Racial differences in pathways to care preceding first episode mania or psychosis: a historical cohort prodromal study

BackgroundThere is evidence suggesting racial disparities in diagnosis and treatment in bipolar disorder (BD) and schizophrenia (SZ). The purpose of this study is to compare psychiatric diagnoses and psychotropic use preceding a first episode of mania (FEM) or psychosis (FEP) in racially diverse patients.MethodsUsing a comprehensive medical records linkage system (Rochester Epidemiology Project, REP), we retrospectively identified individuals diagnosed with BD or SZ and a documented first episode of mania or psychosis. Illness trajectory before FEP/FEM were characterized as the time from first visit for a mental health complaint to incident case. Pathways to care and clinical events preceding FEP/FEM were compared based on subsequent incident case diagnosis (BD or SZ) and self-reported race (White vs. non-White).ResultsA total of 205 (FEM = 74; FEP = 131) incident cases were identified in the REP. Duration of psychiatric antecedents was significantly shorter in non-White patients, compared to White patients (2.2 ± 4.3 vs. 7.4 ± 6.6 years; p < 0.001) with an older age at time of first visit for a mental health complaint (15.7 ± 6.3 vs. 11.1 ± 6.0 years; p = 0.005). There were no significant differences by race in FEM pathway to care or age of first seeking mental health. Overall non-White patients had lower rates of psychotropic use.ConclusionThese data are unable to ascertain reasons for shorter duration of psychiatric antecedents and later age of seeking care, and more broadly first age of initial symptom presentation. If symptoms are confirmed to be earlier than first time seeking care in both groups, it would be important to identify barriers that racial minorities face to access timely psychiatric care and optimize early intervention strategies

Treatment-Resistant Bipolar Depression: Therapeutic Trends, Challenges and Future Directions

Omar H Elsayed,1 Mete Ercis,2 Mehak Pahwa,1 Balwinder Singh2 1Department of Psychiatry and Behavioral Sciences, University of Louisville, Louisville, KY, USA; 2Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN, USACorrespondence: Balwinder Singh, Mayo Clinic, 200 First Street SW, Rochester, Minnesota, 55905, Tel +1 507-255-9412, Fax +1 507-284-3933, Email [email protected]: Bipolar disorder (BD) is a chronic mental illness impacting 1– 2% of the population worldwide and causing high rates of functional impairment. Patients with BD spend most of their time in depressive episodes and up to one-third of patients do not respond to adequate doses of medications. Although no consensus exists for definition of treatment-resistant bipolar depression (TRBD), failure of symptoms improvement despite an adequate trial of two therapeutic agents is a common theme of TRBD. In this paper, we review the evidence base of therapeutic interventions, challenges, and potential future directions for TRBD.Methods: We conducted a literature search for randomized controlled trials on PubMed for the treatment of TRBD and ongoing trials for the treatment of TRBD/bipolar depression on clinicaltrials.gov.Results: Several therapeutic agents have been investigated for TRBD. Adjunctive pramipexole and modafinil have data supporting short-term efficacy in TRBD, along with limited data for racemic intravenous ketamine. Celecoxib augmentation of escitalopram and treatment with metformin in patients with insulin resistance showed promising results. Right unilateral electroconvulsive therapy displayed statistically significant response rate and improvement, but not remission compared to pharmacotherapy. Trials for transcranial magnetic stimulation (TMS) have failed to show a significant difference from sham treatment in TRBD.Future Trends: Pharmacological treatments with novel mechanisms of actions like brexpiprazole and vortioxetine are being investigated following successes in unipolar depression. Modified TMS protocols such as accelerated TMS are under investigation. Innovative approaches like psychedelic-assisted psychotherapy, interleukin-2, fecal microbiota transplantation and multipotent stromal cells are being studied.Conclusion: Evidence on current treatment modalities for TRBD is limited with low efficacy. More research is needed for successful treatment of TRBD. Effective therapies and innovative approaches to treatment are being investigated and could show promise.Keywords: TRBD, bipolar disorder, treatment-refractory depression, ketamin

Diarrhea In Neutropenic Patients: A Prospective Cohort Study With Emphasis On Neutropenic Enterocolitis

Background: Although diarrhea is a frequent complication in neutropenic patients, its true incidence, risk factors and clinical course have not been investigated prospectively. Patients and methods: The study was carried out at Hacettepe University Hospital for Adults and involved patients over 16 years of age. Patients with malignant diseases who were neutropenic on admission or who became neutropenic during their stay in the wards between January 2001 and February 2003 were included. They were monitored daily until discharge, exitus, or recovery from neutropenia-whichever occurred earlier-to monitor the presence of diarrhea and other infections. Results: A total of 317 neutropenic episodes in 215 patients were followed. Diarrhea was observed in 18.6% episodes, and the incidence of NEC was 3.5%. The etiology in 27% episodes of diarrhea could not be identified. The use of anthracyclines and mitoxantrone increased the incidence of diarrhea. Prior use of penicillin derivatives plus beta-lactam inhibitors and N-imidazoline derivatives was associated with decreased incidence of diarrhea. Conclusions: Diarrhea is a common complication in neutropenic patients. Not only specific conditions like NEC, but also nonspecific diseases like parasitosis may be the cause of diarrhea in this patient population.WoSScopu

Treatment of angular cheilitis: a narrative review and authors' clinical experience

Angular cheilitis (AC) is a clinical entity first described in the XIX century, characterized by erythema, rhagades, ulcerations, and crusting of one or both lip commissures and perilabial skin, responsible of an unpleasant and painful discomfort. Aim of this manuscript was to examine and evaluate the therapeutic options actually available for AC. Despite antifungals being the first-line treatment for most of clinicians, very limited scientific evidence supports their reliability, with just two RCTs published between the '70s and the '80s. Furthermore, alternative topical treatments, various techniques of occlusal vertical dimension restoration, B-vitamin supplementation, anti-drooling prosthetic device and photodynamic therapy have been experimented and proposed, mostly in the form of case reports or case-series on a small number of individuals. Our group found in 1% isoconazole nitrate (ISN) and 0.1% diflucortolone valerate (DFV) ointment the most consistent AC treatment, due to the broad spectrum of ISN against many species of dermatohpytes and bacteria, and the anti-inflammatory properties displayed by DFV. However, further and well-designed trials on larger samples of patients are needed to assess the differential profile of consistency of the treatments outlined in literature and claimed by the Authors of this paper. This article is protected by copyright. All rights reserved

Salmonella enterica serotypes and Salmonella infections: A multicenter study covering ten provinces in Turkey [Salmonella enterica serotipleri ve Salmonella enfeksiyonlari: Türkiye'de on ili kapsayan çok merkezli bir çalişma]

PubMed ID: 15490836In order to find the distinctive features of Salmonellae and Salmonella infections in Turkey, 620 Salmonellae strains, isolated from various clinical samples (481 stool, 108 blood, 12 urine, 3 bone marrow, 3 cerebrospinal fluid, 9 pus, and one from each of the bile, pleural fluid, wound, catheter samples) in 13 clinical microbiology laboratories of 10 provinces in Turkey (Ankara, Antalya, Bursa, Edirne, Eskişehir, İstanbul, İzmir, Kayseri, Konya and Trabzon) between July 1, 2000 and June 30, 2002, were serotyped. Among the patients 43% were female, 57% were male, 63.2% were from outpatient clinics and 36.8% were hospitalized patients. Seventy eight percent of the patients had gastroenteritis, 10.7% had septicemia/local infection, 9.8% had typhoid/ paratyphoid fever and 1.5% were carriers. Incidence of gastroenteritis was higher in 0-5 years age group (p<0.001). Of the 620 Salmonella enterica isolates, 47.7% were S.Enteritidis, 34.7% S.Typhimurium, 6% S.Paratyphi B, 2.9% S.Typhi, 0.2% S.Paratyphi A, 6.1% serogroup C1, and 2.4% serogroup C2. S.Enteritidis was the most common serotype in all provinces except for Kayseri, where S.Typhimurium was found to be the most common serotype (68.2%). Overall, the most frequently isolated serotype was S.Enteritidis, also being the most common serotype in stool and blood cultures. During the surveillance period two outbreaks have occurred, the first one by S.Enteritidis strains in Edirne, and the second one by S.Typhimurium strains in Kayseri. As a result, Salmonella infections are still a common health problem in Turkey, and active surveillance of Salmonella infections has vital importance