Factors predicting arrest for homeless persons receiving integrated residential treatment for co‐occurring disorders

Background Homeless individuals are at increased risk for health and criminal justice problems. Aims The aim of this study was to examine risk factors affecting arrest rates in a cohort of homeless people with co‐occurring psychiatric and substance‐abuse disorders. Methods Baseline data were collected from 96 homeless individuals residing in a residential treatment facility for people with co‐occurring disorders. Arrest data were obtained for 2 years following treatment intake. Regression analyses were employed to examine interactions between study variables. Results One third of the sample was arrested during the 2‐year follow‐up period, principally for drug offences. People referred to treatment directly from the criminal justice system were four times more likely to re‐offend than those referred from other sources. Participants' perceived need for mental‐health services reduced risk of arrest while their perception of medical needs increased this risk. Conclusions The relationship between referral from a criminal justice source and re‐arrest after admission to the treatment facility is unsurprising, and consistent with previous literature, but the suggestion of an independently increased risk in the presence of perceived physical health‐care needs is worthy of further study. The lower risk of arrest for people who perceive that they have psychological needs is encouraging. Copyright © 2009 John Wiley & Sons, Ltd.     

Peptic-ulcer disease in the elderly.

Peptic-ulcer disease causes significant morbidity and mortality in the elderly. It frequently presents in an atypical manner and is associated with a high incidence of complications. The prevalence of Helicobacter pylori increases with age and can have an important role in the development of ulcers. Nonsteroidal anti-inflammatory drugs also contribute to the increased incidence of ulcers and the development of complications in the elderly. Although management of ulcer disease in the elderly is similar to that in the younger population, consideration must be given to the potential for increased incidence of side effects and medication interactions. When endoscopy and surgery are performed there should be an appreciation for the risks associated with concurrent illnesses that can accompany advanced age.     

Carnitine as an essential nutrient

Carnitine performs a critically important role in energy metabolism and is synthesized in the healthy adult predominantly in the liver and kidney. The typical well balanced American diet contains significant amounts of carnitine as well as the essential amino acids and micronutrients needed for carnitine biosynthesis. Thus carnitine is an infrequent problem in the healthy, well nourished adult population in the United States. However, carnitine can be a conditionally essential nutrient for several different types of individuals. Preterm infants require carnitine for life-sustaining metabolic processes but have a carnitine biosynthetic capability that is not fully developed. There is an increasing number of documented problems with carnitine metabolism in preterm infants not receiving an exogenous source of carnitine indicating that endogenous biosynthesis of carnitine is not adequate to meet the infant's need. Children with different forms of organic aciduria appear to have a greatly increased need for carnitine to function in the excretion of the accumulating organic acids. This need exceeds their dietary carnitine intake and carnitine biosynthetic capability. Renal patients treated with chronic hemodialysis appear to lose carnitine via the hemodialysis treatment, and this loss cannot be repleted simply by endogenous biosynthesis and dietary intake. Treatment with drugs such as valproic acid and metabolic stresses such as trauma, sepsis, organ failure, etc, can also result in a requirement for exogenous carnitine. Accurate assessment of the carnitine status of patients at risk for carnitine deficiency is fundamental to the identification of those patients who require carnitine as the result of altered metabolism.     

Muscle carnitine levels in neuromuscular disease

The production of energy in muscle from long-chain fatty acid oxidation is dependent upon the presence of carnitine. An abnormally low level of muscle carnitine, as seen in patients with the carnitine deficiency syndrome, results in marked muscle weakness. Muscle from 83 consecutive patients undergoing diagnostic muscle biopsy was assayed for carnitine. Carnitine levels (mean ± SEM, expressed as nmoles carnitine per mg noncollagen protein) in muscle from patients with Duchenne dystrophy (8.1 ± 1.7) and possible Becker dystrophy (10.6 ± 3.0) were significantly (P < 0.001) different from histologically normal muscle (24.0 ± 1.4). Carnitine levels in patients with limb-girdle dystrophy (16.1 ± 3.1) and polymyositis/dermatomyositis (16.6 ± 3.2) were also low, although not as low as in Duchenne dystrophy. Carnitine levels from patients with denervation atrophy (22.1 = 3.6), nonspecific fiber atrophy (21.3 ± 1.3), and a group of miscellaneous neuromuscular diseases (20.4 ± 1.4) were not significantly different from histologically normal muscle. The low values of carnitine seen in Duchenne dystrophy and a group of possible Becker dystrophy patients may be a nonspecific effect, related to severe muscle damage.     

Altered tissue carnitine levels in animals with hereditary muscular dystrophy

Low levels of muscle carnitine have been found in patients with Duchenne dystrophy, a case possibly of Becker dystrophy, and limb-girdle syndrome as well as in patients with the recently described muscle carnitine deficiency syndrome. Tissues of the mouse, hamster, and chicken were analyzed to determine whether tissue carnitine levels were altered in the animal models of muscular dystrophy. Significantly higher levels of carnitine were found in dystrophic mouse muscle, but carnitine levels in plasma, liver and heart were normal. Histological changes in the skeletal muscle of dystrophic hamsters were relatively mild, and both skeletal muscle and plasma levels were normal. The liver carnitine level was higher than normal levels. The dystrophic hamster also had an inherited cardiomyopathy, and interestingly its heart carnitine level was much lower than normal. The red muscle of the normal chicken contained 5 times the level of carnitine found in white muscle. The dystrophic chicken had higher than normal levels of carnitine in the white muscle, but normal levels in the red muscle. Although all 3 animal models of muscular dystrophy studied have altered levels of carnitine in some tissue, none of the animal models had the same pattern of altered tissue carnitine levels seen in human patients.