We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure no-reply@cambridge.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Although radiocarbon-accelerator mass spectrometry (14C-AMS) is an important tool for the establishment of soil chronology, its application is challenging due to the complex nature of soil samples. In the present study, chemical extraction methodologies were tested to obtain the most representative age of Amazonian soil deposition by 14C-AMS. We performed acid hydrolysis with different numbers of extractions, as well as treatments combining acid and bases and quartered and non-quartered samples. The ages of the soil organic matter (SOM) fractions were compared to the ages of naturally buried charcoal samples at similar depths. The results showed that the age of the non-hydrolyzable inert fraction of soil was closer to the age of charcoal and older than the ages of humin. It was also observed that the quartering process can influence the results, since the dating of the humin fraction showed variability in the results. Our results are important to provide information about the most suitable method for the 14C-AMS dating of soil samples for paleoenvironment reconstruction studies.
In recent years, water pollution caused by industrial waste has been a major problem throughout the world. To remove harmful impurities from water, using methylene blue (MB) as a model compound, modified clays were used, as they are capable of adsorbing various substances on their surfaces. The modified clays were obtained by grafting dimethyl sulfoxide (DMSO) and triethanolamine (TEOA) in the space between the layers of Shymkent clay. DMSO was first added to the natural clay; TEOA was also added at a temperature of 180°C and then held at that temperature for 2 h. The resulting modified clays were dried at 60°C for 24 h and characterized by X-ray diffraction (XRD), surface area analysis (SAA), Fourier-transform infrared spectroscopy (FT-IR), elemental analysis, and thermogravimetric analysis (DTA and TGA). Natural and modified clays (0.25–2.5 g L–1, pH=1–12, and 50°C) were used to adsorb MB from an aqueous solution at a concentration of 50 mg L–1. Contact with the adsorbent was maintained for 8 h. As much as 95.9% of the MB was removed from the aqueous solution in as little time as 15 min. Adsorption conditions were optimized, and the clay modified with TEAO showed better results than the natural clay (85% for modified clay vs 40% for original clay, at a clay concentration of 0.5 g L–1); significant adsorption was obtained over a wide pH range (>85% from pH 1 to 12).
The challenge of American tegumentary leishmaniasis (ATL) continues in Brazil, presenting a persistent public health issue despite initiatives aimed at public outreach, vector control and health education. To gain a deeper understanding of this disease, a study was conducted in an endemic region located in the northern region of the state of Minas Gerais, Brazil. The study monitored 30 resident patients diagnosed with ATL, using serum samples from 6 healthy individuals as controls. The localized cutaneous form of the disease was found to be predominant, with lesions appearing on various parts of the body and the majority of the affected individuals being male. The study found significantly higher levels of IgG anti-α-Gal antibodies in ATL-infected patients compared to healthy individuals. Treatment of 19 patients with meglumine antimoniate resulted in limited improvement in symptoms for most. Nonetheless, the study found that 12 patients who completed treatment with epithelialization of the lesions showed a significant decrease in IgG anti-α-Gal antibodies, indicating potential applications of this antibody in the diagnosis and monitoring of the disease. The study also identified Leishmania species in 7 analysed patients, revealing 6 cases infected by Leishmania braziliensis and 1 by L. infantum, with a significant difference in the anti-α-Gal responses. The findings of the study emphasize the urgent need for the development of human vaccines and innovative treatment strategies adapted to the diversity of Leishmania species causing cutaneous leishmaniasis and individual patient responses to improve the clinical management of ATL in Brazil and similar endemic regions.
We described Creptotrema cambeve n. sp. from the intestine of the Brazilian catfish Cambeva davisi (Haseman, 1911) (= Trichomycterus davisi) based on integrative analyses using morphological and molecular approaches. Creptotrema cambeve n. sp. closely resembles morphologically Creptotrema paraense Vicente, Santos & Souza, 1978, which was described from a siluriform fish in Northern Brazil; however, the two species differ mainly in the oral and ventral sucker sizes and the distribution of the vitellaria. The phylogenetic analyses of the 28S rDNA placed the sequences of the new species in a monophyletic clade together with all other Creptotrema spp. and as sister taxon of Creptotrema cruste Alcantara, Ebert, Ferreira-Silva, Forti, Morais, Pérez-Ponce de León & Silva, 2024, a parasite from a Brazilian anuran. Genetic divergences between the new species and other Creptotrema spp. varied from 0.2% to 4.3%, further corroborating the distinction of the new taxon. Creptotrema cambeve n. sp. is the 18th nominal Creptotrema species known from South America and the 22nd erected in the genus. This is the first study reporting a trematode in Cambeva spp. hosts and the second parasitological survey carried out for Ca. davisi, a poorly known small endemic fish.
In the present study, we assessed the sponge fauna, sponge-associated, and planktonic prokaryotic communities residing in Burgers' Zoo Ocean aquarium, Arnhem, the Netherlands. The Ocean aquarium consisted of separate displays and life support systems, and included fish-only systems in addition to a large, 750,000 L tank containing a living, tropical coral reef ecosystem. Sponges were observed throughout the aquarium system and were identified as belonging to the genera Chalinula, Chondrilla, Chondrosia, Cinachyrella, Stylissa, Suberites and Tethya. There was a highly significant difference in composition between sponge-associated and planktonic prokaryotic communities. The tanks in which the sponges were sampled appeared to have a secondary structural effect on prokaryotic composition with sponges and water from the same tanks sharing several microorganisms. Both sponge-associated and planktonic prokaryotic communities housed prokaryotic taxa, which were highly similar to microorganisms previously recorded in sponges or coral reef environments, including taxa potentially involved in nitrification, denitrification, sulphur oxidation, and antibiotic biosynthesis. Several abundant microorganisms were only recorded in sponges and these may play a role in maintaining water quality in the aquarium system. Potential pathogens, e.g. related to Photobacterium damselae, and beneficial organisms, e.g. related to Pseudovibrio denitrificans, were also detected. The present study showed that Burgers' Zoo Ocean aquarium housed diverse free-living and host-associated prokaryotic communities. Future research should focus on identifying conditions and microbial communities conducive to a healthy aquarium environment.
When reading about psychopathology what we find described are experiences similar to our own. Psychiatry deals with anguish, fear, motivation, choice, and many other aspects that makes us human. However, even though psychopathology is rooted in common human experience, mental disorders are often outside the experience of those who don’t suffer from it. Therefore, the distinction between normality and disease is central to psychiatry. The DSM proposes that mental disorders are necessarily linked to distress and/or impairment. However, it adds that the syndrome or pattern must not be an expectable response to an event - it excludes “normal” experiences and responses from the realm of mental illness. But how do we distinguish normal distress from illness? This review investigates how different meanings of normality can help us discern the fine line between mental illness and ordinary human experience.
Objectives
We intend to critically examine and compare different models of normality. Additionally, we seek to discern the implications of these models for distinguishing mental disorders from normal mental experiences.
Methods
Review of the literature.
Results
We analyzed definitions and models of normality throughout the literature and selected the most relevant ones according to their popularity and/or strength of argument. Different models of normality (e.g. Biostatistical, Process, Health, Ideal, Biological advantage, etc.) were examined and compared, and the conceptualization of mental disorder was examined through the lens of each of these frameworks. Our investigation reveals the multifaceted nature of normality, with different models offering unique perspectives on mental health. From statistical approaches to cultural considerations, each model contributes distinct criteria for distinguishing what is normal from what is illness. By synthesizing these results, we gain a comprehensive view of the factors influencing the conceptualization of normality in the context of mental health.
Conclusions
This review emphasizes the importance of adopting a nuanced, cautious and multifactorial approach when discerning mental disorders from normal experiences. Rather than relying on a singular definition, our analysis suggests that a comprehensive understanding of normality can help us to better discern what is normal and what is illness.
Psychological trauma is a significant public health concern with long-lasting effects on physical and mental well-being. Trauma-informed care is an approach to providing support and services that acknowledges and integrates an understanding of the pervasive impact of trauma on individuals. This review delves into the critical imperative of trauma-informed care within the realm of health services. Recognizing the pervasive impact of trauma on individuals’ physical and mental well-being, this REVIEW aims to explore existing literature, identify key objectives, and propose effective methods for implementing trauma-informed strategies in health services.
Objectives
To Review Existing Literature on Trauma: Conduct an review of the literature to comprehend the varied dimensions and consequences of trauma on individuals’ health; To Identify Key Principles of Trauma-Informed Care: Explore established principles of trauma-informed care, highlighting their relevance and applicability within health service settings; To Propose Implementation Strategies: Develop practical strategies for integrating trauma-informed care into health services, ensuring a comprehensive and sensitive approach to patient care.
Methods
A review of published articles, books, and reports related to trauma and trauma-informed care to establish a foundational understanding.
Results
Psychological trauma can have profound and multifaceted impacts on individuals, affecting their mental, emotional, and even physical well-being. The consequences of psychological trauma can vary widely based on the nature, severity, and duration of the traumatic experience, as well as individual factors such as resilience and support systems. Trauma-informed care aims to create an environment that is sensitive to the needs of those who have experienced trauma, and it is based on six key principles: safety, trustworthiness, peer support, collaboration, empowerment, and cultural competence. Healthcare providers need to understand trauma beyond the personal and acknowledge the cultural, historical, social, political, and structural trauma that impact individuals and communities across generations. This approach recognizes that there is a risk of retraumatization in social and health services, especially for minority communities.
Conclusions
This review underscores the pressing need for health services to adopt trauma-informed care strategies. By acknowledging the prevalence and impact of trauma on health outcomes, the healthcare sector can transition towards a more patient-centered and empathetic approach.
Electroconvulsive Therapy (ECT) is one of safest and most effective treatments for severe mental illnesses. The ECT Unit of Centro Hospitalar Universitário de Santo António – Magalhães Lemos Hospital (CHUSA-HML) is a reference center for this treatment modality, providing support to the northern region of Portugal.
Objectives
This study aims to characterize patients undergoing ECT treatment from April to June 2023, at the ECT Unit of CHUSA-HML.
Methods
Retrospective study from April to June/2023. Social, demographic, epidemiological and clinical data were evaluated.
Results
Among the 55 patients who were treated there was a predominance in male sex (56%), the average age was 53 years old and only 9 completed higher education. Half of them were in a long-term relationship. Around 67% of patients are retired, predominantly (62%) due to psychiatric disability.
Most patients (78%) were referred through psychiatric consultation and the remainder came from psychiatric hospitalization (only 3 were never hospitalized). 41 patients were under maintenance treatment and 14 under acute treatment. Concerning the type of treatment 30 were submitted to bilateral ECT. For 33% it wasn’t the first ECT treatment. Almost all patients improved their symptoms, only one patient had complications related to the procedure (tooth loss).
According to the international classification of disease (ICD11) the most frequent primary diagnosis was Schizophrenia or Other Primary Psychotic Disorders (58%). Neurodevelopmental disorders and substance use disorders were the most frequently comorbid diagnoses.
The results presented are preliminary, and other data that may be relevant are being collected and processed.
Conclusions
Severe mental illnesses profoundly impact patients, often imposing substantial limitations and suffering. These findings support the safety and effectiveness of ECT as treatment for severe mental disorders. Founding more specialized centers represents an important step toward enhancing mental health treatments. Access to controlled studies is crucial, fostering a deeper understanding of the ECT technique and long-term benefits.
Duration of untreated psychosis (DUP) is defined as the time between the onset of psychotic symptoms and the initiation of appropriate treatment. DUP has been the subject of intensive research to understand how it is associated with a poorer prognosis in patients with first-episode psychosis (FEP). Involuntary treatment is often necessary in the context of FEP.
Objectives
To characterize the relationship between the duration of untreated psychosis (DUP) and the type of hospitalization (voluntary versus involuntary) in patients admitted for FEP.
Methods
We conducted a retrospective observational study, collecting data from patients admitted between January 2019 and December 2022, in the psychiatric unit at our hospital in Bragança, Portugal. We used the information recorded in the clinical records and statistical analysis of the data was performed using the SPSS program.
Results
Over the 4-year study period, 81 patients with first-episode psychotic symptoms at admission were selected. The average age was 46.98 years, with a slight male predominance. 46.9% (n=38) were admitted involuntarily, and 53.1% (n=43) were admitted voluntarily. The average DUP was 73 days. DUP was 95.92 days for patients admitted involuntarily and 54.72 days for voluntary admission. This difference was not statistically significant.
Conclusions
There was a longer DUP in patients admitted involuntarily, although this association was not statistically significant. However, it is important to emphasize that involuntary hospitalization is frequently linked to more severe cases and poorer prognosis. Therefore, recognizing psychotic symptoms as early as possible is essential to facilitate prompt identification and effective treatment for patients experiencing their first episode of psychosis, ultimately leading to an improved prognosis.
Cannabis is the most used recreational drug worldwide. Cannabinoids have long been known for their anti-emetic properties. Paradoxically, chronic cannabis consumption has been linked to inducing refractory nausea and vomiting, a condition called cannabinoid hyperemesis syndrome (CHS). CHS remains inadequately acknowledged by clinicians.
Objectives
Report a CHS case and discuss this syndrome’s diagnosis, pathophysiology, and management.
Methods
Collection of clinical information and review of the literature.
Results
We share the case of a 38-year-old male who repeatedly recured to the emergency department (ED) due to persistent vomiting, nausea, and abdominal pain. The patient had experienced similar intermittent episodes over the past 12 years. Interestingly, the use of hot showers provided symptomatic relief. Urine drug tests consistently showed positive results for cannabinoids. During acute phases, he required supportive treatment involving fluid therapy. Long-term treatment included cannabis abstinence. CHS is defined by episodic vomiting, following prolonged excessive cannabis consumption, which is alleviated by sustained cessation of cannabis. During the acute phase of the condition, patients often find relief using hot baths and showers, which is a common behavior observed. CHS-related complications encompass acute kidney injury and severe electrolyte disturbances. CHS can result in multiple ED visits, frequent hospitalizations, extensive diagnostic evaluations, and elevated healthcare expenditures. Although the exact pathophysiology of CHS remains unclear, some mechanisms have been proposed. These include reduced gastric motility by gastrointestinal cannabinoid receptors 1 (CB1) overriding, cannabinoid lipid buildup, endocannabinoid system dysregulation, dysregulated stress response, changes in thermoregulation, modifications in the transient receptor potential vanilloid system and genetic polymorphisms in the P450 system. In the acute phase, the foremost concern is providing supportive care including intravenous hydration and electrolyte corrections. The most effective treatment for CHS is cannabis cessation. Nevertheless, there are alternative treatments that have shown promise in alleviating symptoms, such as hot water hydrotherapy, topical capsaicin, haloperidol, benzodiazepines, propranolol and aprepitant.
Conclusions
As cannabis usage becomes increasingly prevalent, it becomes imperative for healthcare providers to acknowledge the long-term effects of cannabinoids, specifically regarding CHS. This diagnosis should be contemplated when evaluating patients who experience recurrent and incoercible vomiting coupled with a history of cannabis consumption. The compulsion to take hot baths or showers can serve as a noteworthy indicator for diagnosing CHS.
Fahr’s Disease, also known as Fahr’s Syndrome, is a rare genetically dominant disease, characterized by the abnormal accumulation of calcium deposits, or calcifications, in various areas of the brain, particularly the basal ganglia. These calcifications, which are typically bilateral and symmetrical, can lead to a wide range of neurological and psychiatric symptoms, making diagnosis and management challenging. It usually manifests between the ages of 40 and 60, primarily after the age of 30.
Objectives
To contribute to the medical literature by sharing this rare case, thereby increasing awareness and knowledge about Fahr’s Disease among healthcare professionals.
Methods
Non systematic review of the literature and access to the medical history of the patient.
Results
We present a case of a 42 year old woman, who came to our hospital with behavior changes, with increasing confusion and new mystical beliefs, insomnia and agitation.
According to the patient’s husband, the patient sounded confused and inappropriate in her speech. The patient was admitted for evaluation of altered mental status. The patient was alert and oriented to person, place, time, and situation in the emergency department, with shudder while neurologically intact. The patient was unpolite, agitated.
Psychiatry was consulted for evaluation. We decided to admit the patient and did a posterior study with a CT scan and MRI. The MRI, as well as CT scan revealed “dense calcification of the dentate nuclei and the basal ganglia”, highly suggestive of Fahr’s syndrome. The patient’s phosphorus level was 3.5 mg/dl (normal level: 2.5-4.5 mg/dl). Parathyroid hormone (PTH) intact was 53 pg/ml (normal level: 15-65 pg/ml), and calcium level was 10,3 mg/dl (normal level: 8.4-10.5 mg/dl). The vitamin D 25-hydroxy concentration was 43,5 ng/ml (normal level: 30-60 ng/ml).
Conclusions
In conclusion, Fahr’s Disease is a rare and complex neurological disorder characterized by idiopathic calcification of the bilateral basal ganglia, resulting in a diverse range of neurological and psychiatric symptoms. Diagnosis involves clinical evaluation and neuroimaging, while treatment is primarily symptomatic. Further research is needed to better understand the underlying genetic and biochemical mechanisms driving calcification in the brain and to develop more effective therapeutic strategies for this challenging condition.
Philosophy of mind grapples with fundamental questions concerning the Consciousness, the Mind-body problem, the Identity, and Free will (as opposed to Determinism). In the context of psychiatry, this philosophical groundwork provides a conceptual framework for comprehending the intricate workings of the human psyche.
Objectives
We aim to discuss how the philosophical investigation of the mind influence and enhance psychiatrists understanding of psychiatric disorders and patient-centered care.
Methods
Review of the literature.
Results
Philosophy of mind explores what it means to be conscious and the nature of subjective experience. This includes questions about the “hard problem” of consciousness, that refers to the difficulty of explaining why and how physical processes in the brain give rise to subjective, first-person experiences (or qualia). The “hard problem” posits that even if we knew everything about the brain’s physical processes and how they relate to cognitive functions, we would still lack an explanation for why these processes give rise to subjective consciousness. Psychiatry often deals with individuals who experience disturbances in their subjective conscious experiences, so the “hard problem” perspective allows psychiatrists to appreciate the diversity of conscious experiences and to empathize with their patients’ unique mental worlds.
Related with the previous topic is the mind-body problem. The elucidation of this problem highlights the challenge of reconciling mental phenomena with neurobiological processes. Integrating philosophical notions of dualism, materialism, and emergentism into psychiatric practice is essential for addressing the holistic nature of mental health.
Concerning to philosophical perspectives on personal identity, questions about the continuity of identity, selfhood, and the role of narrative in shaping one’s sense of self contribute to a deeper understanding of disorders like dissociative identity disorder, borderline personality disorder and even psychosis.
Furthermore, philosophical discussions on free will and determinism are pertinent to psychiatric ethics and the treatment of individuals with behavioral disorders, informing the ethical considerations surrounding involuntary psychiatric hospitalization, medication administration, and the delicate balance between autonomy and paternalism in psychiatric care.
Conclusions
Philosophy of mind provides psychiatry with a rich conceptual landscape, offering insights into the nature of mental phenomena. As our understanding of the brain and consciousness continues to evolve, the philosophy of mind remains an evolving area of philosophical inquiry.
Based on circular economy readiness assessments of six value chain layers, 18 design strategies and five collaboration strategies for circular economy were identified. The design strategies have many applications, from the design of materials, products, and processes to business models, and while some are specific to determined layers, others can be addressed by companies in multiple layers. Furthermore, collaboration across the value chain was found to affect positively the employment of circular economy design strategies, contributing to the fulfilment of solutions’ circularity potential.
Specimens of elasmobranchs, collected in the State of Santa Catarina, Brazil, were parasitized with Poecilacanthoidea trypanorhynch cestodes. Sharks of the species Prionace glauca harboured Callitetrarhynchus gracilis and Floriceps saccatus, and those of the species Sphyrna zygaena were infected with Callitetrarhynchus speciosus. Details of the proglottids of F. saccatus, provided by bright-field, and/or scanning electron microscopy, are described. Adults of F. saccatus are reported for the first time in the Brazilian coast.
OBJECTIVES/GOALS: The goal of theIntegrating Special Populations (ISP) Studiosis tointegrate communityvoice into research design and en hance diversity, equity, and inclusion in research, and disseminate findings in ways that improve health literacy and equity. METHODS/STUDY POPULATION: Based on the Vanderbilt Community Engagement Studio model, the ISP Studiowas designed through multiple phases, including Designand PilotStudioSessions. Stakeholders were diverse representatives of community and academic organizations serving special populations, as well asself-identified persons within special populations as defined by the NIH.Each phase of development and implementation of the Studio included an evaluation consisting of Likert scale and open-ended survey questions for process improvement and to integrate voices of the ISP community continuously. Demographic information and program outcomes were also collected via the evaluation survey. RESULTS/ANTICIPATED RESULTS: All Design Session (N=9) and Pilot Studio (N=10) participants indicated that the Design and Pilot were positive, relevant, bidirectionally useful, and fostered respect, trust, and inclusion. 100% of the panel strongly agreed the Studio met its goals and that the ISP Studios have potentialtobenefitspecial and under represented populations. Qualitative data and discussion on design will also be shared. Additi onaland relevant pointsincludepanelisttraining,compensation for community panelists, and ensuring accessibility. Evaluation outcomes from initial implementation of the ISP Studio will be discussed. DISCUSSION/SIGNIFICANCE: The ISP Studio is an innovative model that may increase engagement of special populations in the research process through co-creation and integration of lived experiences.It has the potential to improve research design, implementation, and impact.
Age-related losses in cognitive control efficiency in the face of response conflict are commonly reported in ageing research. However, it is unclear to what extent this effect reflects changes in actual inhibitory control, or the well-known age-related slowing of processing speed.
Methods:
We compared young (n = 42; 29 women; mean age = 19.6 years; mean formal education = 13 years) and older adults (n = 42; 27 women; mean age = 68.7 years; mean formal education = 12.8 years) using a spatial Stroop task. Participants responded to the direction of an arrow, ignoring its position. Direction and position could be congruent, incongruent or neutral (respectively low, high and no conflict trials). The level of conflict in trial n-1 (high or no conflict) modulated the level of adaptive control in the nth trial. We used multivariate analyses of variance to probe age-group effects on inhibitory efficiency, adaptive (high conflict n-1 trial) and momentary (no conflict n-1 trial). We analysed accuracy and direct as well as proportional reaction times, which respectively integrate and control for differences in general processing speed.
Results:
Older participants showed a larger overall Stroop effect in both direct [Wilks’ λ = .61, F(2,81) = 25.99, p<.001] and proportional reaction times [Wilks’ λ = .79, F(2, 81) = 10.55, p<.001]. Controlling for differences in general processing speed did not impact age-group effects on momentary inhibitory efficiency [F(1,82) = 17.78, p<.001], but eliminated a trend for poorer adaptive inhibitory control in the older group [F(1, 82)=.198, p = .657]. As for accuracy, we unexpectedly found a larger Stroop effect for the younger group [Wilks’ λ = .79, F(2, 81) = 11.07, p=.001].
Conclusion:
Older and younger adults are as effective in using previous response conflicts to prepare for current conflict resolution. Older adults' lower momentary inhibitory effectiveness likely reflects age-related slowing of processing speed as well as, to a degree to be determined in future research, larger strategic reaction times investment in accuracy enhancement.
Recent scientific evidence confirms that employability is extremely important in mental health care. Employment promotes a healthy lifestyle and unemployment leads to a global deterioration in health. This principle is transversal to all areas of health, applying equally to people with mental illness, including serious mental illness such as schizophrenia and bipolar affective disorder.
Objectives
Highlight the importance of employability in the treatment and rehabilitation process of people with mental illness.
Methods
PubMed database searched using the terms “supported employment” and “mental health” and “policies”.
Results
Parallel to conventional psychiatric treatments, employment generates self-confidence, promotes social responsibility, a sense of belonging and, consequently, integration in the community. From an economic point of view, it brings financial autonomy to the sick person, allowing the financing of their own accommodation, the payment of proposed treatments and the enjoyment of structures and leisure activities that until then would be impossible. It is also known that patients who are employed are less likely to resort to psychiatric emergency services and have a lower rate of readmissions to psychiatric hospitals, reflecting a better ability to manage the disease. Overall, employability increases the sick person’s quality of life, not only being an effective short-term treatment, but also one of the only interventions that reduce dependence on the health system in the long term.
Conclusions
The treatment plan should aim for more than the suppression of symptoms.
Knowing that employment generates positive outcomes, gets that as fundamental parameter for the treatment and for the rehabilitation of the person with mental illness, and it must therefore become essential that mental health services help patients to find satisfactory jobs and that protect your needs.
Thus, mental health policies should defend a new mental health treatment paradigm and emphasize employment as an imperative measure in the treatment and psychosocial rehabilitation of the sick person, including supported employment as an essential part of treatment.
Susac Syndrome (SS) is an immune-mediated endotheliopathy that mainly affects young women. It is characterized by the typical triad: subacute encephalopathy, retinal vaso-occlusive disease, and hearing loss. Encephalopathy symptoms are varied and include memory loss, psychiatric disturbances, cranial nerve disorders, seizures, and dementia. The syndrome is considered a rare but important differential diagnosis in various neurological, psychiatric, ophthalmological, and ear-nose-throat disorders.
Objectives
Report a clinical case of SS to reflect on the relationship between psychiatric and neurological symptoms and on immune-mediated psychiatric symptoms.
Methods
Collection of clinical information from the patient described below. Review of the literature about SS.
Results
A 21-year-old woman presented to the Psychiatry Emergency Department in November 2021 for complaints of sadness, anhedonia and emotional lability, with one month of evolution. She also had insomnia and confusional periods, so she stopped driving and quit her work as a storekeeper. She was given sertraline 50mg/day and trazodone 50mg/day. In the past two weeks, the patient had episodes of headache and vomiting, with 8 kg weight loss. She started a fever (38.5ºC) two days before observation. The patient had a prior history of depressive symptomatology four years earlier related to her father’s grief and her medical and surgical history was unremarkable. She was brought in a wheelchair by her mother and was using diapers because she was confined to bed for the past week. Objectively, the patient was somnolent, tearful and confused, with scarce speech and psychomotor slowing. No focal signs were found on neurological examination. Collaboration of Neurology was asked. Routine laboratory studies showed a slight increase in leucocyte count (12 500/mm3) and CRP (17mg/dL). Cerebrospinal fluid analysis showed 15 cells/uL and protein of 2.64 g/L. Cerebral MRI showed multiple striatocapsular periventricular lesions involving the thalamus, the left midbrain, and the medulla oblongata, as well as focal bilateral hemispherical and cerebellar subcortical lesions. The lesions presented high signal in T2 and showed restriction in the diffusion study. She was admitted to the Neurology inpatient department and treated with pulse methylprednisolone 1000 mg/day for five consecutive days, after which cognitive function improved. Ophthalmology observation found cotton-wool exudate and arteriolar interruption in the right eye, supporting the diagnosis of SS.
Conclusions
This syndrome represents the importance of diligent cooperation among different medical specialties to improve diagnosis-making, treatment and recovery. Psychiatric symptoms are frequent in neurological syndromes, so a high degree of suspicion is needed.
Clozapine is the only available treatment for refractory schizophrenia and is rarely associated with the development of myocarditis. Usually, the onset of symptoms occurs within the first month of treatment. The symptoms of myocarditis include fever, flu-like symptoms, fatigue, and dyspnea, symptoms that overlap with the COVID-19 infection. Coronavirus has been associated with cardiovascular complications, including myocarditis. It is not known whether clozapine increases the risk of developing viral myocarditis in patients with COVID-19 infection.
Objectives
Report a case of myocarditis in a patient treated with clozapine, who also had a history of COVID-19 infection.
Methods
Collection of clinical information and review of the literature.
Results
A 24-year-old man was admitted following severe psychotic symptoms that have been developing for the past several months. He presented with disorganized speech and behavior, paranoid delusions, thought alienation, auditory hallucinations, and blunted affect. He had no known medical co-morbidity, but he had tested positive for COVID-19 the month before admission. The lab and imaging tests and the electrocardiogram (EKG) were normal. He was diagnosed with schizophrenia and after treatment failure with three antipsychotics, the patient was started on clozapine, with symptom improvement. Two weeks after clozapine initiation, he started flu-like symptoms, fever, chest pain, and tachycardia. Lab tests showed leukocytosis (12 400 cells/uL), elevated inflammatory markers (C-reactive protein 143,30 mg/L) and cardiac biomarkers (troponin I 12.139 ng/mL, NT-proBNP 9321 pg/ml). The evaluation for viruses, including SARS-CoV-2, was negative. The EKG revealed ST-segment elevations and a transthoracic echocardiogram showed systolic dysfunction (left ventricular ejection fraction was 37%). Cardiac magnetic resonance confirmed severe left ventricular dysfunction and diffuse myocardial edema. The patient’s symptoms resolved following the discontinuation of clozapine and supportive therapies. Troponin and EKG normalized over the following 7 days. By this time, the patient tested positive for COVID-19.
Conclusions
The temporal relationship with the initiation of clozapine supports the diagnosis of clozapine-associated myocarditis. However, the COVID-19 infection may have played a part in the emergence of cardiac alterations. We hypothesize that the co-occurrence of COVID-19 and clozapine treatment may act synergically as both factors increase the risk of developing myocarditis. However, further studies are needed to evaluate the relationship between these factors. While clinicians should stay alert for the risk of clozapine-associated myocarditis, the overall risk is low, and given the effectiveness of clozapine, as well as the absence of other evidence-based treatments, people with refractory schizophrenia should be given a monitored trial of clozapine, regardless of their COVID-19 status.
Up to 30% of individuals with obsessive-compulsive disorder (OCD) present with a current or past history of tics. Simultaneously, OCD is one of the most frequent psychiatric comorbidities in patients with primary tic disorders (TD), such as Tourette syndrome.
Objectives
We present a literature review about the relationship between OCD and movement disorders, including its potential implications.
Methods
A literature review is performed on PUBMED, using the next keywords: "obsessive-compulsive disorder”, “comorbidity”, “movement disorders” and “tic disorders” We focused on data from systematic reviews, clinical trials and meta-analysis published in English on last 10 years.
Results
Goal-directed behaviour, such as compulsions, is orchestrated by the basal ganglia, through parallel but interconnected frontal–striatal circuits. Dysfunction of these circuits is known to play a role in the pathogenesis of TD and may also underlie OCD.
The most common movement disorders comorbid with obsessive-compulsive disorder (OCD) are indeed TD, with obsessive-compulsive symptoms (OCS) occurring in up to 90% of Tourette syndrome cases. OCD comorbid with TD associates with higher frequencies of hoarding, counting rituals, intrusive violent and sexual thoughts/images, somatic obsessions and repetitive movement compulsions. It also associates with earlier age of onset, higher frequency of sensory phenomena, higher male prevalence and familial aggregation.
However, OCD and OCS are also highly prevalent in choreatic movement disorders, such as Huntington’s disease and rheumatic fever with Sydenham’s chorea. There is also evidence for a correlation between streptococcal infections, autoimmunity, tic disorders and OCD, as seen in Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS).
Conclusions
Current evidence shows OCD and movement disorders may share dysfunctional brain circuits, resulting in a neuropsychiatric obsessive–compulsive phenotype, which may differ in terms of clinical characteristics and management.