Aberrantly low STAT3 and STAT5 responses are associated with poor outcome and an inflammatory gene expression signature in pediatric acute myeloid leukemia

The relapse rate for children with acute myeloid leukemia is nearly 40% despite aggressive chemotherapy and often stem cell transplant. We sought to understand how environment-induced signaling responses are associated with clinical response to treatment. We previously reported that patients whose AML cells showed low G-CSF-induced STAT3 activation had inferior event-free survival compared to patients with stronger STAT3 responses. Here, we expanded the paradigm to evaluate multiple signaling parameters induced by a more physiological stimulus. We measured STAT3, STAT5 and ERK1/2 responses to G-CSF and to stromal cell-conditioned medium for 113 patients enrolled on COG trials AAML03P1 and AAML0531. Low inducible STAT3 activity was independently associated with inferior event-free survival in multivariate analyses. For inducible STAT5 activity, those with the lowest and highest responses had inferior event-free survival, compared to patients with intermediate STAT5 responses. Using existing RNA-sequencing data, we compared gene expression profiles for patients with low inducible STAT3/5 activation with those for patients with higher inducible STAT3/5 signaling. Genes encoding hematopoietic factors and mitochondrial respiratory chain subunits were overexpressed in the low STAT3/5 response groups, implicating inflammatory and metabolic pathways as potential mechanisms of chemotherapy resistance. We validated the prognostic relevance of individual genes from the low STAT3/5 response signature in a large independent cohort of pediatric AML patients. These findings provide novel insights into interactions between AML cells and the microenvironment that are associated with treatment failure and could be targeted for therapeutic interventions.

[Growth and differentiation factor 5 (GDF-5) composite improves the healing of necrosis of the femoral head in a sheep model. Analysis of an animal model]

MATERIALS AND METHODS

After creation of necrosis in 23 sheep, the composites were implanted in half of the animals. The animals were sacrificed 6 and 12 weeks after implantation and the femora were harvested. The specimens were investigated by microradiography, computed tomography, and histologically.

RESULTS

The GDF-5 composites were effective in the necrosis model. Osseous regeneration of the necrosis and the drill track were accelerated and enhanced by the composites. In treated animals the necrosis was nearly healed and the drill track was filled with bone after 12 weeks. In the control group the track was partially filled with fibrous tissue and necrotic lesions were still present. Specific side effects of the growth factor or the matrix were not documented. This was documented by histological scoring and CT investigation.

DISCUSSION

The application of an absorbable GDF-5 composite in combination with a core decompression procedure may enhance the healing of devitalized bone defects and is a promising approach for further studies.

Heparin-binding epidermal growth factor-like growth factor: a component in chromaffin granules which promotes the survival of nigrostriatal dopaminergic neurones in vitro and in vivo

Chromaffin cells can restore function to the damaged nigrostriatal dopaminergic system in animal models of Parkinson's disease. It has been reported that a protein which is released from chromaffin granules can promote the survival of dopaminergic neurones in vitro and protect them against N-methylpyridinium ion toxicity. This neurotrophic effect has been found to be mediated by astroglial cells and blocked by inhibitors of the epidermal growth factor (EGF) receptor signal transduction pathway. Here we report the identification of bovine heparin-binding EGF-like growth factor (HB-EGF) in chromaffin granules and the cloning of the respective cDNA from bovine-derived adrenal gland. Protein extracts from bovine chromaffin granules were found to promote the survival of embryonic dopaminergic neurones in culture, to the same extent as recombinant human HB-EGF. Furthermore, the neurotrophic action of the chromaffin granule extract could be abolished by antiserum to recombinant human HB-EGF. We also show that intracerebral injection of recombinant human HB-EGF protected the nigrostriatal dopaminergic system in an in vivo adult rat model of Parkinson's disease. Intracerebral administration of this protein at the same time as a 6-hydroxydopamine lesion of the medial forebrain bundle was found to spare dopamine levels in the striatum and tyrosine hydroxylase-immunopositive neurones in the midbrain. This study has found that the main component in chromaffin granules responsible for their neurotrophic effect on dopaminergic neurones is HB-EGF. Furthermore, HB-EGF has significant protective effects on nigrostriatal dopaminergic neurones in vivo, making it a potential candidate for use in the treatment of Parkinson's disease.

Use of psychiatric emergency services and enrollment status in a public managed mental health care plan

OBJECTIVE

This study examined the sociodemographic and clinical characteristics of acute-care psychiatric patients who visited the emergency department at a large public hospital in terms of the patients' enrollment status in the region's public managed mental health care plan. The results of the analyses were expected to provide information about the degree and types of access to care for individuals who are and are not enrolled in the plan.

METHODS

Data were collected over a seven-month period for 2,419 patients who visited a large, inner-city crisis triage unit. Patients were grouped according to whether they were currently enrolled, previously enrolled, or never enrolled in the public managed mental health care plan. Univariate and logistic regression models were used to determine differences between the three groups.

RESULTS

In general, patients who were currently enrolled in the plan had a higher rate of functional psychosis, past use of psychiatric services, and functional disability and lower rates of substance use and homelessness. Previously enrolled patients had a more moderate rate of psychosis but a higher rate of substance use, functional disability, and homelessness. The never-enrolled patients had a lower rate of psychosis, functional disability, and past use of psychiatric services, and moderate substance use.

CONCLUSIONS

The region's public health plan appeared to be succeeding in engaging and keeping the most psychiatrically impaired patients in treatment; however, individuals with moderate psychiatric symptoms and high levels of substance abuse may never have been enrolled in the plan because of Medicaid ineligibility or because they dropped out of treatment. Problematic behavior and history of hospitalization were the best predictors of enrollment status.

Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder

A growing number of adults are seeking evaluation for Attention-Deficit/Hyperactivity Disorder (ADHD). Screening for substance use disorders should be included as part of any comprehensive ADHD evaluation. We describe the validity and reliability of the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT) in adults seeking evaluation for ADHD. Internal reliability estimates were excellent for both instruments. Scores on the DAST and AUDIT were higher among patients with a DSM-IV diagnosis of current drug abuse or dependence or current alcohol abuse or dependence, respectively. A cutoff score of 6 or above appears to be optimal for identifying individuals who are current drug abusers. A cutoff score of 6 or above on the AUDIT is suggested for detection of current alcohol abuse in this population. Comparable rates of substance use disorders were observed in ADHD and non-ADHD patients. Both measures are valid and reliable instruments for screening for alcohol and drug abuse among adults seeking evaluation for ADHD.

Bone morphogenetic protein-2 and growth and differentiation factor-5 enhance the healing of necrotic bone in a sheep model

INTRODUCTION

Osteotropic growth factors enhance bone repair, but their efficacy in an area of necrotic bone is not known. The purpose of this study was to investigate the effects and potential side effects of an intraosseous application of absorbable bone morphogenetic protein-2 (BMP-2) and growth and differentiation factor-5 (GDF-5) composites in a sheep model for partial necrosis of the femoral head.

MATERIALS AND METHODS

The direct injection of ethanol under fluoroscopy into the superior centre of the right femoral head produced histologically documentable necrosis of the central region of the head in a previous study of ten sheep. Another 27 sheep constituted the sample to study the effects of BMP-2 and GDF-5. Necrosis was produced in the same fashion in these animals. Four weeks later nine sheep received 300 microg recombinant BMP-2 and nine sheep 300 microg recombinant GDF-5 on an absorbable carrier by surgical implantation. Nine sheep received the carrier alone (control group). The animals were sacrificed at 3, 6, and 12 weeks after implantation and both femora were harvested.

RESULTS

Bone density analysis and microscopic examination indicated that bone formation was noticeably induced as early as 3 weeks postoperatively in the growth factor treated animals. Bone regeneration was enhanced by growth factor composites. This was documented by histological scoring and histomorphometric analysis. No severe local side effects secondary to the growth factors, such as heterotopic ossification or inflammation, were observed in either group.

DISCUSSION

The application of an absorbable growth factor composite in combination with established surgical techniques is a promising approach, that may enhance the healing of devitalised bone defects. Based on these results, further studies regarding biodegradation, dosage of the protein and surgical technique are required.

Localization of activin beta(A)-, beta(B)-, and beta(C)-subunits in humanprostate and evidence for formation of new activin heterodimers of beta(C)-subunit

Activin ligands are formed by dimerization of activin ss(A)- and/or ss(B)-subunits to produce activins A, AB, or B. These ligands are members of the transforming growth factor-ss superfamily and act as growth and differentiation factors in many cells and tissues. New additions to this family include activin ss(C)-, ss(D)-, and ss(E)-subunits. The aim of this investigation was to examine the localization of and dimerization among activin subunits; the results demonstrate that activin ss(C) can form dimers with activin ss(A) and ss(B) in vitro, but not with the inhibin alpha-subunit. Using a specific antibody, activin ss(C) protein was localized to human liver and prostate and colocalized with ss(A)- and ss(B)-subunits to specific cell types in benign and malignant prostate tissues. Activin C did not alter DNA synthesis of the prostate tumor cell line, LNCaP, or the liver tumor cell line, HepG2, in vitro when added alone or with activin A. Therefore, the capacity to form novel activin heterodimers (but not inhibin C) resides in the human liver and prostate. Activin A, AB, and B have diverse actions in many tissues, including liver and prostate, but there is no known biological activity for activin C. Thus, the evidence of formation of activin AC or BC heterodimers may have significant implications in the regulation of levels and/or biological activity of other activins in these tissues.

A brief medical necessity scale for mental disorders: reliability, validity, and clinical utility

Managed care organizations (MCOs) use the concept of "medical necessity" to decide whether a prescribed treatment is warranted for a given medical condition. Because mental disorders lack the objective disease criteria common to medical illness, behavioral health administrators need a validated means to identify and quantify the severity of "medically important" aspects of mental disorders. The authors developed and tested a brief medical necessity scale for mental disorders in 205 patients presenting for initial evaluation. The scale had a factor structure with four subscales; good internal consistency, interrater reliability, and concurrent and predictive validity; and modest ability to identify patients requiring hospitalization and, in hospitalized patients, those requiring involuntary hospitalization. The authors propose use of the scale to better clarify decisions about level of care assignments and to better assess patient characteristics predictive of good outcome.

The MOS 36-Item Short Form Health Survey: reliability, validity, and preliminary findings in schizophrenic outpatients

OBJECTIVES

The authors test the reliability and validity of the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) as a written, self-administered survey in outpatients with chronic schizophrenia.

METHODS

Thirty-six schizophrenic outpatients completed a written and oral form of the SF-36. A psychiatrist rated the patients using the Brief Psychiatric Rating Scale to determine severity of psychopathology. Cognitive functioning and academic achievement were also assessed. Internal consistency, test-retest reliability, concurrent and discriminative validity of the oral and written versions were determined.

RESULTS

The SF-36 in both forms was shown to have good internal consistency, stability, and concurrent validity. The mental health SF-36 subscales had poor discriminant validity, compared with the physical functioning scale that demonstrated good discriminant validity.

CONCLUSIONS

The validity of using the written form of the SF-36 on a sample of patients with chronic mental illness was demonstrated. The SF-36 appears to be an appropriate outcome measure for changes in physical and role functioning in consumers of outpatient mental health programs.

Dawn simulation treatment of abstinent alcoholics with winter depression

BACKGROUND

Recent data suggest that winter depression (seasonal affective disorder [SAD]) may be a subtype of affective disorder that is closely related to alcoholism. Dawn simulation has been shown in controlled trials to be effective in SAD. The present study examined the effectiveness of dawn simulation in abstinent alcoholics who met DSM-III-R criteria for major depression, or bipolar disorder, depressed with seasonal pattern.

METHOD

All 12 subjects with winter depression had a history of either alcohol dependence or alcohol abuse according to DSM-III-R and had been abstinent from alcohol for at least 6 months. They also fulfilled criteria for SAD according to Rosenthal and were hypersomnic and drug free. After a 1-week baseline period, the subjects were randomly assigned to a 1-week treatment period at home with either a white 1.5-hour dawn from 4:30 a.m. to 6:00 a.m. peaking at 250 lux or a red 1.5-hour dawn from 4:30 a.m. to 6:00 a.m. peaking at 2 lux. The subjects were told that they would receive daily either a red or a white dawn reaching the same illuminance, an illuminance that would be much dimmer than standard bright light treatment. At the end of each week, the subjects were blindly assessed by a psychiatrist using the Structured Interview Guide for the Hamilton Depression Rating Scale-Seasonal Affective Disorder version (SIGH-SAD).

RESULTS

For the 6 subjects completing the white dawn treatment, the mean SIGH-SAD score decreased from 33.0 at baseline to 15.8 after treatment. For the 6 subjects completing the dim red dawn treatment, the mean SIGH-SAD score decreased from 34.3 to 32.7. The mean post-dawn SIGH-SAD score was significantly lower after the white dawn treatment than after the dim red dawn treatment (ANCOVA with baseline SIGH-SAD as the covariate, F = 12.95, p < .01). Superiority of the white dawn was also found by analogous analyses for the Hamilton Rating Scale for Depression (HAM-D) (p < .01) and the SAD Subscale (p < .05).

CONCLUSION

The present study suggest that dawn simulation may be helpful in decreasing depression in abstinent alcoholics with SAD. Further study is necessary to confirm these preliminary findings and to determine whether dawn simulation might be helpful in preventing relapse in abstinent alcoholics who have SAD.

Psychiatric status, quality of life, and level of care as predictors of outcomes of acute inpatient treatment

OBJECTIVE

The study examined the role of five types of variables--demographic characteristics, psychiatric status, functional quality of life, satisfaction with quality of life, and level of care--in predicting key outcomes of inpatient treatment.

METHODS

Multivariate canonical regression and univariate multiple regression models were constructed using data from 1,053 inpatients at a public hospital in Washington State. The models were used to predict length of stay, change in symptom severity during hospitalization, psychiatrists' ratings of patients' insight into their illness at discharge, patients' global satisfaction with life, and rehospitalization within 18 months. Hierarchical stepwise procedures were used to select variables that were significant predictors of outcomes.

RESULTS

All five classes of predictors were related to the outcomes. The roles of demographic characteristics and diagnoses were minimal. Previous hospitalization and severity of symptoms at admission were strong predictors of psychiatric status. Indicators of functional quality of life and satisfaction with quality of life explained significant variance in all models after accounting for the other classes of predictors. Frequency of family visits was the strongest functional quality-of-life predictor, relating to positive outcomes. Pretreatment satisfaction with life was a significant predictor of most outcomes, and increased satisfaction was associated with positive outcomes.

CONCLUSIONS

Patients' quality of life before psychiatric inpatient treatment predicted treatment outcomes independently of psychiatric status, demographic characteristics, and level-of-care variables. Prospective studies are needed to predict outcomes using multidimensional constructs.

Cost of comorbid alcohol and drug problems

The authors measured the comorbid effect of alcohol and other drug (AOD) problems on medical, surgical, and psychiatric inpatient charges and length of stay (LOS) in an urban hospital by use of retrospective study of hospital clinical computer data comparing AOD-affected patients with non-AOD-affected patients in terms of cost, diagnostic, demographic, and utilization variables (N = 14,768). Patients were men and women with and without comorbid history of AOD problems, admitted for medical, surgical, and psychiatric reasons. For 10 of the 20 most frequent Diagnosis-Related Groups (DRGs), total hospital charges and LOS were significantly lower in patients with comorbid AOD problems (P < 0.001). Overall, for the most frequent 20 DRGs, total charges and LOS remained significantly lower for the AOD group. Most physicians believed that AOD-affected patients were often less ill than non-AOD patients within the same DRG. Alcohol/drug-affected patients had robustly lower costs and LOS. Fragmentation of psychosocial costs and addiction treatment from general health care and the fee-for-service DRG system appear to financially reward acute-care hospitals to repeatedly treat secondary AOD sequelae without providing any apparent incentives for the treatment of the primary alcohol/drug condition itself.

The relationship of patient-administered outcome assessments to quality of life and physician ratings: validity of the BASIS-32

The reliability and validity of a patient-administered version of the Behavior and Symptom Identification Scale (BASIS-32) was compared to the original interviewer-administered version. The construct validity of BASIS-32 subscales was assessed by examining their relationship with functional and satisfaction quality of life and physician ratings of functional and clinical status. A total of 361 acute psychiatric inpatients were given a self-administered BASIS-32, nurse-administered Lehman's Quality of Life Interview (QOLI), and Psychiatrist Assessment Form at admission and discharge. The original factor structure, internal consistency reliability, discriminant validity, and sensitivity to change were replicated. The patient-administered BASIS-32 is equally as reliable and valid as the interview. Construct validity analyses revealed that functional and satisfaction QOLI indices were moderately related to the BASIS-32 in the hypothesized directions. All satisfaction scales were associated with significantly less severity. Physician ratings were only mildly related to the subscales. The BASIS-32 used in outcome assessments with inpatients provides important and unique perspectives on functional and clinical status that are not tapped by clinician-rated assessments.

Longitudinal assessment of quality of life in acute psychiatric inpatients: reliability and validity

This study examined the reliability, validity, and responsiveness of Lehman's Quality of Life Interview (QOLI) as an outcome measure on 981 acutely ill psychiatric inpatients assessed longitudinally at admission and discharge. Patients were stratified into five diagnostic (DX) (depressed bipolar, depressed unipolar, schizophrenia, mania, and other diagnoses) and two substance use disorder (SA) strata (with and without concurrent substance abuse/dependence) based on DSM-III-R criteria. There was good replication of the factor structure, excellent internal consistency, overall and within DX and SA groups. Intercorrelations showed that the functional and satisfaction indices measure unique aspects of the quality of life. The construct consistency of the QOLI was dependent upon psychiatric diagnosis and life domain. Intercorrelations of functional and satisfaction indices for patients with depression were greater than for manic patients. We demonstrated strong consistency of construct validity for family and social relation domains, but not safety or leisure activities. Construct validity was shown to hold longitudinally. Analyses of DX and SA group differences on satisfaction and functional indices of the 8 life domains supported discriminative validity: Depressed patients reported the most dissatisfaction, followed by schizophrenic patients, and manic patients reported the greatest satisfaction in most life domains. Patients with concurrent substance abuse generally reported less satisfaction and lower quality of life than patients without a dual diagnosis. Examination of longitudinal changes in satisfaction indicated the QOLI is responsive to changes in global life, leisure activities, living situation, and social relations from hospital admission to discharge (an average of 2 weeks). This study supports the use of the QOLI as an outcome measure to assess quality of life in acutely ill hospitalized psychiatric patients.

Linking substance abuse services with general medical care: integrated, brief interventions with hospitalized patients

This paper presents the results of implementing on-site alcohol or drug (AOD) brief intervention services across several medical, surgical, and psychiatric services in a county hospital. These integrated brief interventions (IBI) included patient substance abuse assessment, feedback to patient, and referral/recommendations. Three hundred sixty-three patients were referred by hospital staff to these services and 95% of these patients were subsequently confirmed by chemical dependency specialists as having diagnoses of psychoactive substance abuse or dependence. Seventy-nine percent of chemically dependent patients were without current substance abuse treatment, even though 54% were partially motivated and 20% were fully motivated for getting treatment. Of patients contacted at follow-up, 35% reported involvement in some kind of substance abuse treatment or 12-step meetings. Implications for implementing integrated brief intervention services are discussed in light of recent trends in publicly funded treatment availability and brief intervention outcome studies.

Evidence for limited validity of the revised global assessment of functioning scale

The study examined the concurrent validity of the revised Global Assessment of Functioning (GAF) scale, which is highly similar to the Social and Occupational Functioning Assessment Scale (SOFAS) in DSM-IV and which is designed to measure patients' functioning and not their clinical symptoms. Psychiatrists used the revised GAF to rate 337 psychiatric inpatients; the ratings were compared with nurses' ratings of the same sample using Lehman's Quality of Life Scale. Ratings on the revised GAF were most strongly correlated with ratings of clinical symptoms, not functioning. Reliance on the GAF as the only tool to assess patients' functioning may be problematic.

The "WAM" score: sensitivity and specificity of a user friendly biological screening test for alcohol problems in trauma patients

Based on a weighted aggregation of three biological alcohol markers (gamma-glutamyltransferase, blood alcohol and mean corpuscular volume), this study presents a screening instrument for alcohol problems in trauma patients. The sex-specific performance of this instrument was explored on 1088 male and 352 female patients, 18 years or older, admitted with blunt or penetrating trauma during a 30-month period to a regional level one trauma center in Seattle, Washington (USA). The sum of the differentially weighted alcohol markers ("WAM"), determined from one blood sample, formed a "score continuum" ranging from 0 to 24. The WAM scores distributed themselves across the trauma population with higher WAM scores being correlated to higher screening instrument scores for alcohol problems. By using two of the best established screening tests for alcohol problems (CAGE and SMAST) to define cut-off points for likely "alcohol abuse/dependence", the WAM score of > or = 7 in males showed 75% sensitivity and 83% specificity, whereas the WAM score of > or = 6 for females displayed 85% sensitivity and 85% specificity. We conclude that a weighted combination of biological alcohol markers (WAM score) is a useful tool for identifying alcohol problems among trauma patients. Representing an alternative or addition to a more extensive interview, it could be used as a routine part of the care of trauma patients.

The effects of substance use disorder on the clinical presentation of anxiety and depression in an outpatient psychiatric clinic

BACKGROUND

The comorbidity of substance abuse or dependence and psychiatric illness can complicate the diagnosis, clinical course, and treatment of dually diagnosed patients. In this study, we examined the relationship between substance use disorder (SUD) and psychopathology in an outpatient psychiatric setting.

METHOD

Among 391 patients evaluated at an anxiety and effective disorders clinic, 54 patients met DSM-III-R criteria for lifetime substance use disorder and current unipolar depression or anxiety disorder. We selected 54 sex- and age-matched controls with psychiatric illness without SUD as a comparison group. All patients were given a structured diagnostic interview and symptom rating scales. In addition to comparing dual and single diagnosis groups, we compared those within the dual diagnosis group and those with primary psychiatric disorder with those with primary SUD; we also compared those with current versus past SUD.

RESULTS

In contrast to findings in other settings, there were no significant differences in the severity of psychopathology between patients with and without substance abuse/dependence. Within dually diagnosed patients, those with primary mental disorder were more anxious and depressed than those with primary SUD. Patients with primary mental disorder had a significantly higher number of psychiatric diagnoses, an earlier onset of any psychiatric disorder, and were more likely to have received treatment. Conversely, patients with primary SUD had a higher number of substance use disorder diagnoses and an earlier onset of SUD.

CONCLUSION

Dually diagnosed patients had the same degree of psychopathology as patients with only psychiatric disorders in this outpatient psychiatric population. The primary/secondary classification may be useful to distinguish between subgroups of dual diagnosis patients. Future studies are necessary to determine if this distinction can be useful to predict course and outcome in dually diagnosed patients.

A psychiatrist-rated battery of measures for assessing the clinical status of psychiatric inpatients

Despite the increasing demand for outcome assessment measures, no published reports have provided a standardized way to assess psychiatric inpatients that includes diagnosis and observer ratings of psychopathology. This paper reviews general principles for selecting outcome assessment measures, proposes a battery of instruments based on already available measures to assess clinical status in psychiatric inpatients, reviews methods of implementing the battery in an academic inpatient psychiatric setting, and presents preliminary data on its interrater reliability, construct validity, and range of response to acute hospitalization. Preliminary results suggest that the battery may be useful for resident and medical student education and for enhancing quality assurance and continuous quality improvement.

Case manager ratings of the clinical status of dually diagnosed outpatients

OBJECTIVE

The researchers' aim was to evaluate the construct validity of a rating scale used by case managers to assess the clinical status of clients in a large outpatient treatment program for persons with severe mental illness and concurrent drug or alcohol problems.

METHODS

A standardized rating scale for assessing clients' levels of four key clinical problems--psychiatric symptoms, substance use, treatment noncompliance, and overall level of dysfunction--was developed for use by case managers. After being trained in use of the instrument, 20 case managers rated 302 clients along these dimensions. Case manager ratings were compared with data on clients' diagnoses and the level of structure they required in their treatment program.

RESULTS

About 42 percent of the clients assessed had schizophrenia, 28 percent had bipolar disorder, 14 percent had major depression, and 11 percent had other psychotic disorders. The case manager ratings were significantly related to clients' diagnosis and the level of structure in their treatment program. The four dimensions were also correlated with each other; strong correlations were found between severity of substance use and noncompliance and between severity of psychiatric disorder and level of dysfunction.

CONCLUSIONS

Ratings by case managers can be used to measure individual progress in treatment as well as the status of the entire client population in a treatment program.

Symptom severity and utilization of treatment resources among dually diagnosed inpatients

OBJECTIVE

The author's goal was to determine the clinical characteristics of patients admitted to an acute voluntary psychiatric unit with a dual diagnosis treatment program.

METHODS

A total of 104 consecutive patients admitted the unit were divided into three groups based on whether they had a current substance use disorder, a past substance use disorder, or no substance use disorder. On the basis of data derived from extensive structured interviews, the three groups' demographic characteristics, severity of symptoms, and utilization of psychiatric and alcohol and drug treatment services were compared.

RESULTS

The dually diagnosed patients in the sample were more likely to have a mood disorder, and the patients without a substance use disorder were more likely to have a diagnosis of schizophrenia or mania. Patients with a current substance use disorder had more severe symptoms and used more treatment resources than patients in other groups. Patients with a past substance use disorder also had increased symptom severity, with measures of severity about halfway between those of patients with current substance use disorder and those of patients with no substance use disorder.

CONCLUSIONS

Psychiatric patients with a past substance use disorder, like those with a current substance use disorder, may be at risk for increased symptom severity and increased utilization of treatment resources and may need specialized treatment planning. The needs of dually diagnosed patients with mood disorders as well as those with chronic psychotic conditions should be considered in local and national mental health care planning.

The magnitude of acute and chronic alcohol abuse in trauma patients

OBJECTIVE

To assess the incidence of acute alcohol intoxication and the proportion of trauma patients with evidence of chronic alcohol abuse.

DESIGN

Prospective cohort study.

SETTING

Regional level I trauma center.

PARTICIPANTS

Patients aged 18 years and older admitted with blunt or penetrating trauma.

MAIN OUTCOME MEASURES

Admission blood alcohol concentrations (BACs), the Short Michigan Alcohol Screening Test (SMAST), and biochemical markers for chronic alcohol abuse.

RESULTS

Of the 2657 patients enrolled, 47.0% had a positive BAC and 35.8% were intoxicated (BAC > or = 100 mg/dL) on admission to the emergency department. Intoxicated patients were more likely to be 25 to 34 years old, male, and nonwhite; the highest proportion of intoxicated patients was among victims of stab wounds. Three fourths of acutely intoxicated patients had evidence of chronic alcoholism as indicated by a positive SMAST, and 25% to 35% of acutely intoxicated patients had biochemical evidence of chronic alcohol abuse.

CONCLUSIONS

The high prevalence of both acute intoxication and chronic alcoholism in trauma patients indicates the need to diagnose and appropriately treat this pervasive problem in trauma victims.

The effect of acute alcohol intoxication and chronic alcohol abuse on outcome from trauma

OBJECTIVE

To determine the effect of acute alcohol intoxication and chronic alcohol abuse on morbidity and mortality from trauma.

DESIGN

Prospective cohort study.

PATIENTS

Blunt or penetrating trauma patients at least 18 years of age admitted to one trauma center or dying at the injury scene.

MAIN OUTCOME MEASURES

Mortality, complications (infection, pneumonia, respiratory failure, or multiple organ failure), and length of hospital stay.

RESULTS

Acute intoxication had no effect on risk of dying--at the injury scene, within the first 24 hours of hospitalization, after the first 24 hours, or overall. Acute intoxication also did not increase the risk of complications and was associated with shorter lengths of stay. Patients with both biochemical and behavioral evidence of chronic alcohol abuse had a twofold increased risk of complications, particularly pneumonia and any infection, compared with those with no evidence of chronic alcohol abuse.

CONCLUSIONS

Chronic, but not acute, alcohol abuse adversely affects outcome from trauma. Attention to the problem of chronic alcohol abuse in trauma patients is necessary, and screening trauma patients for chronic alcohol abuse appears to be warranted.

Clinical treatment matching models for dually diagnosed patients

The models of serial, parallel, and integrated treatment should help administrators and clinicians to think through resources they have and ones they may be able to share. Certain patients should do better with one or another of the models, but these empirical approaches need testing. Though large controlled outcome studies for various models of dual diagnosis treatment are pending, pilot studies of interventions have been positive, and the need for designing and implementing sensible programs to address the dual diagnosis patient is here right now.

Response to diazepam in sons of alcoholics

Alcohol exerts several of its actions via the chloride channel associated with the central GABA-benzodiazepine receptor complex. To explore a possible role for this receptor complex in risk for alcoholism, and to determine whether risk for alcoholism is associated with risk for benzodiazepine abuse, the authors administered intravenous diazepam to 18 sons of male alcoholics (SOAs) and 18 control subjects. Four logarithmically increasing doses of diazepam and matched volumes of placebo were given in randomized order on separate days about 1 week apart. SOAs were significantly more likely than controls to report euphoric responses to diazepam. At some diazepam doses, SOAs were more likely to report feeling "high" and "intoxicated." SOAs and controls did not differ in feeling "drugged." SOAs and controls may differ in expectations regarding the subjective effects of drugs and/or in the function of the central GABA-benzodiazepine receptor complex. These findings also add further evidence for increased pleasurable effects, and thus possibly increased risk for benzodiazepine abuse, in a subgroup of SOAs.

Stability analysis for grating-tuned strong-external-feedback semiconductor lasers

We give a simple stability analysis within the scope of steady-state solution for the grating-tuned strong-external-feedback semiconductor lasers. In our model, a fluctuation in the refractive index of an active medium through the coupling of carrier density will cause another fluctuation in the refractive index. If the latter is always smaller than the former, the fluctuation will be damped, and therefore the corresponding operating point of the laser is stable. Our analysis indicates that there are various stable and unstable operating-frequency ranges for various reflectivities of the internal facet of the laser diode. In addition, it agrees well with the experimental results and explains the bistability of threshold gain versus operating frequency.

Comparison of the intensity and duration of effects of inhaled bitolterol and albuterol on airway caliber and airway responsiveness to histamine

Inhaled beta-agonists can produce bronchodilatation and reduce airway hyperreactivity in patients with asthma. Using these two measures, we compared inhaled bitolterol (three puffs, 1110 micrograms), albuterol (two puffs, 180 micrograms), and placebo administered by metered-dose inhaler in a blinded, crossover study of 40 subjects with chronic asthma. On each study day, subjects underwent histamine challenges at 1 1/2 hours before, and 1/2, 2, 4, 6, and 8 hours after inhaling one of the three test-drug treatments. Both drugs produced significant bronchodilatation at 30 minutes through 4 hours and significant effects on airway reactivity at 30 minutes through 2 hours (p less than 0.05). Bitolterol also produced small but significant bronchodilator effects at 6 hours and effects on airway reactivity at 4 hours (p less than 0.05). Effects of bitolterol on airway reactivity diminished significantly more slowly than effects of albuterol in subjects with baseline provocative concentration causing a 20% fall in FEV1 greater than or equal to 1.0 mg/ml of histamine (half-life of biologic effect 1.37 versus 0.92 hours; p less than 0.05) but not in subjects with baseline provocative concentration causing a 20% fall in FEV1 less than or equal to 1.0 mg/ml (half-life of biologic effect of 1.01 versus 1.00 hours; p greater than 0.05).

Delayed hypertension with electroconvulsive therapy

A 74-year-old woman with essential hypertension underwent a course of electroconvulsive therapy (ECT) for the treatment of psychotic depression. Her treatments were associated with delayed and significant hypertension. Clonidine, which controlled her baseline blood pressure, was inadequate in treating her post-ECT hypertension. Acute treatment with hydralazine also failed. Labetalol, a short-acting beta-blocking agent with some alpha-1 blocking activity, worked well both acutely (intravenously) and orally to manage essential and ECT-induced hypertension.

Use of bronchial provocation with histamine to compare the pharmacodynamics of inhaled albuterol and metaproterenol in patients with asthma

Because measurement of effects on airway responsiveness may have advantages over the study of bronchodilatation for the evaluation of the effects of inhaled beta 2-agents, we developed a method using airway responsiveness for the independent quantitation of the relative potencies and rates of decline in effect of these drugs. This methodology was applied to the evaluation and comparison of inhaled metaproterenol and albuterol. The effects of two different doses of each drug (one and two inhalations of albuterol and two and four inhalations of metaproterenol from commercially available metered-dose inhalers) were compared with a double-blind, randomized, placebo-controlled, crossover study of 13 subjects. The effects of metaproterenol and albuterol declined at rates that were not significantly different. However, based on the effects on activity ratio at 30 minutes, each puff of metaproterenol was an estimated 0.37 times as potent as each puff of albuterol (95% confidence limits, 0.22 to 0.52). In recommended two puff doses, measurable effects of albuterol persisted longer than effects of metaproterenol. However, this appears to be because of a greater initial effectiveness of two puffs of albuterol rather than differences in the rates at which the effects of the two drugs declined with time. Airway responsiveness thus appears to be a useful tool for evaluating inhaled beta 2-agonists and designing beta 2-agonist dosing regimens.

Schizophrenia

The diagnostic criteria for schizophrenia have been extensively changed by the third edition of the Diagnostic and Statistical Manual of Mental Disorders, recently adopted by the American Psychiatric Association (DSM III). To receive this diagnosis, the patient must have onset of illness before age 45 years, have had a chronic course, manifest the presence of characteristic symptoms, such as delusions, hallucinations, or loose associations during a phase of the illness, and have experienced a downhill social and vocational course; affective disorders and organic brain syndrome must be carefully excluded. The utilization of this "narrow" definition has caused a major shift toward increasing the diagnosis of affective disorders and decreasing the diagnosis of schizophrenia in the United States. The etiology of schizophrenia is still uncertain, but recent research has elucidated one subgroup of schizophrenic patients who have subtle indices of neurological damage and a clinical course similar to that found in dementia. Dopamine excess in the mesolimbic system is the predominant inferred cause for the majority of schizophrenia cases, and antipsychotic medications all rely on dopamine receptor blockade for their efficacy. Antipsychotic medications are effective in schizophrenia but are less potent against such negative symptoms as apathy, neglect of personal hygiene, and social withdrawal.

The dexamethasone suppression test as a diagnostic aid in late onset paranoia

A case of acute paranoia in a 64-year-old woman with a previous history of one depressive episode is described. Accurate diagnosis was hampered by her illogical and tangential answers to questions and the development of an organic brain syndrome while on neuroleptics and anticholinergics. She did not tolerate tricyclic antidepressants and was unresponsive to three electroconvulsive therapy (ECT) treatments. Because of the previous history of depression and the presence of some depressive symptoms, the possibility of a depression underlying her paranoid psychosis was considered. A dexamethasone suppression test (DST) was performed to confirm this and was found to be abnormal. ECT was then continued with the eventual result of complete remission in symptoms. The authors discuss the potential usefulness of the DST in confirming a diagnosis of depression in selected cases of late onset psychosis.

A prospective study of 60 consecutive psychiatric consultations in a family medicine clinic

This paper describes a prospective study collating demographic, medical, psychiatric, and illness behavior characteristics of 60 consecutive patients referred for consultation to a psychiatric liaison physician attending in a family medical clinic. The data were accumulated to add to the developing body of information about the characteristic psychosocial problems family physicians treat. Results showed that the most frequent psychiatric diagnosis in these patients was primary affective disorder depression. The presence of somatic complaints often obscured the recognition and management of psychiatric syndromes such as depression, anxiety neurosis, personality disorder, family and marital discord, psychosis, and alcoholism. The importance of training in psychopharmacology and time limited psychotherapy was underscored by the frequent consultant recommendations for the use of these treatment modalities by the family physician. Patients averaged 2.4 illness problems (psychosocial problems and reactions that arise from a perceived illness), pointing to the need to systematically evaluate and treat them concomitantly with traditional disease problems.

Transcultural psychiatry on an American psychiatric ward

Transcultural psychiatry is generally thought to be an appropriate concern only in distant or unusual environments. But because many immigrant groups in the U.S. maintain their original customs and traditions, a transcultural approach may be necessary in many clinical situations, as illustrated by the case histories of three immigrant patients on a university hospital's psychiatric service. All had manifestations of severe psychiatric disturbance, but their clinical evaluation and management were complicated by difficulties in communication and by culturally linked behavior patterns and family responses at variance with American norms. Careful attention to transcultural factors is necessary for the optimal management of such cases.

Modern diagnosis schizophrenia in hospitalized psychiatric patients

The authors applied modern criteria to the diagnosis of 254 patients admitted to the psychiatric wards of an urban hospital. They found that only 16 (6.3%) met the St. Louis criteria for schizophrenia. Other studies using similar criteria also reported a consistently low prevalence of schizophrenia in general psychiatric inpatient populations. However, 30 "undiagnosed" patients (12%) in this study narrowly missed the definite diagnosis of schizophrenia because of the presence of affective disorder and/or insufficient duration of symptoms. The authors discuss the clinical and research implications of these findings.

Electroconvulsive therapy following pituitary surgery

A 39-year-old female with a history of three psychotic episodes in 6 months developed Cushingoid features and catatonia. Despite the surgical removal of a pituitary basophil adenoma and treatment with neurleptics, her catatonia worsened. Electroconvulsive therapy provided rapid, life-saving relief for this patient. Patient characteristics are discussed and treatment recommendations provided.