Predictors of Mortality in Patients with Delirium Tremens

Objectives:  The objectives were to identify factors that may help predict mortality for patients with delirium tremens (DT).
Methods:  The authors conducted a 1:1 gender- and age-matched case–control study of patients hospitalized for DT. Using McNemar chi-square tests and conditional logistic regression (CLR), risk factors for death, including demographics, location of diagnosis, vital sign derangements, treatment methods, and comorbid conditions, were evaluated. Crude and adjusted odds ratios (OR) and 95% confidence intervals (CI) are reported.
Results:  Thirty-five patients with DT died between January 2000 and June 2006. The majority (31; 88.6%) were male with a mean (±standard deviation [SD]) age of 51.7 (±7.6) years. Hyperthermia in the first 24 hours of DT diagnosis (OR = 10.0, 95% CI = 2.3 to 42.7), persistent tachycardia (OR = 24.0, 95% CI = 3.3 to 177.4), and use of restraints (OR = 7.50, 95% CI = 1.7 to 32.8) were associated with increased mortality by univariate analysis, while an emergency department (ED) diagnosis of DT (OR = 0.18, 95% CI = 0.05 to 0.6) and use of clonidine (OR = 0.10, 95% CI = 0.01 to 0.78) were associated with decreased mortality. In the CLR model, restraint use and hyperthermia were the only variables that remained significant (OR = 5.8, 95% CI = 1.0 to 32.2; and OR = 6.1, 95% CI = 1.2 to 30.4, respectively).
Conclusions:  The use of restraints and hyperthermia is associated with increased odds of death for patients with DT. This study highlights the need for further research into modifiable factors influencing mortality from DT.     

Is The Effect of Compulsory Community Treatment on Preventable Deaths From Physical Disorders Mediated by Better Access to Specialized Medical Procedures?

Objectives

Compulsory community treatment has been shown to reduce preventable deaths from physical disorders—these causes being up to 10 times more common than suicide in psychiatric patients. We investigated whether this was mediated by better access to specialized medical procedures.

Method:

All patients on compulsory community treatment for over 11 years were compared with matched control subjects using linked administrative health data from Western Australia (state population of about 2.24 million). Outcomes were access to revascularization and other specialized procedures at 1-, 2-, and 3-year follow-up. Logistic regression was used to adjust for demographics, prior health service use, diagnosis, and length of psychiatric history.

Results:

There were 2757 patients and 2687 control subjects (total n = 5444). Sixty-five per cent were males (n = 3522), and the average age was 36 years (SD 13.2). Most had schizophrenia or other nonaffective psychoses (74%), followed by affective disorders (26%). At 2-year follow-up, 2% (n = 53) of patients and 2.6% (n = 69) of control subjects had undergone a specialized intervention. Compulsory community treatment did not result in greater access to specialized procedures at all 3 time points even after adjusting for potential confounders.

Conclusions:

Greater access to specialized procedures does not explain the reduced mortality from preventable physical illness that had been reported in patients on community treatment orders. There must be other explanations for this finding, such as mental health staff facilitating access to chronic disease management in primary care. This warrants further research.     

Acute inflammatory response to endotoxin in mice and humans

Endotoxin injection has been widely used to study the acute inflammatory response. In this study, we directly compared the inflammatory responses to endotoxin in mice and humans. Escherichia coli type O113 endotoxin was prepared under identical conditions, verified to be of equal biological potency, and used for both mice and humans. The dose of endotoxin needed to induce an interleukin-6 (IL-6) concentration in plasma of approximately 1,000 pg/ml 2 h after injection was 2 ng/kg of body weight in humans and 500 ng/kg in mice. Healthy adult volunteers were injected intravenously with endotoxin, and male C57BL/6 mice (n=4 to 12) were injected intraperitoneally with endotoxin. Physiological, hematological, and cytokine responses were determined. Endotoxin induced a rapid physiological response in humans (fever, tachycardia, and slight hypotension) but not in mice. Both mice and humans exhibited lymphopenia with a nadir at 4 h and recovery by 24 h. The levels of tumor necrosis factor (TNF) and IL-6 in plasma peaked at 2 h and returned to baseline levels by 4 to 6 h. IL-1 receptor antagonist RA and TNF soluble receptor I were upregulated in both mice and humans but were upregulated more strongly in humans. Mice produced greater levels of CXC chemokines, and both mice and humans exhibited peak production at 2 h. These studies demonstrate that although differences exist and a higher endotoxin challenge is necessary in mice, there are several similarities in the inflammatory response to endotoxin in mice and humans.     

Predictive validity of ICD-10 hyperkinetic disorder relative to DSM-IV attention-deficit/hyperactivity disorder among younger children

BACKGROUND: Little is known about the predictive validity of hyperkinetic disorder (HKD) as defined by the Diagnostic Criteria for Research for mental and behavioral disorders of the tenth edition of the International Classification of Diseases (ICD-10; World Health Organization, 1993), particularly when the diagnosis is given to younger children. METHODS: The predictive validity of HKD was evaluated over a 6-year period and compared to the predictive validity of DSM-IV attention-deficit/hyperactivity disorder (ADHD) in 95 4-6-year-old children who met full criteria for at least ADHD and 122 demographically-matched nonreferred comparison children. Diagnoses were based on structured assessments of both parents and teachers. RESULTS: All children who met full criteria for HKD also met full DSM-IV criteria for ADHD, but only 26% of ADHD children met criteria for HKD. Children who met criteria for HKD (N = 24), children who would have met criteria for HKD but were excluded from the diagnosis because they concurrently met criteria for an anxiety disorder or depression (N = 16), and the remaining children who met DSM-IV criteria for ADHD (N = 55) all exhibited significantly more symptoms of ADHD and greater social and academic impairment during years 2-7 than nonreferred comparison children. Unlike the two other diagnostic groups, however, children who met strict criteria for HKD were not more likely than comparison children to be injured unintentionally or to be placed in special education. CONCLUSIONS: Both ICD-10 HKD and DSM-IV ADHD exhibit predictive validity over 6 years, but ICD-10 HKD appears to under-identify children with persistent ADHD symptoms and related impairment. Children who met criteria for DSM-IV ADHD but not HKD exhibited at least as much functional impairment over time as hyperkinetic children.     

Elective Single Embryo Transfer: an update to UK Best Practice Guidelines

A significant number of multiple pregnancies and births worldwide continue to occur following treatment with Assisted Reproductive Technologies (ARTs). Whilst efforts have been made to increase the proportion of elective single embryo transfer (eSET) cycles, the multiple pregnancy rate or MPR remains at a level that most consider unacceptable given the associated clinical risks to mothers and babies, and the additional costs associated with neonatal care of premature and low birth weight babies. Northern Europe, Australia and Japan have continued to lead the way in the adoption of eSET. Randomised controlled trials or RCTs, meta-analyses and economic analyses support the implementation of an eSET policy, particularly in light of recent advances in ARTs. This paper provides a review of current evidence and an update to the eSET guidelines first published by Cutting et al. (2008) Cutting, R., Morroll, D., Roberts, S., Pickering, S., &; Rutherford, A. (on behalf of BFS and ACE). (2008). Elective Single Embryo Transfer: Guidelines for Practice British Fertility Society and Association of Clinical Embryologists. Human Fertility, 11, 131–146.[Taylor &; Francis Online] , [Google Scholar] intended to assist ART clinics in the implementation of an effective eSET policy.