Responding to a Behavioral Health Crisis: Applying a New Care Model in the Emergency Department

OBJECTIVES

Emergency department (ED) visits for behavioral health (BH) emergencies continue to rise, and institutions across the country encounter barriers and struggle to put BH processes in place to address their needs. After learning of an unanticipated closure of a local psychiatric crisis response center (CRC), our ED implemented quality improvement interventions to respond to an acute surge of BH patients.

METHODS

Interventions included an enhanced BH database, the role of social workers as extenders, shared electronic health record documentation, increased staffing, clinical pathway updates, and processes to improve communication. We aimed to develop a care model to maintain safe care with timely evaluation and patient disposition despite an anticipated surge of ED patients.

RESULTS

After the CRC closure, 7383 patients met our cohort definition over 18 months, whereas 4326 patients met the cohort definition in the 18 months prior the CRC closure. Of the total patients seen in the study period, 42% were evaluated by the ED team with psychiatry and social work, and the median length of stay for discharged patients evaluated by this team decreased from 4.2 hours to 3.5 hours after CRC closure.

CONCLUSIONS

A multifaceted approach allowed our ED to successfully respond to an unexpected surge of BH patients. Other institutions may be able to apply a population health and quality improvement approach when addressing the rising prevalence of ED BH visits. Future studies and practices should explore the optimal role of the acute care setting in the continuum of care of these patients.

Analysis of Missed Sepsis Patients in a Pediatric Emergency Department With a Vital Sign-Based Electronic Sepsis Alert

OBJECTIVE

To characterize the cohort of missed sepsis patients since implementation of an electronic sepsis alert in a pediatric emergency department (ED).

METHODS

Retrospective cohort study in a tertiary care children's hospital ED from July 1, 2014, to June 30, 2017. Missed patients met international consensus criteria for severe sepsis requiring intensive care unit admission within 24 hours of ED stay but were not treated with the sepsis pathway/order set in the ED. We evaluated characteristics of missed patients compared with sepsis pathway patients including alert positivity, prior intensive care unit admission, and laboratory testing via medical record review. Outcomes included timeliness of antibiotic therapy and need for vasoactive medications.

RESULTS

There were 919 sepsis pathway patients and 53 (5%) missed patients during the study period. Of the missed patients, 41 (77%) had vital signs that flagged the sepsis alert. Of these 41 patients, 13 (32%) had a documented sepsis huddle where the team determined that the sepsis pathway was not indicated and 28 (68%) had no sepsis alert-related documentation. Missed patients were less likely to receive timely antibiotics (relative risk, 0.4; 95% confidence interval, 0.3-0.7) and more likely to require vasoactive medications (relative risk, 4.3; 95% confidence interval, 2.9-6.5) compared with sepsis patients.

CONCLUSIONS

In an ED with an electronic sepsis alert, missed patients often had positive sepsis alerts but were not treated for sepsis. Missed patients were more likely than sepsis pathway patients to require escalation of care after admission and less likely to receive timely antibiotics.

Emergency Department Visits for Behavioral Health Concerns After Sexual Assault: A Retrospective Mixed Methods Study

The mental health issues that can follow sexual assault are well described. Mental health service (MHS) referrals can be beneficial but can be challenging to obtain. Absence of MHS can exacerbate mental health issues and lead to subsequent emergency visits. Sexual assault victims may therefore have an increased risk of returning to the emergency department (ED).

OBJECTIVES

The primary purpose of this study was to identify the prevalence of patients who are victims of sexual assault who subsequently return to the ED with behavioral health (BH) concerns. The secondary purpose of this study was to explore potential factors that may affect whether a patient returns to the ED.

METHODS

Using a retrospective design, we examined electronic medical records and a quality improvement database of patients aged 12 to 15 years (inclusive) who sought care in a large, urban, freestanding, tertiary care children's hospital ED after an acute sexual assault.

RESULTS

Our primary finding was that of 192 included patients, 24.5% (95% confidence interval, 18.6%-31.2%) subsequently returned to the ED with BH concerns. Of these, 14 (7.3%) returned within 6 months. Secondary aim results included observed trust and mistrust in providers as documented in ED provider notes among patients with previous experience in the MHS system.

CONCLUSIONS

A substantial proportion of patients who are victims of sexual assault return to the ED for BH concerns at some point. Further investigation is needed to determine factors affecting a return visit to the ED, which can lead to improved services when caring for sexual assault victims.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway

BACKGROUND

Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation.

METHODS

In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision.

RESULTS

The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand.

CONCLUSIONS

By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

Improving Recognition of Pediatric Severe Sepsis in the Emergency Department: Contributions of a Vital Sign-Based Electronic Alert and Bedside Clinician Identification

STUDY OBJECTIVE

Recognition of pediatric sepsis is a key clinical challenge. We evaluate the performance of a sepsis recognition process including an electronic sepsis alert and bedside assessment in a pediatric emergency department (ED).

METHODS

This was a cohort study with quality improvement intervention in a pediatric ED. Exposure was a positive electronic sepsis alert, defined as elevated pulse rate or hypotension, concern for infection, and at least one of the following: abnormal capillary refill, abnormal mental status, or high-risk condition. A positive electronic sepsis alert prompted team assessment or huddle to determine need for sepsis protocol. Clinicians could initiate team assessment or huddle according to clinical concern without positive electronic sepsis alert. Severe sepsis outcome defined as activation of the sepsis protocol in the ED or development of severe sepsis requiring ICU admission within 24 hours.

RESULTS

There were 182,509 ED visits during the study period, with 86,037 before electronic sepsis alert implementation and 96,472 afterward, and 1,112 (1.2%) positive electronic sepsis alerts. Overall, 326 patients (0.3%) were treated for severe sepsis within 24 hours. Test characteristics of the electronic sepsis alert alone to detect severe sepsis were sensitivity 86.2% (95% confidence interval [CI] 82.0% to 89.5%), specificity 99.1% (95% CI 99.0% to 99.2%), positive predictive value 25.4% (95% CI 22.8% to 28.0%), and negative predictive value 100% (95% CI 99.9% to 100%). Inclusion of the clinician screen identified 43 additional electronic sepsis alert-negative children, with severe sepsis sensitivity 99.4% (95% CI 97.8% to 99.8%) and specificity 99.1% (95% CI 99.1% to 99.2%). Electronic sepsis alert implementation increased ED sepsis detection from 83% to 96%.

CONCLUSION

Electronic sepsis alert for severe sepsis demonstrated good sensitivity and high specificity. Addition of clinician identification of electronic sepsis alert-negative patients further improved sensitivity. Implementation of the electronic sepsis alert was associated with improved recognition of severe sepsis.

Reduced Radiation in Children Presenting to the ED With Suspected Ventricular Shunt Complication

BACKGROUND

Ventricular shunt complications in children can be severe and life-threatening if not identified and treated in a timely manner. Evaluation for shunt obstruction is not without risk, including lifetime cumulative radiation as patients routinely receive computed tomography (CT) scans of the brain and shunt series (multiple radiographs of the skull, neck, chest, and abdomen).

METHODS

A multidisciplinary team collaborated to develop a clinical pathway with the goal of standardizing the evaluation and management of patients with suspected shunt complication. The team implemented a low-dose CT scan, specifically tailored for the detection of hydrocephalus and discouraged routine use of shunt series with single-view radiographs used only when specifically indicated.

RESULTS

There was a reduction in the average CT effective dose (millisievert) per emergency department (ED) encounter of 50.6% (confidence interval, 46.0-54.9; P ≤ .001) during the intervention period. There was a significant reduction in the number of shunt surveys obtained per ED encounter, from 62.4% to 5.32% (P < .01). There was no significant change in the 72-hour ED revisit rate or CT scan utilization rate after hospital admission. There were no reports of inadequate patient evaluations or serious medical events.

CONCLUSIONS

A new clinical pathway has rapidly reduced radiation exposure, both by reducing the radiation dose of CT scans and eliminating or reducing the number of radiographs obtained in the evaluation of patients with ventricular shunts without compromising clinical care.

Protocolized Treatment Is Associated With Decreased Organ Dysfunction in Pediatric Severe Sepsis

OBJECTIVES

To determine whether treatment with a protocolized sepsis guideline in the emergency department was associated with a lower burden of organ dysfunction by hospital day 2 compared to nonprotocolized usual care in pediatric patients with severe sepsis.

DESIGN

Retrospective cohort study.

SETTING

Tertiary care children's hospital from January 1, 2012, to March 31, 2014.

SUBJECTS

Patients older than 56 days old and younger than 18 years old with international consensus defined severe sepsis and who required PICU admission within 24 hours of emergency department arrival were included.

MEASUREMENTS AND MAIN RESULTS

The exposure was the use of a protocolized emergency department sepsis guideline. The primary outcome was complete resolution of organ dysfunction by hospital day 2. One hundred eighty nine subjects were identified during the study period. Of these, 121 (64%) were treated with the protocolized emergency department guideline and 68 were not. There were no significant differences between the groups in age, sex, race, number of comorbid conditions, emergency department triage level, or organ dysfunction on arrival to the emergency department. Patients treated with protocolized emergency department care were more likely to be free of organ dysfunction on hospital day 2 after controlling for sex, comorbid condition, indwelling central venous catheter, Pediatric Index of Mortality-2 score, and timing of antibiotics and IV fluids (adjusted odds ratio, 4.2; 95% CI, 1.7-10.4).

CONCLUSIONS

Use of a protocolized emergency department sepsis guideline was independently associated with resolution of organ dysfunction by hospital day 2 compared to nonprotocolized usual care. These data indicate that morbidity outcomes in children can be improved with the use of protocolized care.

Impact of an ICU EEG monitoring pathway on timeliness of therapeutic intervention and electrographic seizure termination

OBJECTIVES

We aimed to determine whether implementation of a structured multidisciplinary electroencephalography (EEG) monitoring pathway improved the timeliness of administration of antiseizure medication in response to electrographic seizures in encephalopathic critically ill children.

METHODS

A multidisciplinary team developed a pathway to standardize EEG monitoring and seizure management in encephalopathic critically ill children, aiming to decrease the time from electrographic seizure onset to antiseizure medication administration. Data were collected to inform the team of improvement opportunities, which were then provided by an institutional pathway, staff education, and streamlined communication. Measurements were obtained before and after pathway implementation to assess for improvement.

RESULTS

We collected data on 41 patients before and 21 after pathway implementation. There were no differences between the baseline and pathway groups in demographic characteristics, acute encephalopathy etiologies, or antiseizure medications utilized. The median duration [interquartile range, IQR] from seizure onset to antiseizure medication administration was shorter for patients treated with the pathway (64 min [50, 101]) compared to patients treated prior to pathway implementation (139 min [71, 189]; p = 0.0006). The median [IQR] interval from seizure onset to antiseizure medication order was shorter for the pathway group (31 min [20, 49]) than the baseline group (71 min [33, 131]; p = 0.003). The median [IQR] interval from antiseizure medication order to administration was shorter for the pathway group (30 min [19, 40]) than the baseline group (40 min [17, 68]) (p = 0.047). Seizure termination was more likely to occur following initial antiseizure medication administration in the pathway than baseline group (67% vs. 27%, p = 0.002).

SIGNIFICANCE

Implementation of the pathway resulted in a significant reduction in the duration between electrographic seizure onset and antiseizure medication administration, and a significant increase in the rate of electrographic seizure termination following an initial antiseizure medication. Further study is needed to determine whether these changes are associated with improved outcomes.

Making strides towards better mental health care in Peru: Results from a primary care mental health training

Our program attempted to improve attitudes and confidence of Peruvian primary care physicians (PCPs) providing mental health care. The training program underwent an evaluation to determine impact of sustained confidence in performing medical and psychiatric procedures, and application of learned skills. Fifty-two Peruvian primary care practitioners were trained at the Harvard Program in Refugee Trauma (HPRT) over a two-week period. There was significant improvement in PCPs' confidence levels of performing psychiatric procedures (counseling, prescribing medications, psychiatric diagnosis, assessing the risk for violence, and treating trauma victims) when comparing baseline and post-two-week to one year follow-up. When comparing post-two-week and one-year follow-up quantitative measures, confidences levels went slightly down. This may be an implication that the frequency of trainings and supervisions are needed more frequently. In contrast, qualitative responses from the one-year follow-up revealed increase in victims of violence clinical care, advocacy, awareness, education, training, policy changes, accessibility of care, and sustainment of diagnostic tools. This study supports the feasibility of training PCP's in a culturally effective manner with sustainability over time.

Patient and institutional characteristics associated with initial computerized tomography in children presenting to the emergency department with kidney stones

PURPOSE

Professional associations recommend ultrasound as the initial imaging study in children with suspected nephrolithiasis but computerized tomography remains frequently used. We identified patient and institutional characteristics associated with computerized tomography as the first imaging study in children with nephrolithiasis diagnosed in the emergency department.

MATERIALS AND METHODS

We performed a cross-sectional study of children 2 to 18 years old with nephrolithiasis who were referred to a freestanding pediatric hospital from 2003 to 2012. We identified the imaging modality first used to evaluate the child. Medical directors at the emergency department where children were first evaluated were sent a questionnaire to ascertain emergency department characteristics. Multivariate hierarchical logistic regression models were used to determine patient and institutional characteristics associated with initial computerized tomography.

RESULTS

Of 536 eligible children 323 (60.2%) were evaluated at emergency departments from which surveys were returned. Of the 323 children 238 (71%) underwent computerized tomography as initial imaging. Ultrasound was available at all emergency departments. Older patient age was associated with higher initial computerized tomography use (OR 1.09, 95% CI 1.04-1.16). A more recent year of diagnosis (OR 0.80, 95% CI 0.72-0.88) and a clinical care pathway that used ultrasound as initial imaging (OR 0.29, 95% CI 0.01-0.38) were associated with lower initial computerized tomography use.

CONCLUSIONS

A clinical care pathway in the emergency department was the only institutional characteristic associated with lower computerized tomography use. Future studies are needed to determine whether care pathways using ultrasound for initial imaging in children with suspected nephrolithiasis would decrease inappropriate computerized tomography and improve adherence to national guidelines.

Six-year follow-up of a point-source exposure to CWD contaminated venison in an Upstate New York community: risk behaviours and health outcomes 2005-2011

OBJECTIVES

It is currently unknown whether chronic wasting disease (CWD), a transmissible spongiform encephalopathy of cervids, is transmissible to humans. Reported on here are the behavioural risk factors and health conditions associated with a six-year follow-up of a known point-source exposure to a CWD infected deer in an Upstate New York community.

STUDY DESIGN

Longitudinal.

METHODS

The Oneida County Chronic Wasting Disease Surveillance Project was launched in 2005 in response to a point-source exposure to a CWD infected deer at a March 2005 Sportsmen's feast in Upstate New York. Eighty-one exposed individuals participated in the 2005 baseline data collection, and were sent follow-up questionnaires following each deer hunting season between 2005 and 2011.

RESULTS

Over a six year period, participants reported a reduction in overall venison consumption. Participants reported no significant changes in health conditions, although several conditions (vision loss, heart disease, type 2 diabetes, weight changes, hypertension, and arthritis), were significantly associated with age.

CONCLUSIONS

To this day, this incident remains the only known large-scale point-source exposure to a CWD infected deer. Prion diseases can incubate for multiple decades before the manifestation of clinical symptoms; thus, continued surveillance of this exposed study population represents a unique opportunity to assess the risk of CWD transmission to humans. This project is uniquely situated to provide the first epidemiological evidence of CWD transmission to humans, should it occur.

Enhancing the emergency department approach to pediatric sexual assault care: implementation of a pediatric sexual assault response team program

OBJECTIVES

The objectives of this study were to describe the experience of a novel pediatric sexual assault response team (SART) program in the first 3 years of implementation and compare patient characteristics, evaluation, and treatment among subpopulations of patients.

METHODS

This was a retrospective chart review of a consecutive sample of patients evaluated at a pediatric emergency department (ED) who met institutional criteria for a SART evaluation. Associations of evaluation and treatment with sex, menarchal status, and presence of injuries were measured using logistic regression.

RESULTS

One hundred eighty-four patients met criteria for SART evaluation, of whom 87.5% were female; mean age was 10.1 (SD, 4.6) years. The majority of patients underwent forensic evidence collection (89.1%), which varied by menarchal status among girls (P < 0.01), but not by sex. Evidence of acute anogenital injury on physical examination was found in 20.6% of patients. As per the Centers for Disease Control and Prevention guidelines for acute sexual assault evaluations in pediatric patients, menarchal girls were more likely to undergo testing for sexually transmitted infections and pregnancy (P < 0.01) and to be offered pregnancy, sexually transmitted infection, and HIV prophylaxis (P < 0.01).

CONCLUSIONS

In an effort to improve quality and consistency of acute sexual assault examinations in a pediatric ED, development of a SART program supported the majority of eligible patients undergoing forensic evidence collection. Furthermore, a substantial number of patients had evidence of injury on examination. These findings underscore the importance of having properly trained personnel to support ED care for pediatric victims of acute sexual assault.

Management of neonates with hyperbilirubinemia: improving timeliness of care using a clinical pathway

BACKGROUND

Neonatal hyperbilirubinemia is a common reason for neonates to present to the emergency department (ED). Although clinical practice guidelines provide recommendations for evaluation and therapy, few studies have evaluated ways to apply them effectively in the ED setting. The primary objective of this study was to compare time to phototherapy in neonates presenting to the ED with jaundice before and after implementation of a nursing-initiated clinical pathway. Secondary outcomes included time to bilirubin result and ED length of stay in neonates.

METHODS

We performed a retrospective historical control study comparing neonates presenting to the ED with jaundice during 9-month periods before and after initiation of the pathway. Charts were abstracted for times of assessment and treatment and final disposition.

RESULTS

Three hundred neonates were included in this study: 149 before and 151 after pathway implementation. Median time to phototherapy (historical control: 128 minutes vs postintervention group: 52 minutes; P < .001), median time to bilirubin result (157 vs 99; P < .001), and median ED length of stay (268 minutes vs 195 minutes; P < .001) were shorter for neonates treated after the implementation of the clinical pathway. No complications were reported during the study period.

CONCLUSIONS

After implementation of a clinical pathway for the management of neonates with jaundice in the ED, we observed a reduction in time to phototherapy, time to bilirubin measurement, and overall length of stay.

Injury to the proximal deep medial collateral ligament

Most injuries to the medial collateral ligament (MCL) heal well after conservative treatment. We have identified a subgroup of injuries to the deep portion of the MCL which is refractory to conservative treatment and causes persistant symptoms. They usually occur in high-level football players and may require surgical repair.

We describe a consecutive series of 17 men with a mean age of 29 years (18 to 44) who were all engaged in high levels of sport. Following a minor injury to the MCL there was persistent tenderness at the site of the proximal attachment of the deep MCL. It could be precipitated by rapid external rotation at the knee by clinical testing or during sport. The mean time from injury to presentation was 23.6 weeks (10 to 79) and none of the patients had responded to conservative treatment. The surgical finding was a failure of healing of a tear of the deep MCL at its femoral origin which could be repaired. After a period of postoperative protective bracing and subsequent rehabilitation the outcome was good. All the patients returned to their sports and remained asymptomatic at a mean of 48 weeks (28 to 60) post-operatively.

Recognition of this subgroup is important since the clinical features, the course of recovery and surgical requirement differ from those of most injuries to the MCL.

Description of a novel pediatric emergency department-based HIV screening program for adolescents

Several emergency department (ED)-based HIV screening programs have been described. However, the majority of these programs have been aimed at adults and older adolescents, and few have taken place in a dedicated pediatric ED. Given that many adolescents seek care in hospital EDs, and that the ED may be an adolescent's only contact with the health care system, we decided to implement an HIV-counseling and testing program in the ED of an urban children's hospital. The program included a dedicated health educator who provided sexual health counseling in a 30-minute session as well as optional HIV testing and test results to patients aged 14-24 years, and arranged necessary follow-up care for adolescents who tested positive for HIV. We collected aggregate data on the number of youth counseled, tested, and followed up. A total of 1287 patients were approached for potential counseling and testing during the first 3 years of the project. Of these, 643 (50.0%) agreed to meet with the health educator and were counseled. Three hundred eighteen (49.5%) of these patients agreed to HIV testing. One hundred eighty-seven (58.8%) patients returned for follow-up. Two patients (0.6%) whose previous HIV status was unknown tested positive for HIV; both of these patients were successfully linked to care. Fifty-six health care providers (17.3% of ED providers) were surveyed about their opinions of the program; although 93% were supportive of the program, several respondents were concerned about the appropriateness of HIV testing in the ED setting. This project suggests that, if appropriate resources are available, a dedicated HIV counseling and testing program can be successfully implemented in a busy, urban, pediatric ED. Providing access to these services to high-risk adolescents has the potential to significantly impact their health.

An unusual cause of locking

This case report describes the discovery of a plastic foreign body in a patient's knee joint 21 years from the initial injury. The patient was thoroughly investigated radiologically with plain X-rays both immediately after the initial injury and years later in orthopaedic outpatients. He also subsequently received an MRI. All these were reported as normal. The patient's symptoms persisted and an arthroscopy was performed. At this procedure the presence of the foreign body was confirmed and the offending plastic was safely removed. The patient's symptoms of intermittent locking resolved. This experience stresses this importance of clinical suspicion despite apparently normal radiology.

A phase I clinical and pharmacokinetic study of fenretinide combined with paclitaxel and cisplatin for refractory solid tumors

BACKGROUND

Fenretinide is a semi-synthetic retinoid that has pro-apoptotic effects as a single agent and synergistically with chemotherapy in vitro. We performed this study to determine the toxicity of cisplatin, paclitaxel and fenretinide in patients with advanced cancer, the recommended phase II dose of these agents together, and the pharmacokinetics (PK) of fenretinide when administered with chemotherapy.

PATIENTS AND METHODS

Fourteen patients (mean age 57.3) were assessable for pharmacokinetics, toxicity and response. Fenretinide was given orally in 2 divided daily doses for 7 days, starting 24 hours prior to cisplatin and paclitaxel. Cisplatin and paclitaxel were given in standard fashion. Cycles were repeated every 3 weeks. Cycle one fenretinide PK was obtained on days 2 and 8.

RESULTS

Dose limiting toxicity (Gr 3 diarrhea and Gr 4 neutropenia) was encountered in two patients during cycle one at 80/175/1,800 mg/m(2) of cisplatin/paclitaxel/fenretinide (dose level 2), respectively. Seven patients received 2-8 cycles at the recommended level of 60/135/1,800 (dose level 1). Severe cumulative toxicities included fatigue, nausea/vomiting, neuropathy, and dehydration. Two patients had a partial response and 4 patients had stable disease for up to 8 cycles. PK analysis demonstrated a reduction in fenretinide Cmax on day 8 compared to day 2, accompanying a decrease in AUC.

CONCLUSIONS

Cisplatin/paclitaxel/fenretinide can be administered safely at 60/135/1,800 mg/m(2) respectively on an every three-week schedule. This combination may have activity in a variety of tumors, however, the number of pills required complicates oral dosing of fenretinide, and limits the applicability of this regimen.

Displacement of the common peroneal nerve in posterolateral corner injuries of the knee

We reviewed the relationship between the pattern of damage to the posterolateral corner of the knee and the position of the common peroneal nerve in 54 consecutive patients with posterolateral corner disruption requiring surgery. We found that 16 of the 18 patients with biceps avulsions or avulsion-fracture of the fibular head had a displaced common peroneal nerve. The nerve was pulled anteriorly with the biceps tendon. None of the 34 proximal injuries resulted in an abnormal nerve position.

Whenever bone or soft-tissue avulsion from the fibular head is suspected, the surgeon should expect an abnormal position of the common peroneal nerve and appreciate the increased risk of iatrogenic damage.

Magnetic resonance imaging of bone bruising in the acutely injured knee—short-term outcome

AIM

To investigate the short-term outcome and associated injuries of bone bruising in the acutely injured knee.

METHOD AND MATERIALS

Thirty patients (age range 17-39 years, mean 28 years) with bone bruising identified on magnetic resonance imaging (MRI) after an acute knee injury were rescanned 12-14 weeks post-injury. The volume of bone bruising was measured on coronal STIR (short TI inversion recovery) images and correlation made with the presence and type of ligamentous and osteochondral injuries.

RESULTS

All bone bruises were present on repeat MRI. Twenty of the 30 patients (67%) had associated anterior cruciate ligament (ACL) injuries, seven of the 30 (23%) had collateral ligament injuries and three of the 30 (10%) had no associated ligamentous injuries. Greater than 50% reduction in bone bruise volume was demonstrated at repeat scanning in 24 of the 30 patients (80%) and less than 50% in five of the 30 patients (17%). One patient showed an increase in volume of bone bruising at follow-up. There was no correlation between initial size or size reduction of bone bruising and the presence/absence or type of associated injuries. In 21 patients the bone bruises resolved from the periphery, whilst eight patients showed bone bruises that resolved towards the joint margin, all of whom had associated osteochondral injuries. Of the 30 patients, 17 showed bone bruising that extended to the joint margin, 10 of whom had associated osteochondral injuries on MRI. On clinical review some degree of knee pain was still present in all but one of the patients reviewed. The single patient who reported complete resolution of symptoms was one of the three patients with isolated bone bruising.

CONCLUSION

Bone bruises persist for at least 12-14 weeks, which is longer than previously quoted. Two discrete patterns of bone bruise resolution have been demonstrated. The size and persistence of bone bruising is not related to the presence or absence or type of associated ligamentous injuries.

Predictors of outcome of mammography in the National Health Service Breast Screening Programme

BACKGROUND

Little is known about the factors influencing the risk of recall for assessment, invasive diagnostic procedures, and early rescreening after screening mammography.

METHODS

From June 1996 to March 1998 women attending screening at 10 National Health Service Breast Screening Programme (NHSBSP) centres completed a self administered questionnaire and were followed up for their screening outcome.

RESULTS

1969 (3.3%) out of 60 443 women aged 50-64 who had never used hormone replacement therapy (HRT) were recalled for assessment but were not diagnosed with breast cancer (defined here as false positive recall). After adjustment for the variation between centres, false positive recall was decreased significantly among women who were likely to have had a previous NHSBSP mammogram (odds ratio (OR) 0.49, 95% confidence interval (95% CI) 0.38 to 0.63 for likely versus unlikely), who were postmenopausal (OR 0.65, 95% CI 0.56 to 0.76 for postmenopausal v premenopausal) and increased significantly for women reporting previous breast surgery (OR 1.64, 95% CI 1.42 to 1.89). Although false positive recall decreased significantly with parity and increasing body mass index, these effects were not large and no significant variation was found with age, education, family history of breast cancer, oral contraceptive use, sterilisation, exercise, smoking, or alcohol consumption. Altogether 655 (1.1%) women had an invasive diagnostic procedure; no personal characteristics were predictive of this outcome, 286(0.5%) were referred for early rescreening, and this was increased significantly by nulliparity and a family history of breast cancer.

INTERPRETATION

Premenopausal women, those without a previous NHSBSP mammogram, and women with previous breast surgery have an increased risk of false positive recall by the NHSBSP.

Can physical trauma cause breast cancer?

The objective of this study is to explore the effect of lifestyle on the risk of invasive breast carcinoma in women aged 50-65 years. A case-control study using a questionnaire and a semi-structured interview. Cases (n = 67) and controls (n = 134) were closely matched on known risk factors for breast cancer including age, family history, age at menarche, parity, age at first birth and menopausal status. Controls were chosen from a pool of 5600 women who attended for breast screening and filled in a questionnaire giving details to allow matching with cases. The study took place at the North Lancashire Breast Screening Service. Women were aged 50-65 years and presented with breast cancer or attended for breast screening. Women with breast carcinoma were more likely to report physical trauma to the breast in the previous 5 years than were the controls (odds ratio (OR) 3.3, 95% confidence interval (CI) 1.3-10.8, P < 0.0001). There were no significant differences in a wide range of other lifestyle indicators including factors relevant to social class, education, residence, smoking and alcohol consumption. In conclusion, recall bias is an unlikely explanation for these results in view of the nature and severity of physical trauma. Models of epithelial cell generation indicate that a causal link between physical trauma and cancer is plausible. A latent interval between cancer onset and presentation of under 5 years is also plausible. The most likely explanation of the findings is that physical trauma can cause breast cancer.

[Reconstruction of mental health services in Bosnia and Herzegovina]

Psychiatric services in Bosnia-Herzegovina before the war disaster was fairly developed and one of the best organized services amongst the republics of the former Yugoslavia. The psychiatric care system was based on psychiatric hospitals and small neuropsychiatric wards within general hospitals, accompanied by psychiatric services in health centers. The onset of war in B&H brought devastation and destruction in all domains of life, including the demolition and closing of numerous traditional psychiatric institutions, together with massive psychological suffering of the whole civilian population. Already during the war, and even more so after the war, the reconstruction and reorganization of the mental health services was undertaken. The basis of mental health care for the future is designed as a system where majority of services is located in the community, as close as possible to the habitat of the patients. The key aspect of the system of the comprehensive health care is primary health care and the main role is assigned to family practitioners and mental health professionals working in the community. Large psychiatric institutions were either closed or devastated, or have their capacities extensively reduced. There will be no reconstructions or reopening of the old psychiatric facilities, nor the new ones will be built. The most integrated part of the psychiatric system are the Community based mental health centers. Each of these centers will serve a particular geographic area. The centers will be responsible for prevention and treatment of psychiatric disorders, as well as for the mental health well being. Chronic mental health patients without families and are not able to independently live in the community will be accommodated in designated homes and other forms of protected accommodation within their communities. The principal change in mental health policy in B&H was a decision to transfer psychiatric services from traditional facilities into community, much closer to the patients. Basic elements of the mental health policy in B&H are: Decentralization and sectorization of mental health services; Intersectorial activity; Comprehensiveness of services; Equality in access and utilization of psychiatric service resources; Nationwide accessibility of mental health services; Continuity of services and care, together with the active participation of the community. This overview discusses the primary health care as the basic component of the comprehensive mental health care in greater detail, including tasks for family medicine teams and each individual member. 1. Comprehensive psychiatric care is implemented by primary health care physicians, specialized Centers for community-based mental health care, psychiatric wards of general hospitals and clinical centers in charge of brief, "acute" inpatient care; 2. Primary mental health care is implemented by family practitioners (primary care physicians) and their teams; 3. Specialized psychiatric care in community is performed professional teams specialized mental health issues' within Mental health centers in corresponding sectors; 4. A great deal of relevance is given to development of confidence and utilization of links between primary health care teams and specialized teams in Mental health centers and psychiatric in patient institutions; 5. Psychiatric wards within general cantonal hospitals, departments of psychiatric clinics in Sarajevo, Tuzla, and Mostar, and Cantonal Psychiatric hospital in Sarajevo (Jagomir) shall admit acute patients as well as chronic (with each new relapse). Treatment in these facilities is brief an patients are discharged to return to their homes, with further treatment referral to their family practitioner or designated Mental health center; 6. Chronic mental patients with severe residual impairment in social, psychological, and somatic functioning, shall live in the community with their families or independently. Those chronic patients without families and economic and other resources to live independently shall be placed in supervised Homes in the communities where they live. The above delineated strategy of mental health care program in B&H has several fundamental and specific objectives, among which the most important are: Reduction of incidence and prevalence of some mental disorders, particularly war stress-related disorders and suicide; Reduction of level of functional disability caused by mental disorders through improvement of treatment and care of individuals with mental health problems; Improvement of psychosocial well being of people with mental health problems, through implementation of comprehensive and accessible service for community mental health care; and Respect of basic human rights of individuals with mental health disabilities. The program has been updated since 1996, after the two-year pilot program. The main goals for current two- and five-year period are: Implement the mental health care reform program by launching all 38 Mental health centers in the Federation of BiH by 2002; Complete the 10-day education and re-education of at least 50% of all professionals employed in mental health services in FB&H by 2002; and Achieve that 80 percent of all mental health problems are treated by family medicine teams (primary care practitioners) and specialized mental health services (Community mental health care centers) by 2005.

The measurement using passive dosemeters of the neutron component of aircraft crew dose

The cosmic radiation field at aviation altitudes can be measured with simple passive detectors. The non-neutron component may be measured by means of thermoluminescence dosimetry or other techniques, and the neutron component may be measured using poly allyl diglycol carbonate (PADC) dosemeters as described in this paper. Effective dose from neutron radiation becomes the larger component for altitudes above about 10 km, in general. The dominance is more pronounced for higher latitudes. The neutron energies range up to the maximum of the incident protons, that is many GeV. However the majority of the dose is contributed by neutrons of a few hundred MeV and less, with two maxima in the fluence spectrum, one between 1 and 10 MeV and the other between 50 and 150 MeV. We have used PADC dosemeters, electrochemically etched, to estimate the neutron component of effective dose. Up to 50 dosemeters are used in a single measurement to obtain an estimate of sufficient precision for total neutron effective doses of 50 microSv and less. The neutron fluence response characteristics of the dosemeter have been measured up to 70 MeV. These are extrapolated up to 180 MeV. This extrapolation is validated, partially, by a comparison of measured and predicted readings in the CERN reference field. From the dosemeter readings for exposure on board aircraft, neutron fluence may be estimated assuming an isotropic radiation field and the estimated neutron fluence spectrum. The neutron fluence may then be converted to effective dose using published values of conversion coefficients with the same assumptions of isotropy and known fluence spectrum. For the measurement results reported here, the calculated spectrum for the CERN concrete shielded field is used.

Longitudinal study of psychiatric symptoms, disability, mortality, and emigration among Bosnian refugees

CONTEXT

Evidence is emerging that psychiatric disorders are common in populations affected by mass violence. Previously, we found associations among depression, posttraumatic stress disorder (PTSD), and disability in a Bosnian refugee cohort.

OBJECTIVE

To investigate whether previously observed associations continue over time and are associated with mortality emigration to another region.

DESIGN, SETTING, AND PARTICIPANTS

Three-year follow-up study conducted in 1999 among 534 adult Bosnian refugees originally living in a refugee camp in Croatia. At follow-up, 376 (70.4%) remained living in the region, 39 (7.3%) were deceased, 114 (21.3%) had emigrated, and 5 (1%) were lost to follow-up. Those still living in the region and the families of the deceased were reinterviewed (77.7% of the original participants).

MAIN OUTCOME MEASURES

Depression and PTSD diagnoses, based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria and measured by the Hopkins Symptom Checklist-25 and the Harvard Trauma Questionnaire, respectively; disability, measured by the Medical Outcomes Study Short-Form 20; and cause of death, determined by family interviews with review of death certificates, if available.

RESULTS

In 1999, 45% of the original respondents who met the DSM-IV criteria for depression, PTSD, or both continued to have these disorders and 16% of respondents who were asymptomatic in 1996 developed 1 or both disorders. Forty-six percent of those who initially met disability criteria remained disabled. Log-linear analysis revealed that disability and psychiatric disorder were related at both times. Male sex, isolation from family, and older age were associated with increased mortality after adjusting for demographic characteristics, trauma history, and health status (for male sex, adjusted odds ratio [OR], 2.63; 95% confidence interval [CI], 1.17-5.92; living alone, OR, 2.40; 95% CI, 1.07-5.38; and each 10-year increase in age, OR, 1.91; 95% CI, 1.34-2.71). Depression was associated with higher mortality in unadjusted analysis but was not after statistical adjustment (unadjusted OR, 3.12; 95% CI, 1.55-6.26; adjusted OR, 1.85; 95% CI, 0.82-4.16). Posttraumatic stress disorder was not associated with mortality or emigration. Spending less than 12 months in the refugee camp (OR, 11.30; 95% CI, 6.55-19.50), experiencing 6 or more trauma events (OR, 3.34; 95% CI, 1.89-5.91), having higher education (OR, 1.90; 95% CI, 1.10-3.29), and not having an observed handicap (OR, 0.11; 95% CI, 0.02-0.52) were associated with higher likelihood of emigration. Depression was not associated with emigration status.

CONCLUSIONS

Former Bosnian refugees who remained living in the region continued to exhibit psychiatric disorder and disability 3 years after initial assessment. Social isolation, male sex, and older age were associated with mortality. Healthier, better educated refugees were more likely to emigrate. Further research is necessary to understand the associations among depression, emigration status, and mortality over time.

Changes in insurance coverage and extent of care during the two years after first hospitalization for a psychotic disorder

OBJECTIVE

This study examined changes in insurance coverage during the 24 months after first admission for a psychotic disorder and the relationship of insurance type to the extent of care.

METHODS

The sample consisted of 443 persons who were enrolled in the Suffolk County (New York) Mental Health Project. Information about coverage-private insurance, Medicaid-Medicare, or no insurance-was obtained from hospital records and interviews. The insurance status groups were compared to examine differences in the percentage of days they received inpatient, outpatient, and day hospital care.

RESULTS AND CONCLUSIONS

The proportion of persons with no insurance decreased from baseline to 24 months, from 42 percent to 21 percent. The proportion of persons with private insurance remained similar, 42 and 37 percent. The proportion of those with Medicaid-Medicare increased from 15 percent to 42 percent. Of those with Medicaid-Medicare at baseline (67 persons), 88 percent had such coverage 24 months later. Of those with private insurance at baseline (188 persons), 73 percent had the same coverage 24 months later. Of those with no insurance at baseline (188 persons), 35 percent had no insurance at 24 months, 54 percent had Medicaid-Medicare, and 11 percent had private insurance. Over the 24 months, the Medicaid-Medicare group had the most days of care, the private insurance group had the least inpatient care, and those with no insurance were least likely to receive outpatient care. There was a linear relationship between receiving more outpatient care and spending less time in the hospital and the day hospital.

Localized pigmented villonodular synovitis presenting as recurrent dislocation of the patella

A 31-year-old woman presented with a 1-year history of recurrent dislocation of the patella. On examination, she was found to have a mass at the medial patellofemoral joint line. Arthroscopy showed this to be a vascular synovial tumor extending into the medial patellofemoral joint and causing lateral deviation of the patella. The mass was resected with resolution of her symptoms and histologic examination showed this to be pigmented villonodular synovitis. There are an increasing number of case reports of these lesions causing varying mechanical symptoms in the knee and they should be considered as a differential diagnosis.

Congruence of diagnoses 2 years after a first-admission diagnosis of psychosis

BACKGROUND

Diagnostic changes may reflect evolution of an illness, emergence of newly disclosed information, or unreliability of assessment. This study evaluates the stability of research diagnoses in a heterogeneous first-admission sample with psychosis.

METHODS

A group of 547 subjects initially diagnosed with a psychosis were reassessed 6 and 24 months after enrollment. The DSM-IV consensus diagnoses were formulated by psychiatrists blind to previous research diagnoses. The analysis focuses on agreement over time and the effects of demographic, family history, and clinical variables on the shift from a nonschizophrenia diagnosis to schizophrenia.

RESULTS

Seventy-two percent of 6- and 24-month diagnoses were congruent. The most temporally consistent 6-month categories were schizophrenia (92%), bipolar disorder (83%), and major depression (74%); the least stable were psychosis not otherwise specified (44%), schizoaffective disorder (36%), and brief psychosis (27%). The most frequent shift in diagnosis at 24 months was to schizophrenia spectrum (n=45). These 45 subjects had a similar illness course after 6 months as the 171 subjects in this category at both assessments, but their prior clinical functioning was better. Risk factors predicting change to a schizophrenia spectrum diagnosis include facility variables (schizophrenia diagnosis, longer stays, and given antipsychotic medication on hospital discharge); prehospital features (psychotic > or =3 months before admission, poorer adolescent adjustment, lifetime substance disorder); and negative symptoms.

CONCLUSIONS

Changes in diagnosis, particularly to schizophrenia, are mostly attributable to the evolution of the illness. Rigid adherence to DSM-IV requirements may have led to underdiagnosis of schizophrenia. The findings support the need for a longitudinally based diagnostic process in incidence samples.

A randomized trial of interferon alpha therapy for HIV type 1 infection

The immunologic and virologic efficacy and safety of interferon a (IFN-alpha) administered in combination with zidovudine (ZDV) and zalcitabine (ddC) was evaluated in HIV-infected subjects with CD4+ cell counts between 300 and 500 cells/ml and no more than 14 weeks of prior antiretroviral therapy. A total of 256 subjects enrolled in an open-label, randomized controlled trial. Subjects were randomized equally into treatment groups. All subjects received ZDV and ddC, while half also receive IFN-alpha (3 MU subcutaneously every 24 hr). At 48 weeks the median average area under the curve minus baseline (AAUCMB) for plasma HIV-1 RNA for the two-drug group was -0.68 versus -0.75 log10 copies/ml for the IFN-alpha group (p = 0.046). Mean HIV-1 RNA changes from baseline to 48 weeks for these groups were -0.65 and -1.12 log10 copies/ml, respectively (p = 0.010). The median AAUCMB for CD4+ cell count for the two-drug group was 28 versus -1 cells/mm3 for the IFN-alpha group (p = 0.011). Neutropenia, anemia, and drug intolerance were more common in the IFN-alpha group. This study demonstrates that IFN-alpha inhibits HIV-1 replication but attenuates the CD4+ cell response to dual therapy with ZDV and ddC.

Is there an association between duration of untreated psychosis and 24-month clinical outcome in a first-admission series?

OBJECTIVE

The authors examined the duration of untreated psychosis, defined as the interval from first psychotic symptom to first psychiatric hospitalization, in a county-wide sample of first-admission inpatients who had received no previous antipsychotic medication. Differences between diagnostic groups in 24-month illness course and clinical outcomes as well as relationships between outcomes and duration of untreated psychosis were evaluated.

METHOD

The data were derived from subjects in the Suffolk County Psychosis Project who were diagnosed at 24-month follow-up according to DSM-IV as having schizophrenia or schizoaffective disorder (N=155), bipolar disorder with psychotic features (N=119), or major depressive disorder with psychotic features (N=75). Duration of untreated psychosis was derived from the Structured Clinical Interview for DSM-III-R, medical records, and information from significant others. Measures at 24-month follow-up included consensus ratings of illness course, Global Assessment of Functioning Scale scores for the worst week in the month before interview, and current affective and psychotic symptoms.

RESULTS

The median duration of untreated psychosis was 98 days for schizophrenia, 9 days for psychotic bipolar disorder, and 22 days for psychotic depression. Duration of untreated psychosis was not significantly associated with 24-month illness course or clinical outcomes in any of the diagnostic subgroups.

CONCLUSIONS

Although these findings require replication in other epidemiologically based first-admission samples, at face value they do not support the suggestion of a psychotoxic effect of prolonged exposure to untreated psychosis.

Medication treatment in adolescents vs. adults with psychotic mania

An epidemiologic sample of first admission psychotic patients is used to examine naturalistic treatment of psychotic mania. Specifically, we examined if 15-20 year olds receive different medications, or respond differently from patients over age 30 who are also early in their course of illness. The major difference in the two groups, besides their age, is the presence of comorbid externalizing disorder and substance abuse in the younger group. This report further examines the impact of this comorbidity on the presence of further episodes and overall outcome. The findings indicate that acute treatment is very similar in the two groups, and that over a 4 year follow-up, about 40% of patients discontinue medication. In spite of that, 32% of the YOUTH subjects and 48% of the ADULT group did not have a second episode. Of those externalizing YOUTH with a single episode, 64% took no medication during follow-up. However, the major difference between admission, 24 month follow-up and 48 month follow-up was the discontinuation of substance/alcohol use and the improvement in functioning. Medication did not invariably make that difference. This community sample reveals that at 48 months, a significant minority of young and adult subjects hospitalized with psychotic mania will have a single episode, and that short term course in younger patients is considerably worse than longer term course.

Disability associated with psychiatric comorbidity and health status in Bosnian refugees living in Croatia

CONTEXT

The relationship between psychiatric symptoms and disability in refugee survivors of mass violence is not known.

OBJECTIVE

To determine if risk factors, such as demographics, trauma, health status, and psychiatric illness, are associated with disability in Bosnian refugees.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional survey conducted in 1996 of Bosnian refugee adults living in a camp established by the Croatian government near the city of Varazdin. One adult aged 18 years or older was randomly selected from each of 573 camp families; 534 (93%) agreed to participate (mean age, 50 years; 41% male).

MAIN OUTCOME MEASURES

Culturally validated measures for depression and posttraumatic stress disorder (PTSD) included the Hopkins Symptom Checklist 25 and the Harvard Trauma Questionnaire, respectively. Disability measures included the Medical Outcomes Study Short-Form 20, a physical functioning scale based on World Health Organization criteria, and self-reports of socioeconomic activity, levels of physical energy, and perceived health status.

RESULTS

Respondents reported a mean (SD) of 6.5 (4.7) unduplicated trauma events; 18% (n=95) had experienced 1 or more torture events. While 55.2% reported no psychiatric symptoms, 39.2% and 26.3% reported symptoms that meet DSM-IV criteria for depression and PTSD, respectively; 20.6% reported symptoms comorbid for both disorders. A total of 25.5% reported having a disability. Refugees who reported symptoms comorbid for both depression and PTSD were associated with an increased risk for disability compared with asymptomatic refugees (unadjusted odds ratio [OR], 5.02; 95% confidence interval [CI], 3.05-8.26; adjusted OR, 2.06; 95% CI, 1.10-3.86). Older age, cumulative trauma, and chronic medical illness were also associated with disability.

CONCLUSIONS

In a population of Bosnian refugees who had recently fled from the war in Bosnia and Herzegovina, psychiatric comorbidity was associated with disability independent of the effects of age, trauma, and health status.

Appendicitis in childhood

Ultrasonography, CT scanning, and prolonged observation may improve diagnostic accuracy of appendicitis in children with atypical presentations. This article describes diagnostic pitfalls, including early presentation and abnormal appendiceal location.

Mortality from acute pancreatitis. Late septic deaths can be avoided but some early deaths still occur

CONCLUSION

In patients with acute pancreatitis, late "septic" deaths resulting from infection of pancreatic tissue can be avoided, but some early deaths are unavoidable owing to serious multiorgan dysfunction often combined with age or other comorbid conditions.

METHODS

A retrospective review was conducted of 105 patients admitted to the Royal Lancaster Infirmary with the diagnosis of acute pancreatitis over a 2-yr period (January 1, 1996 to December 31, 1997).

RESULTS

Six patients admitted during the study period died with a mortality rate of 5.7%. All patients died within 6 d of admission and received care in the intensive care unit. All presented with serious comorbid medical problems and/or developed early multiorgan dysfunction syndrome (MODS). Ten patients underwent pancreatic necrosectomy with no mortality.

Preschoolers with syphilis

Syphilis in preschoolers is rarely described in current medical literature, despite the rise in syphilis in both the adult and the pediatric populations during the past decade. Since that time, 3 children between 3 and 4 years of age have been diagnosed with syphilis at the Children's Hospital of Philadelphia. The presentations and clinical manifestations of syphilis in these 3 children are described, and the difficulty in identifying the source of infection is discussed. The presentations of these children included nephrosis and secondary syphilis, the corymbiform and palmar rash of syphilis, and subtle signs of late congenital infection in an otherwise asymptomatic child. One child had documented congenital infection, 1 had probable congenital infection that went untreated, and 1 did not have appropriate neonatal testing documented. None of the children gave a verbal history of sexual abuse, although it is likely that all three cases resulted from sexual abuse. The evaluation of preschool children with syphilis is confounded by the interpretation of acquired infection in consideration of a history of possible or documented congenital disease. The assessment is complicated further by problems with recognition of clinical disease, the inability of young children to provide a history, prenatal and neonatal testing methods used, changes in treatment recommendations made during the past decade, and inadequate follow-up to document cure of congenitally infected infants. With the increase in syphilis seen in recent years, physicians are more likely to encounter preschoolers with syphilis. Our ability to document acquired infection, however, is hampered by the difficulties encountered in following recommended guidelines for evaluation and follow-up and by limitations in interviewing young victims of sexual abuse, which may impair our ability to protect children from additional harm. Understanding the pathophysiology and progression of this disease remains challenging even in this modern era.

Prevalence and severity of substance use disorders and onset of psychosis in first-admission psychotic patients

BACKGROUND

Past studies have found inconsistent evidence that substance use disorders are related to earlier onset of schizophrenia or more severe symptoms. This study examines prevalence and severity of current substance use disorders and onset of psychotic illness in a multi-facility sample.

METHODS

Data are from the Suffolk County Mental Health Project, an epidemiological study of first admission psychosis. The SCID and instruments measuring symptomatology, personality and background characteristics were administered. Respondents were stratified into three groups: (a) no life-time substance diagnosis; (b) in remission or reporting current mild use at admission; and (c) current moderate-severe substance abuse at admission.

RESULTS

Using the SCID severity rating, 17.4% of males and 6.2% of the females had moderate or severe current substance abuse, while 41.5% of males and 68.2% of females had no lifetime substance diagnosis. In almost all cases categorized as moderate-severe, the substance diagnosis predated onset of psychosis. Females categorized as moderate-severe have an earlier age of onset of psychosis than did females in the other groups. There were only slight differences in symptom severity among the groups but more marked antisocial behaviour in the moderate-severe group. Variables discriminating the moderate-severe from non-abuse groups were BPRS thought disturbance, adult anti-social behaviour and current cigarette smoking for males and adult anti-social behaviour and child-teen antisocial behaviour for females.

CONCLUSIONS

Severity of substance abuse does not appear to be a pivotal correlate of the early features of psychotic illness.

Relationship between type of insurance and care during the early course of psychosis

OBJECTIVE

Little is known about the relationship between insurance and care in the early course of psychosis. This study explored the insurance status of first-admission psychotic patients and the relationship between type of insurance and care received up to this admission.

METHOD

Data are from the Suffolk County Mental Health Project, an epidemiologic study of first-admission psychosis. Data on insurance status (N=525) were pooled from hospital records, respondents, and significant others. Logistic regression analysis, controlling for key background variables and diagnosis, was used to study the relationship between insurance and care.

RESULTS

At first admission, 233 (44%) of the patients had no insurance, 78 (15%) had Medicaid or Medicare, 203 (39%) had private insurance, eight (1.5%) were insured by the Veterans Administration, and the insurance status of three (1.5%) was unknown. Having private insurance increased the likelihood of having received previous mental health treatment (psychotherapy specifically), being admitted voluntarily, being hospitalized in a community hospital rather than a public hospital, and being hospitalized within 3 months of onset of psychosis. Having Medicaid/Medicare increased the likelihood of receiving nonantipsychotic medication before this hospitalization, admission to a community hospital rather than a public hospital, having received previous mental health treatment in general, and voluntary admission.

CONCLUSIONS

During the early course of psychotic illness, many people lack any type of health insurance, and this is associated with a decreased likelihood of obtaining care before their first hospital admission.

Ice-water test in the urodynamic evaluation of spinal cord injured patients

The purpose of this study was to determine the clinical utility of the ice-water test (IWT) during urodynamic evaluation in spinal cord injured (SCI) patients. Thirty-two suprasacral SCI patients with documented detrusor hyperreflexia (DH) underwent urodynamic study and IWT. Fifteen patients had repeated testing 2 weeks later. The IWT was performed with the patient in the supine position; 100 mL of sterile saline water at 4-8 degrees C was injected manually. If cystometric capacity was <200 mL, a volume of about 50% of the individual cystometric bladder capacity was used. The cold fluid was left within the bladder for 3 minutes. The test was considered positive if an involuntary bladder contraction > or =15 cm H2O was registered. All patients with cervical or thoracic level SCI had DH, which had 100% test-retest reproducibility on urodynamics. Seventy-two percent of patients with DH had a positive IWT and 28% had a negative IWT. IWT (same volume, 2 weeks later) in 4 (27%) of the 15 repeated tests gave different responses. Autonomic hyperreflexia, manifested as systolic blood pressure increase > or =50 mm Hg within 3 minutes of ice-water instillation, occurred in 16 (57%) of 28 patients with lesions above T7. In SCI patients, the IWT did not contribute to their management because of the insensitivity and nonspecificity. Autonomic hyperreflexia can occur during evaluation. The IWT did not influence clinical management in this group of SCI patients.

Pharmacokinetics of oral ganciclovir alone and in combination with zidovudine, didanosine, and probenecid in HIV-infected subjects

The aim of this study was to determine whether oral ganciclovir interacted pharmacokinetically with zidovudine (AZT), didanosine (ddI), or probenecid. A multicenter, open-label, randomized, crossover pharmacokinetic study with four phases was undertaken at an outpatient private research center and at university research clinics. Twenty-six HIV-infected adults (23 men, 3 women) with cytomegalovirus (CMV) seropositivity and CD4+ T-lymphocyte count > or =100 cells/microl were studied. Patients had to be stable on antiretroviral therapy for at least 4 weeks. Patients with a history of opportunistic infection or gastrointestinal symptoms were excluded. Measurements included serial blood and urine samples during the dosing intervals at steady state. The steady-state pharmacokinetics of ganciclovir were determined after the participants had stabilized and were tolerating AZT or ddI therapy. When a 1000-mg dose of oral ganciclovir was taken every 8 hours, there was a significant mean increase in Cmax and dosing interval area under the serum concentration time curve over a dosing interval (AUC) for the two antiretroviral drugs: for AZT, 61.6% and 19.5%, respectively; for ddI when administered sequentially (2 hours before ganciclovir), 116.0% and 114.6%; and for ddI administered simultaneously with ganciclovir, 107.9% and 107.1%, respectively. There was no significant change in renal clearance for either antiretroviral drug, suggesting that the interaction did not occur through a renal mechanism. There was no significant change in mean ganciclovir Cmax and AUC(0-8) when coadministered with AZT. Mean increases in Cmax and AUC(0-8) of oral ganciclovir averaged 40.1% and 52.5%, respectively, when coadministered with probenecid, but decreased by 22.1% and 22.7%, respectively, when oral ganciclovir was administered 2 hours after ddI. There was no change in the mean ganciclovir Cmax or AUC(0-8) when administered simultaneously with ddI. The mean renal clearance of oral ganciclovir was not affected by AZT or ddI coadministration intake, but there was a mean decrease of 19% when coadministered with probenecid. We conclude the increased serum concentration and reduced renal clearance of ganciclovir suggests competition with probenecid for secretion at the renal tubule. The mechanism of the interaction of oral ganciclovir with either AZT or ddI remains to be determined. The magnitude of the effect of oral ganciclovir on ddI pharmacokinetics may result in an increase in ddI concentration-related toxicities. Similarly, the small but significant decrease in ganciclovir concentration with sequential combination ddl therapy may impair the efficacy of oral ganciclovir. For HIV-infected patients receiving ganciclovir and ddI, clinicians should recommend administering the two drugs simultaneously, and patients should be monitored closely for ddI-associated toxicities.