The propensity to interpret data according to prior beliefs, confirmation bias is one of the most insidious forms of bias in research: old and modern examples are offered. Misinterpretation of study results is commonplace in the courtroom, often described under the rubric of “junk science.” The association of a rare exposure with a rare outcome is increasingly the focus of biomedical research, this incurs increased opportunity for bias to influence study results. Absolute rather than relative risks are an important form of interpreting rare study data. Reverse causality is a profound source of error: Is the disease responsible for increasing exposure to the putative risk factor? Various biases are linked with time: In the context of public health screening, there is lead time bias and length time bias; and for survival studies, immortal time bias. Stein’s paradox offers a caution that the results of a larger sample may actually be more predictive of the subgroup experience within that sample than the study result observed for that subgroup.

This chapter explores the phenomenon of anosognosia—unawareness of illness—in individuals with schizophrenia and related serious mental illnesses (SMI). Drawing on decades of research, Amador argues that anosognosia is not a psychological defense or denial but a neurobiological symptom resulting from brain dysfunction. The chapter critiques the use of the term “insight” and advocates for the more accurate and neutral term “anosognosia.” It reviews the etiology, prevalence, and clinical consequences of this symptom, including treatment nonadherence, increased hospitalization, and criminalization. Amador introduces the Scale to Assess Unawareness of Mental Disorder (SUMD) and other multidimensional tools for assessing anosognosia. The chapter also presents the LEAP (Listen, Empathize, Agree, Partner) communication strategy as an evidence-based, non-confrontational method to build trust and improve treatment adherence in patients with anosognosia. Finally, the chapter discusses the ethical and legal implications of involuntary treatment, emphasizing the need for compassionate, informed approaches that balance civil liberties with the realities of impaired decision-making capacity in SMI.

1. Supplemental oxygen therapy (ex: nasal cannula, high flow nasal cannula) should be the immediate first step in managing MPE-related dyspnea and hypoxia.

2. Bedside ultrasound is the initial diagnostic imaging of choice.

3. Use caution against early diagnostic closure in the dyspneic cancer patient, especially if their dyspnea appears out of proportion to the size of their pleural effusion. Alternative considerations should include pulmonary embolism, pneumonia, pneumonitis, heart failure, acute coronary syndrome, pericardial effusion, cirrhosis, hypoalbuminemia, pancreatitis, esophageal rupture, or aortic dissection.

4. Thoracentesis is the first-line temporizing intervention for symptomatic malignant pleural effusions.

5. First-line definitive pleural interventions exist, but they may require multidisciplinary discussion with procedural teams and the patient’s oncologist.

1. The diagnosis of cancer-related pericardial effusion is usually incidental, but cancer accounts for approximately one third of all cardiac tamponades.

2. IV fluids may assist in expanding the right ventricle to avoid compression in tamponade.

3. Beck’s triad includes hypotension, jugular venous distention (JVD), and muffled heart sounds. However, shortness of breath and chest pain are the most common presenting symptoms.

4. Echocardiogram is the gold standard for diagnosis of pericardial effusion. Assess for fluid collection, diastolic collapse beginning with the right atrium, and inferior vena cava (IVC) and/or hepatic vein flow.

5. Drainage, typically through pericardiocentesis, is needed when cancer or treatment-related pericardial effusion leads to hemodynamic compromise.

Anosognosia, defined as a lack of knowledge of the disease, was originally identified in neurological disorders and is common in schizophrenia. These deficits are commonly referred to as “lack of insight” or “unawareness of illness.” They include challenges in accurate judgments of the reality of experience, as well as global and specific personal abilities. Related to inaccuracies in self-assessment are response biases when an incorrect self-assessment is made. We adopted a perspective focused on Introspective Accuracy (IA) and Introspective Bias (IB). IA is the ability to accurately judge several domains of experience and functioning. These include the reality of clinical symptoms, the experience of mood states, momentary competence in the performance of cognitive assessments and everyday functional skills, and the ability to accurately anticipate the success of future performance. IB is the direction of response bias in the context of impairments in IA. Deficits in insight, judgment inaccuracies, and response bias are highly relevant as these difficulties come with downstream impacts including difficulties with treatment adherence, an increase in severity of symptoms, greater everyday disability, reduced response to cognitive training interventions, and a need for increased intensity of interventions to maintain community residence. In this article, we review the research in IA and IB in schizophrenia, including differences in momentary versus global self-assessments, and the clinical correlates and functional impacts of inaccurate self-assessments and response biases in the context of self-assessment errors. We also examine the existing data regarding the neurobiological basis of impairments in IA.

This review article explores the legislative differences across Canadian jurisdictions with respect to involuntary admission and treatment pending appeal. Some jurisdictions restrict involuntary admission for mental illness to when there is a risk for serious bodily harm or physical impairment. However, the majority of jurisdictions recognize non-bodily harms or substantial mental or physical deterioration as grounds for involuntary admission when other criteria are met. Once a person is involuntarily admitted, jurisdictions differ on how treatment is authorized and whether treatment can commence while a person contests a finding of incapacity to treatment to the courts. Some jurisdictions permit treatment pending appeal while others do not. This article compares Canadian jurisdictions’ mental health legislation and addresses discrepancies through the lens of the Canadian Charter of Rights and Freedoms and the Canada Health Act.

The history of Italian general psychiatry and forensic psychiatry over the last 50 years has been unique in the European and Western healthcare landscape. Western politicians often visit Italy to observe the successful community-based systems that have developed in that country. This article represents a first step toward a necessary attempt, to explore how specific political decisions, such as the Italian one, have produced positive outcomes for patients with psychotic disorders, outcomes not observed in many Western countries, which are instead grappling with negative outcomes such as the complicated management of homelessness and the incarceration of people who would instead require psychiatric care. In its historical context, the 1978 decision to abandon the asylum tradition in favor of socialization for patients living with severe mental disorders represented a difficult choice. This choice led to inevitable critical issues, which today are still not completely dormant. This choice has also, undoubtedly, restored dignity to people living with serious mental illness, even when that person commits a crime. To understand these changes, it is appropriate to mention the regulations that finally led to Lawnumber 180 of 1978, which decreed the closure of psychiatric hospitals (Ospedale Psichiatrico) throughout Italy and continued after 2015 with the closure of high-security psychiatric hospitals (Ospedale Psichiatrico Giudiziario) as well. Culturally, much has changed throughout this time in assistance to the mentally ill in Europe.

1. After assessing and securing airway, breathing, and circulation, hypercalcemia treatment begins with IV fluid resuscitation. Patients should receive IV fluid bolus(es) followed by high volume maintenance fluid.

2. Treatment of hypercalcemia should be started regardless of etiology or symptoms if calcium is greater than 14 mg/dL.

3. Initial treatment for hypercalcemia includes volume repletion with normal saline, discontinuation of any calcium or vitamin D supplementation and initiation of medications that block bone resorption (most commonly bisphosphonates).

4. Loop diuretics should not be given routinely, instead it should be used as a method of maintaining appropriate volume resuscitation.

5. Hemodialysis is an appropriate method of calcium removal, but is often used only in cases of very severe mental status changes or inability to give saline, such as extreme volume overload.

1. Emergency physicians should maintain a high level of suspicion for transfusion related acute lung injury (TRALI) in patients with respiratory symptoms that occur within 6 hours of a transfusion and anticipate the need for endotracheal intubation and critical care.

2. In patients already intubated for other conditions (such as trauma or compromised airway), TRALI can be detected if a sudden drop in oxygenation follows a blood transfusion.

3. Although TRALI is rare and declining in incidence due to prevention strategies, incidence can be as high as 8% in populations receiving multiple transfusions, such as oncologic patients.

4. TRALI can be distinguished from transfusion associated circulatory overload (TACO) by stable natriuretic peptide levels and no risk factors for fluid overload such as cardiomyopathy or renal insufficiency. Avoid diuretics as they may precipitate hypotension.

5. Suspected transfusion reactions must always be reported to the Blood bank for initiation of appropriate work up and donor tracing.

Among the key constructs of biomedical research (random error [chance], risk, and bias in the search for causation), bias (or systemic error) is the most formidable source of inefficient and wasteful research, leading to incorrect or exaggerated results. The cause of most disease is complex, owed to many inherent (genetic) and environmental risk factors. It is in studying the interplay of these, each incurring modest risk, that many biases come into play.

1. Although immune related myasthenia gravis (irMG) is a rare complication of immune checkpoint inhibitors, its associated morbidity and mortality is extremely high and knowledge of and identification of this complication is important.

2. Patients with irMG almost always require admission for observation and treatment as their initial symptoms may not reflect how quickly they can proceed to life threatening complications such as respiratory failure.

3. Consider concurrent immune related adverse events in patients presenting with irMG, including myositis, myocarditis, hepatitis, pneumonitis, and peripheral neuropathy.

4. Treatment often requires steroids as well as IVIG and PLEX.

5. In patients that you are worried about myositis, also consider other potential causes, including medications like statins that could be contributing.

The chapter details the journey of Bethany Yeiser, an individual living with schizophrenia, from her promising academic and musical beginnings to her descent into homelessness and psychosis. Despite facing challenges such as delusions, hallucinations, and homelessness, Bethany eventually found help through involuntary hospitalization, leading to her recovery with the use of clozapine. The narrative highlights the lack of education and support for individuals with schizophrenia, emphasizing the importance of effective treatment and advocacy. Bethany’s experiences have inspired her to establish the CURESZ Foundation to provide education, advocacy, and support for those affected by schizophrenia, promoting hope and recovery for those in need.

Treatment of patients suffering from schizophrenia in Austria: Treatment of patients with schizophrenia in the healthcare system is generally voluntary. This applies both to outpatient care provided by specialists in private practice, hospital outpatient clinics, or social psychiatric outpatient clinics and to inpatient care in hospitals. However, there is an exceptional situation in which the patient’s freedomofwill is restricted by law. This is the case when acute danger to self or others caused by the disorder is present. With the involvement of the district court, the patientadvocate, a possible adult representative, and an external expert, the patient’s freedom of movement can be restricted for a certain period of time to enable treatment. The acceptance of psychopharmacological therapy remains the patient’s decision in this situation,with the exception of explicit authorization by the court. Treatment under the consideration of proportionality, meaning that coercion is only applied in the case of an acute risk of severe bodily harm, is therefore possible for themajority of patients with schizophrenia. However, this does notmean that patients are able to connect to the care network in all cases. Some patients fail because the contact threshold is still too high. In order to reduce this, outreach care has been integrated into the existing services in many cases. Thesemulti-professional teams oftenmanage to establish contact with the patients and thus create a willingness to undergo treatment in order to counteract the long-term consequences, including complete social isolation and disintegration.

Much biomedical research is funded by governments. The examples of abortion, gun safety, and some breast cancer research are offered to demonstrate political bias in prioritizing research. Limited evidence for bias during funding review and bias in citation are discussed.

1. Changes in the severity, location, or characterization of pain in patients with solid tumors requires careful and thorough evaluation.

2. Opioids are the cornerstone of management for moderate to severe acute pain. Selection should consider individual patient risk factors, with specific caution for those with impaired kidney function. Morphine, hydromorphone, oxycodone, and fentanyl have distinct profiles and safety considerations.

3. IV formulations are preferred for severe pain due to rapid onset though clinicians should note the variable duration of action among different opioids. All patients require frequent reassessment and possibly dose adjustments to ensure adequate analgesia and to prevent complications such as respiratory depression and oversedation.

4. Practitioners must be aware of implicit biases that may affect opioid administration and prescribing. Studies show disparities in opioid prescriptions for Medicaid, uninsured, Black, or Latino patients in emergency departments.

5. Decisions on hospital admission versus discharge depend on individual cases. Effective communication with the patient's outpatient care team is key for continuity of care and preventing readmissions.