The link between creativity and serious mental illness (SMI) is widely discussed. Jackson Pollock is one example of a giant in the field of art who was both highly creative and experiencing an SMI. Pollock created a new genre of art known as abstract expressionism (“action painting”) defined as showing the frenetic actions of painting. The question arises whether his SMI playedany role in the way he created his drip paintings, especially when he was overactive and manic. Furthermore, did visual hallucinations or enhanced visual perception associated with mania or psychosis facilitate Pollock in embedding and camouflaging images under layers of thrown paint? Seeing images in Pollocks drip paintings has been a controversy ever since these paintings were created. Some experts attribute this to pareidolia—perceiving specific images out ofrandom or ambiguous visual patterns—a phenomenon known to be enhanced by fractal fuzzy edges such as seen in Rorschach ink blots as well as in Pollock drip paintings. So, are Pollock’s drip paintings merely giant Rorschach images, or did Pollock insert polloglyphs—images that are encrypted that tell a story about Pollock’s inner being—into his paintings and then disguise them with drippings? Here, we explore answers to these questions and discuss images that Pollock included in his earliest sketches and used repeatedly in his abstract paintings and later in his drip paintings to argue that these images are not accidental.

1. Gastrointestinal hemorrhage is common in cancer patients and special consideration should be given to type of cancer, chemotherapy use, and other comorbidities.

2. Early distinction between upper and lower GI bleed source should be made with consideration based on symptoms, lab work, and imaging.

3. Initial treatment includes assessment of ABCs, early fluid resuscitation, blood transfusions, and reversal of any coagulopathy or anticoagulation.

4. High dose PPI treatment in upper GI bleeds should be given in conjunction with initial treatments in anticipation of endoscopy

5. Endoscopy and/or colonoscopy should be performed early in the clinical course. IR embolization or palliative radiation can be considered if endoscopy fails to result in hemostasis or if rebleeding occurs.

All of the data needed to examine and model an epidemic are difficult to obtain with any accuracy, during a pandemic. This includes: case fatality, calculating the number of infections, estimating the effective reproduction number (R, how many additional cases will be infected by a single case), the incubation period (time from infection to symptoms), and the serial interval (time from start of symptoms in the infector to symptoms starting in the infectee). The COVID-19 pandemic is used to demonstrate these difficulties. Secondary health effects are an important consequence of pandemics and bias in these studies is discussed, as is pandemic modeling.

1. Patients with neutropenic fever who are found to be low risk based on clinical judgment and MASCC or CISNE score, can be discharged home with oral antibiotics and close follow up. Those who are found to be high risk, should be admitted for IV antibiotics.

2. Patients who are taking an oral fluoroquinolone for prophylactic therapy are not candidates for fluoroquinolone therapy for treatment of neutropenic fever and should be admitted to the hospital for IV antibiotics.

3. Patients who use a feeding tube as their primary route for nutrition and medication are not appropriate for outpatient neutropenic fever treatment.

4. If a patient is monitored in the ED and continues to be febrile despite administration of antibiotics, the patient may need to be admitted for IV antibiotics versus being discharged home on oral antibiotics.

5. If a patient is known to have a history of multidrug resistant organisms consider consulting Infectious Disease for assistance in antibiotic selection.

1. Colitis secondary to an immune related adverse event can occur at any time during the course of treatment, including years after treatment has been completed.

2. Having a high index of suspicion in patients treated or previously treated with immunotherapy is important since symptoms may present subtly.

3. Grade 2 colitis and higher often require steroids for treatment; consider second line treatments in those that are not responding appropriately to steroids.

4. In grade 3 colitis, immunotherapy is typically paused until steroids have been tapered to less than 10 mg per day, but require weighing the risks and benefits of resuming treatment with immunotherapy.

5. Grade 4 colitis requires cessation of immunotherapy treatment.

Despite being considered the most compelling single study design for attributing causation to observed associations, randomized controlled trials (RCTs) carry their own susceptibility to bias. Secure randomization procedures are necessary and the conduct of the RCT must be exemplary. How study drop-outs are managed, and who enters data analysis, can substantially influence the RCT result. Other aspects of patient care, such as co-interventions, must be carefully managed. Is outcome data complete for all patients, and do the trialists fully report all the RCTs hypothesized outcomes? Is “intent-to-treat” the primary analytic strategy?

Increasing numbers of Americans are affected by serious mental illness and severe substance use disorders. While funding has increased for the treatment of these conditions in recent years, increases in service needs have outstripped resources. Further, too often those living with these conditions are incarcerated, held for inordinate periods without treatment in emergency departments, and/or relegated to the streets as part of the burgeoning numbers of homeless in the United States. These conditions require innovative approaches to care that should include integrated medical care and community resources to decrease isolation and to improve the response to crises as they occur. There are numerous opportunities already in place that, used appropriately, can improve outcomes for some of our most vulnerable people and will improve community living for all. This perspective describes available resources that can better address the mental health and substance use crisis facing the American people.

1. For patients with mucositis, early intervention with IV fluids, electrolyte repletion, and symptomatic care are crucial to minimize hospitalizations and interruption of treatment.

2. The differential diagnosis for mucositis includes drug eruptions, Stevens-Johnson Syndrome, secondary infections with candida or herpes simplex virus (HSV), and, in myelosuppressed patients, infection due to other viruses, bacterial infection, or deep fungal infection.

3. Symptom onset for mucositis associated with chemotherapy may be as early as 24-48 hours after treatment for intestinal mucositis or within 3-4 days of treatment initiation for oral mucositis.

4. Emergency department treatment for mucositis may provide a teachable moment for prevention in future rounds of chemotherapy. Educating on basic oral hygiene, including brushing twice daily with a soft toothbrush and bland rinses with tap water, saline, or bicarbonate solution is simple but important.

5. Oral rinses with honey, benzydamine, glutamine, or mucoadhesive gels can be recommended or prescribed at discharge, as can probiotics with Lactobacillus for prevention of diarrhea. Patients can also be referred to their oncologist to ask if photobiomodulation (light therapy) or IV palifermin is appropriate prevention for their treatment.

1. Hematopoietic cell transplants are becoming increasingly common and ED providers should remain vigilant for post-transplant complications.

2. These patients are at high risk for post-transplant emergencies due to their pre-existing comorbid conditions, toxicities from high-dose chemotherapy, prolonged immunosuppression, and opportunistic infections resulting from their immunocompromised state.

3.Hematopoietic cell transplant patients face significant risks for complications such as Graft-versus-host disease (GVHD), which further complicates their recovery and requires vigilant monitoring.

4. GVHD is a common and treatable post-transplant complication but must be recognized early to avoid complications.

5. Treatment of post-hematopoietic cell transplant complications should be performed in close collaboration with hematology/oncology, and often these complications result in hospitalization.

1. It is important to have a high index of suspicion for bowel obstruction in patients with a history of cancer who present with nausea, vomiting and abdominal pain.

2. Malignant bowel obstructions can result from a primary tumor or secondarily from metastatic disease.

3. CT is the imaging modality of choice for the diagnosis of a bowel obstruction.

4. Initial management includes placement of a nasogastric tube for decompression as well as supportive care followed by admission.

5. Surgical consultation is recommended, but not all patients are operative candidates due to higher morbidity and mortality. In these patients, palliative venting gastrostomy can be considered.

1. Initial assessment and stabilization of airway patency, breathing, and circulation should be performed.

2. It is important to have a high index of suspicion for adrenal insufficiency (AI) in cancer patients with refractory hypotension. AI can occur as a result of adrenal suppression from chronic glucocorticoid treatment, or less commonly, from metastatic disease to both adrenal glands.

3. Consider obtaining other laboratory work to evaluate for concomitant electrolyte abnormalities.

4. Review patient’s medication lists whenever accessible to evaluate for chronic steroid use.

5. Treatment involves resuscitation of blood pressure acutely with IV hydrocortisone and intravenous fluids followed by admission to the hospital.

Objective. Over the decades, research has demonstrated that Conditional Release Programs(CONREP) and Compulsory community treatment can reduce recidivism among forensic patients discharged from inpatient commitment. This study synthesizes current knowledge— including findings from a 2024 California Department of State Hospitals report—to evaluate theimpact of involuntary community treatment on recidivism and patient outcomes. Methods. We retrospectively analyzed 2613 patients discharged from California state hospitals between 2012 and 2017. Patients were either directly discharged to the community (N = 2011) or referred to CONREP (N = 602). Data on rearrests for general and violent offenses were obtained through 2018. Variables with established relationships to recidivism (e.g., commitment category, mental health diagnoses, lengths of stay) were included. Statistical analyses, including chisquare tests, Cox regression, and logistic regression, were conducted to compare recidivism rates and identify significant predictors. Results. CONREP-treated patients demonstrated dramatically lower fixed recidivism rates at 1, 3, and 5 years compared with directly discharged patients. Direct discharge was associated with up to a sevenfold increased likelihood of rearrest within 1 year. The median time to rearrest was 400 days for directly discharged patients versus 500 days for CONREP patients (p < .004). Logistic regression revealed that direct discharge, younger age, and a higher number of state hospital commitments were significant predictors of rearrest.Conclusions. Structured, court-supervised community treatment via CONREP substantially reduces recidivism among forensic patients, promoting safer community reintegration and improved outcomes. These findings support expanding CONREP services to enhance public safety and patient rehabilitation.

A description is provided of the current situation in Aotearoa New Zealand with regard to compulsory treatment of people with schizophrenia. This is placed within the context of homelessness in New Zealand and the provision of services to the incarcerated mentally ill. There are high rates of homelessness and incarceration and services are struggling to meet their needs. This is particularly a problem for the indigenous population. The current Mental Health Act allows for compulsory treatment of people who as a result of schizophrenia are seriously impaired in their capacity to care for themselves, and this will include people where there is a nexus between homelessness and their illness. The Mental Health Act is being reformed, with a new act likely to emphasize autonomy and capacity to a greater degree. Finally, the author considers the learnings from 5 years working within the Fixated Threat Assessment Centre, which provides a unique perspective on these issues.

1. It is important to have a high index of suspicion for pneumonitis in patients with exposure to immune checkpoint inhibitor therapy who present with respiratory symptoms as delay in appropriate treatment can be lethal.

2. Patients on combination immune checkpoint inhibitor therapy are at added risk for toxicities, including pneumonitis.

3. Because of the potential of benign presenting symptoms, such as cough, and the variability in the imaging presentation, diagnosis can be difficult. Ground glass opacities are most often present.

4. Early consultation with the oncologist and a pulmonologist is encouraged.

5. The emergency physician should be familiar with the established grading symptoms and treatment recommendations to ensure optimal care.

This chapter follows the story of Jordon, a young man with schizophrenia who becomes entangled in the criminal justice system due to his untreated illness. The narrative highlights the challenges faced by individuals with severe mental illness, the failures of the mental health system, and the impact of policy and legal structures on their lives. Through the experiences of healthcare professionals and experts in the field, the chapter explores the need for a paradigm shift in the treatment of psychosis, advocating for humane and effective care for individuals across the spectrum of illness severity. The narrative culminates in a call to action to revolutionize the treatment of psychosis in America, emphasizing the importance of understanding, compassion, and evidence-based interventions for those affected by severe mental illness.