The risk of early suicide and diagnostic issues in Cotard's syndrome associated to self-starvation

BACKGROUND AND OBJECTIVE

Cotard's syndrome is a rare neuropsychiatric disorder in which the patient holds nihilistic delusions concerning his/her own existence, including the conviction of being dead or having lost parts of the body. There are occasional reports of Cotard's syndrome being accompanied by nutritional deficiencies or self-starvation.

METHODS

The authors describe the peculiar case of a 40-year-old man who developed severe malnutrition within a few months. At first, a diagnosis of anorexia nervosa was made. The man was admitted to the hospital where other significant psychopathological symptoms emerged.

RESULTS

One of the consequences of Cotard's syndrome is self-starvation because of negation of existence of self. The presented case points out that, although Cotard's syndrome has been reported to be associated with various organic conditions and other forms of psychopathology, loss of appetite and nutritional deficits can erroneously lead to mistake this diagnosis for anorexia nervosa, thus underestimating the high risk of these patients of committing suicide following hospital discharge.

CONCLUSION

Taking into account its rarity and possible subdiagnosis, as a distinct clinical entity the aim of this case report is to emphasize that these patients may initially be addressed to general practitioners, due to the dysmetabolic consequences of malnutrition, rather than to psychiatrists. An early recognition of signs indicative of Cotard's syndrome can be vital to prevent the situation from worsening. In fact, missed diagnoses can put these patients at an higher risk of suicidal behaviour.

Female Murderers and Stigma: Coping With the "Bad Woman" Label

Among the stereotypes of female delinquency, the article focuses on "bad women" par excellence, that is to say, those convicted of murder who have not benefited from the possibility of being perceived and portrayed as "victims" because of their unorthodox femininity. The aim of the study was to understand how the label of "bad woman" is incorporated into the narration of identity of five women condemned for murder; to this end, we focus on the narratives implemented in order to cope with the stigma (narrative criminology), tracing them back to their past and the traumatic experiences they lived (psychosocial criminology). Four narratives emerge: the denied stigma, the disregarded stigma, the despairing stigma and the processed stigma. Psychosocial criminology consents to "go beyond" the surface and to find a "fil rouge" that can explain the discrepancies and the contradictions found in the way of coping with the imposed label.

P217 SACUBITRIL/VALSARTAN IN ADVANCED HEART FAILURE: SAFETY AND EFFECTS ON HAEMODYNAMIC PARAMETERS

Aims

The angiotensin–II receptor neprilysin inhibitor (ARNI), sacubitril/valsartan has been shown to be effective in treatment of patients with heart failure (HF), but limited data is available in patients with advanced disease. This retrospective observational study assessed the effects of ARNI treatment in patients with advanced HF.

Methods

We reviewed medical records of all advanced HF patients evaluated at our center for unconventional therapies from September 2016 to January 2019. We studied 44 patients who started ARNI therapy and who had a hemodynamic assessment before beginning ARNI and after 6 ± 2 months. The primary endpoint was variation in pulmonary pressures and filling pressures at 6 months after starting ARNI therapy.

Results

Mean patient age was 51.6±7.4 years; 84% were male. At 6±2 months after starting ARNI, there was significant reduction of systolic pulmonary artery pressure (PAP) (32 mmHg, IQR 27–45 vs 25 mmHg, IQR 22.3–36.5; p < 0.0001) and median PAP (20 mmHg, IQR 15.3–29.8 vs 17 mmHg, IQR 13–24.8; p = 0.046). Five of 22 patients (23%) were deferred from the heart transplant (HTx) list because of improvement, while four were listed de novo. After 23 ± 9 months, 3 patients were treated with a left ventricular assist device (LVAD) implantation, while 6 patients underwent Heart transplantation (one in emergency conditions for refractory ventricular tachycardia).

Conclusions

Sacubitril/valsartan is effective in reducing filling pressures and pulmonary pressures in patients with advanced HF. The absence of adverse events during follow–up suggests that sacubitril/valsartan is safe and well–tolerated in this cohort of patients.

The mourning process and "living with the dead": Two case reports and a review of the literature

The discovery of mummified bodies in domestic settings is not unusual in the medico-legal context. It is often a marker of social isolation, even in our urban modern society, and usually occurs among elderly people living alone or in precarious conditions. However, bereaved subjects can sometimes be found managing their grief by deliberately keeping the corpses of their loved ones at home. Investigation of these atypical cases can be challenging and often requires a multidisciplinary effort by different forensic specialists. We report two cases of people who lived for several months with the mummified remains of a relative. In both cases, the judge ordered a forensic psychiatry assessment of the survivors' competency and the reasons for this peculiar behavior, which is regarded as abnormal in our society. Case 1 describes a shared psychosis, which developed out of a condition of extreme seclusion of the entire family. Case 2 shows that even a mild personality disorder on which a series of traumatic events operates can trigger psychotic decompensation, causing extreme denial of the reality of death. The analysis of these cases contributes to our knowledge of the scantly studied phenomenon of "Living with the Dead" and raises questions about the psychopathology behind it. It is useful to identify subjects who are more prone to developing this "deviant" behavior, in order to distinguish people with mental illness from those who merely want to profit from the death of a loved one.

A new method for characterization of small capacity wind turbines with permanent magnet synchronous generator: An experimental study

This work presents a new and useful method to dimension wind turbines and control systems and to optimize their mechanical design. This method allows determining the principal curves for characterizing a small capacity wind turbine designed with a Permanent Magnet Synchronous Generator (PMSG). For the wind turbine characterization it was considered the losses in the process of energy transformation in the wind rotor, electric generator and in the bridge rectifier. The equivalent electric model of the synchronous generator was used to determine the electric parameter performance. The work of the wind rotor was considered in its maximum power curve and the PMSG performance in the linear region of its magnetization curve. This leads to develop a new methodology for the complete wind turbine characterization from the nominal parameters of the wind rotor and the electric generator. This method also allows obtaining the power curves and the parameters of voltage, current and efficiency around the wind speed domain and angular speed in the wind rotor. The method was tested for small-capacity wind turbine (1 kW and 10 kW) performances and the numerical and experimental results are described.

A Decision Support System for the Treatment of Patients with Ventricular Assist Device Support

Background: Heart failure (HF) is affecting millions of people every year and it is characterized by impaired ventricular performance, exercise intolerance and shortened life expectancy. Despite significant advancements in drug therapy, mortality of the disease remains excessively high, as heart transplant remains the gold standard treatment for end-stage HF when no contraindications subsist. Traditionally, implanted Ventricular Assist Devices (VADs) have been employed in order to provide circulatory support to patients who cannot survive the waiting time to transplantation, reducing the workload imposed on the heart. In many cases that process could recover its contractility performance.

Objectives: The SensorART platform focuses on the management and remote treatment of patients suffering from HF. It provides an inter-operable, extendable and VAD-independent solution, which incorporates various hardware and software components in a holistic approach, in order to improve the quality of the patients’ treatment and the workflow of the specialists. This paper focuses on the description and analysis of Specialist’s Decision Support System (SDSS), an innovative component of the SensorART platform.

Methods: The SDSS is a Web-based tool that assists specialists on designing the therapy plan for their patients before and after VAD implantation, analyzing patients’ data, extracting new knowledge, and making informative decisions.

Results: SDSS offers support to medical and VAD experts through the different phases of VAD therapy, incorporating several tools covering all related fields; Statistics, Association Rules, Monitoring, Treatment, Weaning, Speed and Suction Detection.

Conclusions: SDSS and its modules have been tested in a number of patients and the results are encouraging.

C-type natriuretic peptide transcriptomic profiling increases in human leukocytes of patients with chronic heart failure as a function of clinical severity

The aim of this study was to evaluate the transcriptomic profiling of C-type natriuretic peptide (CNP) and of its specific receptor, NPR-B in human leukocytes of heart failure (HF) patients as a function of clinical severity, assessing the possible changes with respect to healthy subjects (C). mRNA expression was evaluated by Real-Time PCR and total RNA was extracted from leukocytes of C (n=8) and of HF patients (NYHA I-II, n=7; NYHA III-IV, n=13) with PAXgene Blood RNA Kit. Significantly higher levels of CNP mRNA expression were found in HF patients as a function of clinical severity (C=0.23±0.058, NYHA I-II=0.47±0.18, NYHA III-IV=2.58±0.71, p=0.005 C vs NYHA III-IV, p=0.017 NYHA I-II vs NYHA III-IV) and NPR-B transcript levels resulted down-regulated in HF patients with higher NYHA class (C=2.2±0.61, NYHA I-II=2.76±0.46, NYHA III-IV=0.29±0.13, p=0.001 C vs NYHA III-IV, p<0.0001 NYHA I-II vs NYHA III-IV). A significant negative correlation between CNP and NPR-B mRNA expression (r=0.5, p=0.03) was also observed. These results suggest a co-regulation of NPR-B and CNP expression supporting the relevance of this receptor in human disease characterized by a marked inflammatory/immune component and suggesting the possibility of manipulating inflammation via pharmacological agents selective for this receptor.

Cesare Lombroso: Methodological ambiguities and brilliant intuitions

This paper on Cesare Lombroso aims to assess his contribution to the criminological sciences. Although much praised worldwide, Lombroso was also the target of scathing criticism and unmitigated condemnation. Examination of Lombroso's method of data collection and analysis reveals his weakness. Indeed, his approach was extremely naive, simplistic and uncritical, aimed at irrefutably demonstrating the hypotheses that he championed, without exercising the methodological caution that was already beginning to characterize scientific research in his day. However, we must acknowledge that his biological theories of crime are undergoing new developments as a result of the recent success of biological psychiatry. On the other hand we should recognize that his work was not limited to his biological central theory; rather, it covered a range of cues and concepts, for the most part ignored, that demonstrate his interest in the economic, cultural and social factors that impact on crime. For these reasons, Lombroso appears to have anticipated many modern conceptions regarding delinquent behavior and criminal justice, such as those of restorative justice, the so-called "situational" theories of criminal behavior and white collar crime.

Sudden death and antipsychotic treatment: Typical and atypical antipsychotic drugs’ safety in the real world

The most up-to-date guidelines recommend to use atypical antipsychotic drugs (APDs). This is due to their better tolerability and safety, especially as far as the risk of sudden death is concerned. Nevertheless, in clinical practice several patients are still treated with typical APDs. Aim of this study is to evaluate the QTc in the real world, where psychotic Pts are still treated with typical APDs. 169 consecutive acute psychotic inpatients (mean age 39 ± 12.5, 84 female), hospitalized in psychiatric ward from January 2005 to December 2007, and treated for at least 6 months with APDs (haloperidol n = 43, risperidone n = 41, aripiprazole n = 42, olanzapine n = 43) underwent ECG recording. Pts with family history of SD or treated with QTc altering drugs were excluded. Three different cardiologists performed blinded QTc measurement for all Pts in order to asses the risk of SD. There were no statistical differences among the QTc values measured by the three cardiologists. 2 out of 169 Pts showed borderline QTc. 2 out of 169 Pts had a high risk QTc. Female gender and age were well distributed in the treatment groups as well as serum electrolytes were in normal range.

ANOVA test showed no consistent statistical differences in the QTc between the use of Haloperidol or other atypical APDs. In our experience, the cohorts of Pts treated with Haloperidol or other atypical APDs have no differences in QTc and therefore the risk of SD dose not depend on the choice of the antipsychotic drug.

Criminal profiling as a plotting activity based on abductive processes

In this article the authors analyze the nature and aims of criminal profiling from a theoretical point of view. The need to become increasingly "scientific" has given rise to the modern approaches of profiling, which have been particularly successful in cases of serial homicides and sex crimes, given that compulsive (perverse) acts, because of their ritual nature, have been described as being more easily foreseeable and presumably linkable to the psychological and even personal characteristics of a given criminal. On this basis, the authors analyze profiling from an epistemological point of view and show how, in the concrete activity of profiling, profilers depart from the "certainty" of the scientific models (those that are based on deductive-inductive processes); the epistemological basis of reasoning changes as there is no longer an induction-deduction model but rather an abductive model (as conceived and explained by Peirce) in which the importance of plotting (the weaving of a narrative) becomes greater.

The prevalence of acne in the north of Portugal

BACKGROUND

Acne is a disease that affects almost all teenagers (60-90%), and it is the pathology exhibiting the highest morbidity in the 10-24 year-olds age group. There are no consistent data at national level by which we can evaluate the preponderance of this pathology in the Portuguese population.

OBJECTIVE

To estimate the prevalence of acne in teenage school students (10-12 year-olds).

STUDY DESIGN

A study was carried out involving all 8 regions in the north of Portugal. One school per region was selected at random.

RESULTS

As expected, the figure we obtained for the prevalence of this pathology was high (82.4%) with males being the most affected. Nevertheless, only 44% of the affected treated their acne, although the face is the part of the body most affected. In the females high androgenization (which is manifested by the presence of hair on the upper lip and on the side of the face) doubles the median of the degree of acne registered. Regional asymmetry was found in relation to information about the disorder. The degrees of acne are higher in schools in the interior. In the more rural areas, the pharmacist still plays an important role in prescribing treatment.

CONCLUSION

As a rule, individuals are correctly informed about acne, confirming that the search for treatment and awareness of its value are generally helping to gradually eliminate some of the stigmas from the past.

The narrative structure of psychiatric reports

The present contribution illustrates the findings of a research about the narrative structure of psychiatric expertise. We have analysed a sample of nine expertises, using the methodology proposed by Roland Barthes in his book S/Z, in which he applies it to Honoré de Balzac's "Sarrasine". Barthes suggests that every narrative is characterized by the presence of five codes (hermeneutical, proairetic, semantic, symbolic and referential): we have searched for them in the expertises, but we have also observed the presence of many lapsus calami. As for our results, we have interpreted the massive presence of symbolic code in an expertise as a proof of the elaboration of the horror elicited by crime in the expert's narrative and, on the other side, the presence of referential code as the proof of the incapacity to treat such feeling and the necessity to defend himself from it. In this vision, lapsuses arise when the expert is astonished by the horror of the crime, and does not succeed in elaborating it either by using symbolic code or through his cultural resources (referential code). Finally, some reflections are made upon the difficulty for the voice of the defendant to be heard in the texts written about him.

The ethnobotanical study of local Mediterranean food plants as medicinal resources in Southern Spain

We studied medicinal and food plant species, recording an extraordinary number of species and uses in Castilla-La Mancha, Murcia and Valencia in Spain. Focusing on two demographically distinct regions - Castilla-La Mancha and Lower Segura Valley. A high proportion of the flora (20 to 30 %) is known for its medicinal properties, and, interestingly, a high number of medicinal-food plants (5 to 7 %) is recorded. The concept of "Local Food" involves the whole repertory of species that characterises the local diet (incl. local cultivars and non-cultivated gathered food plants). The number of food plant species varies between 15 and 25 % of the vascular flora, and for the gathered food plants (GFP) this decreases to a 3 to 8 %. Those GFP that are also used for medicinal purposes are only 2 to 4 % of the total vascular flora. The relevant plant families are very similar in relative numbers along the different areas: Compositae, Rosaceae and Umbelliferae, followed of Boraginaceae, Liliaceae, Cruciferae, and Caryophyllaceae. Chenopodiaceae, Polygonaceae and Gramineae are less uniformly represented or in lesser numbers. The high species diversity does not imply a general dietary relevance of this particular plant family. For instance Caryophyllaceae with a relatively low number of species comprises the "collejas" (Silene vulgaris) that have shown to be the more widely consumed species. Information regarding 145 species has been recorded. Among the Gathered Food Plant Species 81 are used in medicine, in double proportion than the cultivated food plants. 61 are orally administered, in the same form as food.

Gamma heavy chain disease associated with Hodgkin's disease. Clinical, pathologic, and immunologic features of one case

This report describes the clinical, pathologic, and immunologic features of a patient with gamma heavy chain disease (gamma-HCD) associated with Hodgkin's disease (HD). The diagnosis of gamma-HCD was established by serum electrophoresis and immunoelectrophoresis and confirmed by biochemical analysis of patient's serum showing the presence of an incomplete gamma chain, with an approximate molecular weight of 40 kilodaltons. The diagnosis of HD rested upon the presence of systemic lymphadenopathy, the typical histologic pattern and reactivity of Reed-Sternberg cells with the LeuM1-CD15 monoclonal antibody. The two diseases developed independently, in the absence of any immunosuppressive treatment. Furthermore, there was some evidence suggesting that HD tissue was not responsible for the production of the incomplete gamma chain. This and similar cases may provide a model for a better understanding of the events leading to the simultaneous outgrowth of two lymphoid neoplasias in the same patient.

Studies on the oncogenic potential of Epstein-Barr-virus (EBV)-infected B cells in AIDS-related disorders

Spontaneous lymphoblastoid cell lines (LCLs) were established from the peripheral blood of 10 human immunodeficiency virus (HIV)-seropositive patients in order to investigate whether or not progression of the cells towards a malignant state could be traced. The LCLs studied displayed no differences in their surface phenotype, karyotype, and tumorigenicity in nude mice as compared with a wide panel of control LCLs. Furthermore, no c-myc rearrangement could be detected in any of the LCLs. However, 4 of the 10 LCLs derived from HIV-seropositive patients formed colonies in agar with a cloning efficiency of 0.1-0.9%. This percentage was much lower than that of a control neoplastic B cell line (50%), but consistently higher than that observed for a battery of spontaneous LCLs. The cells of a number of sublines that were derived from the agar colonies expressed new activation markers (CD10 and Bac-1) but did not induce tumors in nude mice or display chromosomal abnormalities. These sublines might comprise cells that have progressed towards a more markedly transformed state.