National study of suicide method in violent criminal offenders

Background

Gaining a greater knowledge of the mechanisms and means by which violent offenders die by suicide can inform tailored preventive strategies.

Methods

Using interlinked national Danish registry data we constructed a nested case-control study dataset of all adult suicides during 1994–2006: N=9708 cases and N=188,134 age and gender matched living controls. Completely ascertained International Classification of Diseases 10th revision cause-specific mortality codes were examined, with all criminal charges since 1980, and covariate information on psychiatric treatment and socio-demographics. Self-poisonings were classified as ‘nonviolent’ suicide and all other methods as being ‘violent’ ones.

Results

Compared with the general population, risk among male and female violent offenders was strongly and significantly elevated for suicide by either a violent or a nonviolent method, although the relative risk was greater for nonviolent suicide. These patterns were also observed among nonviolent offenders, albeit with smaller effect sizes. Risk was especially raised for self-poisoning with narcotics & hallucinogens. We could only examine the full range of suicide methods in male violent offenders. In these men, hanging was the most frequently used method, although risk was markedly and significantly elevated virtually across the entire range of regularly used suicide methods.

Limitations

We lacked sufficient statistical power for undertaking a detailed profiling of specific suicide methods among female violent offenders.

Conclusions

Our findings indicate that comprehensive and broadly-based preventive approaches are needed for tackling the markedly raised risk of suicide by both violent and nonviolent means in this population. Their high relative risk for self-poisoning by illicit or illegal drugs underlines the importance of access to means and of prevailing subculture.     

A treatment for substance abusing pregnant women

We describe the adaptation of a manualized behavioral treatment for substance using pregnant women that includes components of motivational interviewing and cognitive therapy. In a pilot study conducted in 2006–2007, five non-behavioral health clinicians were trained to provide the treatment to 14 women. Therapy was administered concurrent with routine prenatal care at inner-city maternal health clinics in New Haven and Bridgeport, Connecticut, small urban cities in the USA. Substance use was monitored by self report, and urine and breath tests. Treatment fidelity was assessed using the Yale Adherence and Competence System. Behavioral treatment delivery in this setting is feasible and is being evaluated in a randomized, controlled, clinical trial.     

急性氯气染毒对小白鼠耳廓微循环及肺形态学的影响

目的 观察急性高浓度氯气染毒时小白鼠耳廓微循环及肺形态学的改变,并探索其在肺损伤中的作用,为急性氯气染毒寻找更有效的解救措施。方法 选取健康小白鼠26只,分别观察高浓度氯气染毒前及染毒后5min、15min的耳廓微循环。小白鼠死亡后,观察其肺系数以及肺形态学的改变,并与对照组进行对照。结果 小白鼠高浓度氯气染毒后1、微循环:早期,小动静脉、细动静脉痉挛收缩,毛细血管网关闭达70％,血流较快;随中毒时间延长,小静脉、细静脉开始扩张,15min时扩张最明显,染毒后5min、15min小动静脉、细动静脉以及毛细血管网改变分别与染毒前相比差异均有非常显著性(P<0.01),动脉系统扩张不明显,毛细血管网逐渐开放,血流逐渐变慢,呈粒缓流、粒摆流,最后停止,其间伴有血细胞聚集,血色暗红,血管周围有渗出、出血。2、肺系数:小白鼠氯气染毒后肺系数明显增大。与对照组相比差异有非常显著性(P<0.01)。3、肺形态结构:肺脏大体观察:染毒后小白鼠肺脏外观明显肿胀、边缘圆钝、体积增大,肺脏表面弥漫性淤血和出血,呈深红色,剪开肺组织可有血性泡沫液体流出。镜下观察:肺泡腔大小不一,部分肺泡气肿,有肺大泡,肺泡壁破裂不完整,部分肺泡腔内充满红细胞和蛋白样液体,肺血管腔明显变小,肺泡壁毛细血管扩张,其内充满红细胞,支气管     

Physician assistants training on firearm injury prevention

Objective

The purpose of this study was to assess physician assistant training programs incorporation of firearm injury prevention training in their curricula. Also, content of such programs as well as perceived benefits and barriers of providing such training were explored.

Methods

A three-wave postal mailing of a 24-item questionnaire was sent to the population (n = 145) of physician assistant program directors.

Results

The majority (77%) of directors responded. The majority (81.3%) reported they had not seriously thought about providing such training (pre-contemplation). The three most important barriers to providing firearm injury prevention training were: lack of time, lack of faculty expertise on the topic, and lack of standardized teaching materials. Those programs that offered training averaged one-half hour. Yet, 77.7% thought that firearm injuries were a very large or large problem to the health and wellbeing of the U.S. population.

Conclusion

There is a paucity of professional training for physician assistants regarding firearm injury prevention. It appears unlikely that physician assistants are playing a role in helping to reduce one of the leading causes of death in the U.S., firearm trauma. The American Academy of Physician Assistants needs to take the lead in improving training in this area for physician assistants.

Practice Implications

Physician Assistant training program directors should consider offering firearm injury prevention training to help reduce patient suicides and homicides.     

The Developmental Behavior Genetics of Drug Involvement: Overview and Comments

The papers in this special issue have in common an interest in developmental variations in the heritability of substance use, abuse, and problems. A number of the studies are longitudinal, and even those that are cross-sectional are analytically focused on whether heritability, shared, and nonshared environmentality effects are constant or change over the period from onset of use to the time when problem use is more constant. This commentary provides an overview of the work from a developmental psychopathology perspective. Findings are linked to the existing longitudinal/developmental literature on the epigenesis of substance use disorders and similarities and contradictions are noted. Suggestions for next step work, involving the need for increased differentiation of the substance abuse phenotypes, the utilization of phenotypic measures that delineate heterogeneity of course, and more precise definition of the specific environmental variations that underlie shared and nonshared environmental liability, are provided.Edited by Michael Stallings     

Challenges in Genetic Studies of the Etiology of Substance Use and Substance Use Disorders: Introduction to the Special Issue

Misuse of psychoactive substances is associated with substantial costs to users and to society. A growing literature suggests individual differences in vulnerability to develop substance related problems are influenced to a large degree by genetic factors. We review the evidence from genetic epidemiologic and molecular genetic studies of problematic use of alcohol, tobacco, and other drugs, then discuss the challenges for the next generation of studies of genetic influences on substance use. These challenges are addressed in the remaining papers of this special issue. The papers cover a variety of approaches, substances, and non-human as well as human studies, but are united by their focus on going beyond heritability estimates to address the mechanisms and processes underlying the development of substance use and substance related problems, including measurement, precursors of substance abuse, stages of substance involvement, and specificity of genetic influences.     

T lymphocyte subsets and viral infections in Sardinian parenteral drug abusers: relationship to HIV infection

To investigate whether the human immunodeficiency virus (HIV) infection or the abuse of narcotic drugs or other viral infections may be responsible for immunologic abnormalities in parenteral drug abusers, sera from 168 consecutive individual patients were collected from 1985 to 1986. The sera were tested for antibody to HIV (anti-HIV), and the clinical, immunologic, and serologic characteristics of 83 seropositive and 53 seronegative parenteral drug abusers were compared. The presence of anti-HIV was significantly associated with a decreased number of T helper lymphocytes (P less than .001), a reduced T helper/suppressor ratio (P less than .001). Of the 83 seropositive patients, 63 (76%) had generalized lymphadenopathy and 16 (18%) had AIDS-related complex. No patient had AIDS. Parenteral drug abusers with AIDS-related complex had significant reductions in the number of T helper cells (P less than .01) and the T helper/suppressor ratio (P less than .01) compared with patients with lymphadenopathy syndrome (LAS), suggesting that parenteral drug abusers with HIV infection develop a progressive immunodeficiency. IgG antibody to cytomegalovirus was found in 75% of anti-HIV-positive and 45% of anti-HIV-negative parenteral drug abusers (P less than .01), but significant associations between anti-HIV and markers for other viruses were not found. Our data confirm that HIV infection is the major cause of low T helper cells and reversed T helper/suppressor ratio in parenteral drug abusers.(ABSTRACT TRUNCATED AT 250 WORDS)     

Substance misuse and substance use disorders in sex offenders: a review

Substance abuse has often been associated with committing sex offenses. In this article, the following will be reviewed: 1) studies that assessed substance abuse in sex offenders; 2) differences in substance abuse among different types of sex offenders; 3) differences in substance abuse between sex offenders and nonsexual offenders and substance abuse in the normal population; 4) sex offenders’ intoxication at the time of the offense; and 5) differences in intoxication at the time of the offense among different types of sex offenders. Studies will be discussed according to the method they used to assess substance abuse, i.e., file research, screening instruments or semi-structured interviews. This review shows that about half of the sex offenders has a history of substance abuse, a quarter to half of the sex offenders has a history of alcohol misuse and that about one fifth to a quarter of the sex offenders has a history of drug misuse. Furthermore, about a quarter to half of the sex offenders appeared to be intoxicated at the time of the offense. The review results in recommendations for future research. Because of the high prevalence of substance abuse in sex offenders it is advisable to routinely screen for substance abuse and, if necessary, to treat substance abuse.     

Postpartum Blues

An experience that occurred during an obstetrics 3rd year clerkship on the postpartum wards elaborates on and reflects upon the interaction between a student and patient.The stressful interaction and ultimate resolution underpin the sometimes critical moments in education that help define patient-physician relationships.     

The Time between Paraquat Ingestion and a Negative Dithionite Urine Test in an Independent Risk Factor for Death and Organ Failure in Acute Paraquat Intoxication

To identify a prognostic marker that is less sensitive to variations in the elapsed time since paraquat ingestion, we assessed the time between paraquat ingestion and a negative dithionite urine test as a prognostic parameter in patients with acute paraquat intoxication. Forty-one patients with acute paraquat intoxication were enrolled in this study and analyzed to verify significant determinants of mortality and organ dysfunction. The amount of paraquat ingested, paraquat plasma levels, and the time to a negative urine dithionite test were significant independent risk factors predicting mortality. The amount of paraquat ingestion, and the time to a negative urine dithionite test were independent risk factors predicting organ dysfunction. With a cut-off value of 34.5 hr for the time to negative conversion of the urine dithionite test, the sensitivity and specificity for mortality were 71.4% and 75.0%, respectively. The incidence of acute kidney injury and respiratory failure above 34.5 hr were 100% and 85.0%, respectively. In conclusion, the time to a negative urine dithionite test is the reliable marker for predicting mortality and/or essential organ failure in patients with acute paraquat intoxication, who survive 72 hr.     

我国首批美沙酮维持治疗试点工作效果分析

目的对我国首批8个美沙酮维持治疗试点门诊的工作效果进行评估。方法在美沙酮门诊开诊时、运行6个月及1年后三个时点,对受治者的人口学特征及吸毒有关行为等进行问卷调查,比较吸毒、违法行为、家庭关系等变化情况。结果共有585人、609人和468人分别参加了基线调查、6个月评估和1年评估调查。受治者过去1个月注射吸毒的比例从基线的69.1%分别下降到6个月后的8.9%和1年后的8.8%;在有注射行为人群中,过去1个月注射次数由参加治疗前的平均90次下降到6个月和1年后的平均2次;受治者有工作的比例从治疗前的22.9%上升到6个月后的43.2%和1年后的40.6%。自我报告过去1个月因吸毒而发生违法犯罪行为的比例从治疗前的20.7%下降到6个月后的3.6%和1年后的3.8%。自我感觉家庭关系良好的比例从治疗前的49.6%上升到1年评估时的65.8%。95.9%的受治者对试点门诊提供的服务表示满意。结论首批美沙酮维持治疗试点工作已在减少毒品使用、减少与吸毒有关的高危行为、减少与吸毒有关的违法犯罪行为以及恢复受治者的社会家庭功能方面取得效果。美沙酮门诊可作为针对吸毒者开展多种形式综合服务的平台。     

Contraception in obese older women

Obesity is increasing in most western countries and rises significantly with age. Obese women are as sexually active as women of normal weight, and new sexual relationships in the older reproductive years are becoming more commonplace and still require effective contraception. Continuation of pregnancy in a woman over 40 carries health risks which are exacerbated by the presence of obesity. A high proportion of pregnancies in women over 40 are unplanned and end in therapeutic abortion. The prevalence of obesity and the high rates of contraceptive use amongst older women mean that any increase in associated risk is likely to be of public health concern. There are very few data on the specific risks of contraceptive use in obese older women. As fertility declines with age, all methods become increasingly effective. No single method is contraindicated by age alone but particular caution is required where the use of estrogen containing preparations is considered as the risks associated with estrogen are all also independently associated with increasing age and body mass index. Non-estrogen containing methods are available, whether hormonal, barrier or surgical, which are effective, acceptable and safer in the obese older woman. Some methods of contraception may indeed have particular non-contraceptive benefits for this population.     

Working memory and depressive symptoms in patients with schizophrenia and substance use disorders

Background. Substance abuse is highly prevalent in schizophrenia and it has been associated with negative consequences on the course of the pathology. Regarding cognition, the prevailing literature has produced mixed results. Some groups have reported greater cognitive impairments in dual diagnosis schizophrenia, while other groups have described the reverse.

Objective. The current cross-sectional study sought to investigate the potential differences in psychiatric symptoms and cognition between schizophrenia patients with and without substance use disorders.

Methods. Fifty-three schizophrenia patients were divided into two groups: with (n=30) and without (n=23) a substance use disorder (DSM-IV criteria). Psychiatric symptoms were measured with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS). Psychomotor speed and spatial working memory were measured using Cambridge Neuropsychological Tests Automated Battery (CANTAB).

Results. Patients in the dual diagnosis group displayed more severe depressive symptoms and poorer strategy during the working memory task.

Conclusions. These results are in keeping with the prevailing literature describing negative consequences of substance abuse in schizophrenia. Substance abuse may exacerbate depressive symptoms and interfere with metacognition in schizophrenia.     

Pioneer women in the development of toxicology in Brazil

Women have always played an important role in the development of toxicology all over the world. Specifically in Brazil, toxicology has had greater female representation than other countries, but women''s participation at high hierarchical levels is low. Although more than 62% of the members of the Brazilian Society of Toxicology are women, only 7 out of the 22 presidents have been women throughout its 48 years of existence. This article aims to celebrate women in the field of toxicology in Brazil, based on interviews with five of these scientists who have changed the field of toxicology in Brazil as we know it today, each in their specific sub-areas. These women are: Dr. Ester de Camargo Fonseca Moraes, Dr. Silvia Berlanga de Moraes Barros, Dr. Alice Aparecida da Matta Chasin, Dr. Gisela de Aragão Umbuzeiro, and Dr. Tania Marcourakis. They are not only pioneers but they are also examples of admirable persistence in fighting the adversities presented to them. They broke the glass ceiling and opened doors for future generations of women in science. We hope that this article helps inspire women in their careers in toxicology.     

Sexual response models in women

Over the past 40 years or so, a number of models have been proposed to understand the female sexual response. Early, simpler, linear models have evolved to incorporate more sophisticated understanding of the complexity of female sexuality. Updated sexual response models can help therapists in understanding how to help women with various sexual dysfunctions.     

Muscle fiber types in women athletes and non-athletes

Summary Muscle biopsies were obtained from the vastus lateralis muscle of 5 female collegiate field hockey players and 5 untrained female students. The fibers were classified histochemically as fast-twitchoxidative-glycolytic (FOG), fast-twitch-glycolytic (FG) and slow-twitch-oxidative (SO). The fibers were found to be similar to those of males in distribution and histochemical properties, but were smaller. In the women athletes all 3 fiber types were larger than the respective fibers in the controls. Also, the athletes had a much higher percentage of oxidative fibers (SO+FOG), 83% vs. 46%. A direct relationship between fiber size and oxidative activity was observed in fasttwitch fibers, whereas the reverse was found in slowtwitch fibers.     

Do you feel alright? Attenuated neural processing of aversive interoceptive stimuli in current stimulant users

Inability to appropriately process afferent interoceptive stimuli may contribute to initiation and/or escalation of substance use. An aversive interoceptive stimulus probed neural processing in problem stimulant users (PSU; n = 19), 18 desisted stimulant users (DSU; n = 18), and healthy comparison subjects (CTL; n = 21). Participants completed a continuous performance task while they anticipated and experienced 40 cm H₂O/L/sec inspiratory breathing loads during fMRI. PSU exhibited lower left dorsolateral prefrontal cortex and inferior frontal gyrus (IFG) activation than DSU and CTL across trials. Greater lifetime drug use due to stimulants was also linked to lower activation in these regions. In addition, PSU displayed lower right IFG and insula activation during breathing load than DSU and CTL. Findings suggest that transition to stimulant use disorders is marked by weakened attentional salience of aversive stimuli.     

Dexmedetomidine infusion to facilitate opioid detoxification and withdrawal in a patient with chronic opioid abuse

Many patients are admitted to the intensive care unit (ICU) for acute intoxication, serious complication of overdose, or withdrawal symptoms of illicit drugs. An acute withdrawal of drugs with addiction potential is associated with a sympathetic overactivity leading to marked psychomimetic disturbances. Acute intoxication or withdrawal of such drugs is often associated with life-threatening complications which require ICU admission and necessitate prolonged sedative analgesic medications, weaning from which is often complicated by withdrawal and other psychomimetic symptoms. Dexmedetomidine, an alpha-2 (α(2)) agonist, has been used successfully to facilitate withdrawal and detoxification of various drugs and also to control delirium in ICU patients. Herein, we report a case of a chronic opioid abuse (heroin) patient admitted with acute overdose complications leading to a prolonged ICU course requiring sedative-analgesic medication; the drug withdrawal-related symptoms further complicated the weaning process. Dexmedetomidine infusion was successfully used as a sedative-analgesic to control the withdrawal-related psychomimetic symptoms and to facilitate smooth detoxification and weaning from opioid and other sedatives.