quetiapine contributed to a death where it had not apparently been prescribed, including the death of a 15 year old boy and one of a 34 year old female. Overall, misuse of quetiapine did not appear to be a significant issue in this cohort; use of the drug only occasionally led to fatalities when used in excess or concomitantly with interacting drugs. However, considering that it is a recent social concern, it is possible that analysis of cases post 2009 would reveal more cases of quetiapine abuse. Close monitoring of quetiapine is therefore advised to prevent adverse outcomes, particularly in vulnerable populations such as substance abusers.
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Affiliation(s)
- Jennifer L Pilgrim
- Department of Forensic Medicine, Monash University, 57-83 Kavanagh Street, Southbank, VIC, 3006, Australia.
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Hanagama M, Inoue H, Kamiya M, Shinone K, Nata M. Gene expression on liver toxicity induced by administration of haloperidol in rats with severe fatty liver. Leg Med (Tokyo) 2008; 10:177-84. [PMID: 18280196 DOI: 10.1016/j.legalmed.2007.12.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2007] [Revised: 12/14/2007] [Accepted: 12/26/2007] [Indexed: 01/23/2023]
Abstract
Sudden deaths are often encountered in schizophrenic patients prescribed with antipsychotic drugs, and fatty liver may be more prevalent among patients with schizophrenia. The aim of this study is to investigate the adverse effects of antipsychotic drugs on fatty liver. We administered haloperidol intraperitoneally to fatty liver rats and examined the mRNA expression in the liver. Basic expressions of cytochrome P450 (CYP)1A2, CYP2C11 and CYP3A2 decreased, and response of these CYPs to haloperidol was reduced in the fatty liver. Metabolism of haloperidol was also suppressed in the fatty liver rats. Moreover, hepatic injury by administration of haloperidol was shown pathohistologically and molecular-biologically in severe fatty liver. These results suggest that fatty liver increases susceptibility to adverse effects of haloperidol, possibly leading to life-threatening events. It should be noted by clinicians that excessive dose of antipsychotic drugs may be more harmful in patients with fatty liver.
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Affiliation(s)
- Masakazu Hanagama
- Department of Forensic Medicine and Sciences, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu City, Mie 514-8507, Japan
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Freeman B, Levy W, Gorman JM. Successful monotherapy treatment with aripiprazole in a patient with schizophrenia and prolactinoma. J Psychiatr Pract 2007; 13:120-4. [PMID: 17414690 DOI: 10.1097/01.pra.0000265771.47153.a0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bradley Freeman
- University of South Florida College of Medicine, Tampa, FL, USA
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Centorrino F, Wurtman JJ, Duca KA, Fellman VH, Fogarty KV, Berry JM, Guay DM, Romeling M, Kidwell J, Cincotta SL, Baldessarini RJ. Weight loss in overweight patients maintained on atypical antipsychotic agents. Int J Obes (Lond) 2007; 30:1011-6. [PMID: 16432547 DOI: 10.1038/sj.ijo.0803222] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Weight gain and associated medical morbidity offset the reduction of extrapyramidal side effects associated with atypical antipsychotics. Efforts to control weight in antipsychotic-treated patients have yielded limited success. METHODS We studied the impact of an intensive 24-week program of diet, exercise, and counseling in 17 chronically psychotic patients (10 women, seven men) who entered at high average body weight (105.0+/-18.4 kg) and body mass index (BMI) (36.6+/-4.6 kg/m(2)). A total of 12 subjects who completed the initial 24 weeks elected to participate in an additional 24-week, less intensive extension phase. RESULTS By 24 weeks, weight-loss/patient averaged 6.0 kg (5.7%) and BMI decreased to 34.5 (by 5.7%). Blood pressure decreased from 130/83 to 116/74 (11% improvement), pulse fell slightly, and serum cholesterol and triglyceride concentrations changed nonsignificantly. With less intensive management for another 24 weeks, subjects regained minimal weight (0.43 kg). CONCLUSIONS These findings add to the emerging view that weight gain is a major health problem associated with modern antipsychotic drugs and that labor-intensive weight-control efforts in patients requiring antipsychotic treatment yield clinically promising benefits. Improved treatments without weight-gain risk are needed.
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Affiliation(s)
- F Centorrino
- Consolidated Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, USA.
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Kitabayashi Y, Narumoto J, Kitabayashi M, Fukui K. Body mass index among Japanese inpatients with schizophrenia. Int J Psychiatry Med 2006; 36:93-102. [PMID: 16927581 DOI: 10.2190/3v6l-82au-x663-nwxn] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Many studies have emphasized the high frequency of obesity in schizophrenic patients. However, the characteristics of the Body Mass Index (BMI) distribution in Japanese schizophrenic patients remain unknown, and the aim of this study was to clarify these characteristics in a Japanese schizophrenic inpatient population. METHODS The subjects were 273 inpatients (males: 141, females: 132) with schizophrenia. The patient BMI distribution was compared with normal control data obtained from the 2003 Japanese National Health and Nutrition Survey. RESULTS The mean patient BMI was 23.0 +/- 4.3, and the BMI showed a normal distribution. The proportion of patients who were obese, of normal weight and underweight was 30.8%, 53.1%, and 16.1%, respectively. No statistical evidence of a higher frequency of obesity was found in male patients, compared to normal controls, but a higher frequency of underweight patients and a lower frequency of normal-weight patients were apparent in most decades of age. In female schizophrenia patients, a higher prevalence of obesity occurred in patients aged 50-59 years old, compared to controls. A higher rate of underweight elderly patients and a lower rate of normal-weight patients aged 40 to more than 70 years old were also apparent. CONCLUSIONS The results suggest that not only obesity but also weight problems related to an underweight condition occur more frequently in Japanese schizophrenic inpatients than in normal controls. The deviation of the BMI distribution in Japanese schizophrenic inpatients may have a relationship with higher mortality and sudden death in schizophrenia.
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Flanagan RJ, Connally G. Interpretation of analytical toxicology results in life and at postmortem. ACTA ACUST UNITED AC 2005; 24:51-62. [PMID: 16042504 DOI: 10.2165/00139709-200524010-00004] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Interpretation of analytical toxicology results from live patients is sometimes difficult. Possible factors may be related to: (i) the nature of the poison(s) present; (ii) sample collection, transport and storage; (iii) the analytical methodology used; (iv) the circumstances of exposure; (v) mechanical factors such as trauma or inhalation of stomach contents; and (vi) pharmacological factors such as tolerance or synergy. In some circumstances, detection of a drug or other poison may suffice to prove exposure. At the other extreme, the interpretation of individual measurements may be simplified by regulation. Examples here include whole blood alcohol (ethanol) in regard to driving a motor vehicle and blood lead assays performed to assess occupational exposure. With pharmaceuticals, the plasma or serum concentrations of drugs and metabolites attained during treatment often provide a basis for the interpretation of quantitative measurements. With illicit drugs, comparative information from casework may be all that is available. Postmortem toxicology is an especially complex area since changes in the composition of fluids such as blood depending on the site of collection from the body and the time elapsed since death, amongst other factors, may influence the result obtained. This review presents information to assist in the interpretation of analytical results, especially regarding postmortem toxicology. Collection and analysis of not only peripheral blood, but also other fluids/tissues is usually important in postmortem work. Alcohol, for example, can be either lost from, or produced in, blood especially if there has been significant trauma, hence measurements in urine or vitreous humour are needed to confirm the reliability of a blood result. Measurement of metabolites may also be valuable in individual cases.
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Affiliation(s)
- Robert J Flanagan
- Medical Toxicology Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK.
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