Evaluation of health services use following the initiation of risperidone long-acting therapy among schizophrenia patients in the veterans health administration

WHAT IS KNOWN AND OBJECTIVE

The introduction of long-acting injection antipsychotic agents has been associated with better treatment persistence and better subsequent patient outcomes. However, limited empirical data are available on patient outcomes resulting from the initiation of long-acting injectable antipsychotic agents. In this study, we assessed patterns of health-care utilization following the initiation of risperidone long-acting therapy (RLAT), the first and only second generation long-acting injectable antipsychotic agent, in schizophrenia patients within the Veterans Health Administration.

METHODS

Patients were identified if they initiated RLAT between 1 October 2005 and 30 September 2006, were ≥ 18 years of age at the time of initiation, and had at least four injections following the initiation. Paired t-tests and McNemar tests were used to compare patterns of health services use during 12 months pre- and post-initiation.

RESULTS AND DISCUSSION

Among 924 eligible study subjects, about 94% were male with mean age of 51·1 years and as high as 60% had >3 and 29% had >5 comorbid conditions. The initiators of RLAT had an average of 17·3 (SD ± 9·7) injections within the 12 months following the initiation, with an average of 14 days between injections. Between the pre- and post-initiation periods, although the number of psychiatric-related outpatient visits increased from 24·6 to 39·1 (P < 0·001), the number of psychiatric hospitalizations decreased from 1·4 to 1·0 (P < 0·001) with an average length of stay reducing from 20 to 14 days (P < 0·001). The percentage of patients who experienced at least one or two psychiatric-related hospitalizations decreased from 68·9% to 45·7% (P < 0·001) and from 34·9% to 24·4% (P < 0·001), respectively.

WHAT IS NEW AND CONCLUSION

Despite the values of RLAT in treating patients with schizophrenia, RLAT is largely underutilized in routine clinical practice. This observation highlights the importance for future research to ascertain the cost-effectiveness of initiating RLAT, especially the extent to which medication adherence influences the prescription pattern of RLAT and subsequent costs of initiating RLAT.

Sudden death due to undetected mediastinal germ cell tumor

A 32-year old man, apparently asymptomatic, was found dead in his apartment. Autopsy revealed a large necrotic mediastinal mass with liver and occipital brain metastases, the latter having produced acute intraparenchymal and intraventricular hemorrhage with cerebellar tonsillar herniation. Histologically, the mediastinal mass and metastases were consistent with immature extragonadal teratoma, with malignant transformation of the intestinal-type epithelium. Undiagnosed neoplasms as causes of sudden death are quite rare and usually reported in older age groups; however, in one study of autopsies in a 25-to 46-year-old age group, a significant 3.2% was reported. Germ cell tumors of the mediastinum are the most common extragonadal primary site, accounting for approximately 50%-70% of extragonadal germ cell tumors (EGCTs) and primarily affecting 20- to 35-year-old men. EGCTs are usually symptomatic at the time of diagnosis, although a large proportion may be asymptomatic. This case represents one the few reported cases of sudden death as a result of mediastinal EGCT; it also demonstrates the natural course of this disease and underscores the importance of medicolegal autopsies in cases of sudden death.

Adult-onset MELAS. Evidence for involvement of neurons as well as cerebral vasculature in strokelike episodes

BACKGROUND

We report a 46-year-old woman with implications regarding pathogenesis of strokelike episodes in MELAS (mitochondrial encephalomyopathy, lactic acidosis, and strokelike episodes). She had a 10-month history of episodic seizures, strokes, cognitive decline, vomiting, and ileus. She also had sensorineural hearing loss, insulin-dependent diabetes mellitus of several years' duration, and persistent lactic acidosis. Family history was pertinent for a similar syndrome in her deceased mother (onset in her sixties), for hearing loss and diabetes mellitus in two brothers, and for hearing loss in her only child, a son.

CASE DESCRIPTION

Serial MRIs of the brain revealed severe but evanescent cerebral cortical abnormalities. A left temporal brain biopsy was performed to exclude encephalitis. Light microscopy revealed a diffuse fibrillary gliosis with abundant reactive gemistocytes, focal evidence of ischemic neuronal injury, and edema. Electron microscopy revealed bizarre enlarged mitochondria and changes consistent with cellular edema. Succinate dehydrogenase staining was strongly reactive within cerebral blood vessels and within neurons. A point mutation was subsequently found at nt 3243 of the mitochondrial tRNA(Leu(UUR) gene in peripheral leukocytes and in brain, confirming the clinical diagnosis of MELAS. Quantitation revealed that 82% of brain mitochondria carried the disease mutation, indicating that most, if not all, tissues were affected.

CONCLUSIONS

Our findings suggest that strokelike episodes in MELAS result from defects in neuronal metabolism, as well as in cerebral vasculature.

Anatomy of the palmar cutaneous branch of the median nerve: clinical significance

A detailed anatomic, histologic, and immunohistochemical study of the palmar cutaneous branch of the median nerve (PCBMN) and its distal arborization was undertaken on 12 fresh human cadaveric hands. Small unmyelinated fibers terminated in the superficial loose connective tissue of the transverse carpal ligament. There were no nerve fibers detected in the deep, dense collagen aspect of the ligament. Based on these findings, during open carpal tunnel release, the skin incision should be placed along the axis of the ring finger to avoid injury to the superficial branches of the PCBMN. When open release is used, the very small terminal branches in the loose tissue of the ligament will be transected; this may in part be responsible for postoperative soft tissue pain. For endoscopic releases, some risk for transection of the main trunk of the PCBMN at the proximal incision exists. Repeated passes of the endoscopic knife should be avoided in an attempt to limit damage to the small fibers in the superficial aspect of the ligament.

A case of external beveling with an entrance gunshot wound to the skull made by a small caliber rifle bullet

The external beveling caused by an entrance gunshot wound to the skull has not been completely explained, but the mechanism is probably a combination of several factors including the angle of shot, twisting force of a rotating bullet, blow-back effect, velocity, shape and size of the bullet, outspread of the kinetic energy from the bullet, and resistance of the skull.

Oxidation of uric acid. 4. Synthesis, structure, and diabetogenic action of 5-imino-2,4,6(1H,3H,5H)-pyrimidinetrione salts and their alloxan-like covalent adducts

Three synthetic routes to salts of 5-amino-5-hydroxy-2,4,6(1H,3H,5H)-pyrimidinetrione (10) are described. The key reactions involved acid-catalyzed cleavage of 5-amino-5-ureido-2,4,6(1H,3H,5H)-pyrimidinetrione (7), conversion of uramil (8) to dehydrouramil (9) and subsequent hydration, and the condensation of alloxan (5) with ammonium salts. The carbinol ammonium salt structure 10a was unambiguously established by X-ray crystallography. New alloxan-like compounds 7, 9, and 10 were evaluated for diabetogenic activity in rats. Compound 7 was inactive, whereas compounds 9 and 10 showed the highest activity comparable to that of streptozotocin (12).