Psychotic symptoms and disorders and the risk of violent behaviour in the community

This study uses data from the Epidemiologic Catchment Area (ECA) surveys to examine the strength of the association between psychotic symptoms and violent behaviour, controlling for underlying mental disorder, substance abuse, sociodemographic characteristics and use of mental health services, in a representative sample of community residents. A replication is conducted of a study that found an increased risk of violence associated with a particular cluster of psychotic symptoms involving perceived threat and internal control-override (TCO). Respondents who reported TCO symptoms were about twice as likely to engage in assaultive behaviour as those with hallucinations or other psychotic symptoms, and about five times as likely as those with no mental disorder. The combination of substance use disorders with TCO symptoms added significantly to the risk of violent behaviour. Those with a history of using mental health services also posed a higher risk of violence, probably due to the differential selection of more severely ill and ‘dangerous’ individuals into treatment settings. Copyright © 1996 Whurr Publishers Ltd.     

Can involuntary outpatient commitment reduce hospital recidivism?: Findings from a randomized trial with severely mentally ill individuals

OBJECTIVE: The goal of this study was to evaluate the effectiveness of involuntary outpatient commitment in reducing rehospitalizations among individuals with severe mental illnesses. METHOD: Subjects who were hospitalized involuntarily were randomly assigned to be released (N = 135) or to continue under outpatient commitment (N = 129) after hospital discharge and followed for 1 year. Each subject received case management services plus additional outpatient treatment. Outpatient treatment and hospital use data were collected. RESULTS: In bivariate analyses, the control and outpatient commitment groups did not differ significantly in hospital outcomes. However, subjects who underwent sustained periods of outpatient commitment beyond that of the initial court order had approximately 57% fewer readmissions and 20 fewer hospital days than control subjects. Sustained outpatient commitment was shown to be particularly effective for individuals with nonaffective psychotic disorders, reducing hospital readmissions approximately 72% and requiring 28 fewer hospital days. In repeated measures multivariable analyses, the outpatient commitment group had significantly better hospital outcomes, even without considering the total length of court-ordered outpatient commitments. However, in subsequent repeated measures analyses examining the role of outpatient treatment among psychotically disordered individuals, it was also found that sustained outpatient commitment reduced hospital readmissions only when combined with a higher intensity of outpatient treatment. CONCLUSIONS: Outpatient commitment can work to reduce hospital readmissions and total hospital days when court orders are sustained and combined with intensive treatment, particularly for individuals with psychotic disorders. This use of outpatient commitment is not a substitute for intensive treatment; it requires a substantial commitment of treatment resources to be effective.     

Gastrointestinal and Hepatic Manifestations of COVID-19: Evolving Recognition and Need for Increased Understanding in Vulnerable Populations

The novel coronavirus, SARS-CoV-2, has caused a global pandemic with high morbidity and mortality. It was first observed to cause a severe acute respiratory syndrome. However, gastrointestinal and hepatic manifestations have been increasingly recognized.Gastrointestinal symptoms include diarrhea, epigastric pain, nausea, and vomiting. Diarrhea is the most common GI manifestation of SARS-CoV-2 and can present without or without respiratory symptoms. Patients with GI symptoms have been associated with longer duration of illness and may be associated with more severe illness. Mechanism of diarrhea is thought to be related to direct viral cytotoxicity occurring when the SARS-CoV-3 enters GI cells via the ACE-2 receptor. Inflammatory response and cytokine release likely contributes to symptoms.SARS-CoV-2 can cause hepatic injury. Studies have shown mild to moderate elevation of liver enzymes. The pattern of liver abnormalities can be hepatocellular, cholestatic or mixed. Patients with severe infection have significantly higher rates of liver injury and worse outcomes. Proposed mechanisms for injury include immune mediated systemic inflammatory response, direct cytotoxicity from viral replication and hypoxia-reperfusion dysfunction.Recent data suggests that GI and hepatic injury may be under-recognized manifestation of SARS-CoV-2 infection. Patients with diarrhea and liver disease may have a worse prognosis. The rapidly evolving literature continues to reveal a growing body of information which enables updated guidance for management. More investigation is needed which focuses on vulnerable patients, including the elderly, those with underlying illness, as well as, racial and ethnic minorities.     

Genetic markers of resistance to pyrimethamine and sulfonamides in Plasmodium falciparum parasites compared with the resistance patterns in isolates of Escherichia coli from the same children in Guinea-Bissau

The antifolate drugs sulphadoxine and pyrimethamine are used for treatment of chloroquine-resistant Plasmodium falciparum in Africa. Resistance to pyrimethamine has been associated with point mutations in the dhfr-gene and resistance to sulphadoxine with mutations in the dhps-gene. There is concern that the use of the antifolates trimethoprim and sulphamethoxazole for treatment of other infectious diseases will result in the selection of malaria parasites with mutations in these genes. In Guinea-Bissau, where sulfonamide and trimethoprim-containing drugs have been used extensively, we decided to assess the prevalence of mutations in the dhfr-and dhps-gene in P. falciparum isolated from children suffering from acute malaria and to assess the resistance patterns to trimethoprim/sulphamethoxazole in Escherichia coli isolated from the same patients. A thick film and a blood sample for polymerase chain reaction (PCR) were obtained from 100 children attending the Bandim Health Centre in Bissau with symptoms compatible with malaria. Furthermore, a stool sample was collected from the same children and cultured for E. coli. Of the cultured E. coli, 67% were resistant both to sulfonamides and trimethoprim, 4% to sulfonamides alone, 3% to trimethoprim alone while 26% were fully sensitive to both drugs. PCR was successfully performed in 97 blood samples. Of these, 41% had triple mutations at the dhfr-gene (at codons 51, 59 and 108), and 15% had triple mutations plus mutation at codon 437 in the dhps-gene. Only 45% harboured the wild-type dhfr-gene. Thus both bacterial resistance and mutations in the parasitic genes were common, but not linked in the individual child. As sulphadoxine-pyrimethamine has only been used as a second line treatment for chloroquine resistant malaria in Guinea-Bissau for a few years, it is worrying to find a high prevalence of mutations in the parasitic genes coding for resistance to these drugs. Therefore, restricting the use of sulphadoxine-pyrimethamine for the treatment of chloroquine resistant malaria might not be sufficient to prevent the development of resistance in the parasites as long as antifolate drugs are used extensively.     

A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.     

Assessing violence risk among youth

Despite recent declines in the reported rate of juvenile violence, there appears to be increasing public and professional concern about violent behavior among children and adolescents. Media accounts of school shootings and juvenile homicides have prompted a need to develop approaches for systematically assessing violence risk. This article describes the task of assessing general violence risk among youth, and argues that a somewhat different approach is required to assess cases where an identified or identifiable young person may pose a risk to a specifically identified or identifiable target (also referred to as "targeted violence"). Key risk factors for violent behavior among children and adolescents are identified, fundamental principles for conducting an assessment of violence potential in clinical and juvenile justice contexts are outlined, and an approach to assessment when an identified person engages in some communication or behavior of concern that brings him or her to official attention is briefly described.     

Tissue carnitine reserves of newborn infants

This study assessed the tissue reserves of carnitine at birth in a group of neonates (n = 22) of varying gestational age dying within 24 h of birth, prior to possible changes in carnitine status induced by postnatal intervention. Tissue carnitine concentration was highest in the muscle in each infant. The mean (+/- SD) muscle carnitine concentration of 8.4 +/- 3.6 nmol/mg noncollagen protein (NCP) in very immature infants (less than or equal to 1000 g birth weight) was significantly lower than the corresponding mean (+/- SD) values of 14.0 +/- 3.2 nmol/mg NCP in larger preterm infants (1001-2500 g; P less than 0.01) and 19.4 +/- 2.6 nmol/mg NCP in term infants (greater than or equal to 2501 g; P less than 0.001). Muscle carnitine concentration correlated positively with gestational age (r = 0.832; P less than 0.001) and with body dimensions. Liver and heart carnitine concentrations did not correlate significantly with gestation or body dimensions. The mean (+/- SD) liver carnitine concentration for all the neonates as a group was 4.1 +/- 1.5 nmol/mg NCP. The mean (+/- SD) heart carnitine concentration was 4.7 +/- 1.3 nmol/mg NCP. In comparison to adult controls, tissue carnitine concentrations were markedly lower in neonates, particularly in immature newborns. These data suggest that newborn infants, especially premature babies, are born with limited tissue reserves of carnitine and are therefore at an increased risk for developing carnitine deficiency and its adverse effects in the postnatal period, particularly if maintained on carnitine-free intravenous nutrition for prolonged periods of time.