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Co-Director, Meharry Medical College School of Medicine

Other clinicians then provide individual and/or group psychotherapeutic interventions. For children and adolescents, the recommended treatment model is the team approach (3). In this interdisciplinary management approach, general medical care clinicians. The biopsychosocial nature of anorexia nervosa and bulimia nervosa dictates the need for interdisciplinary treatment, and each aspect of care must be developmentally tailored to the treatment of adolescents (22). In unusual circumstances, psychiatrists may be qualified to act as the primary provider of comprehensive medical care. Binge-eating/purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behavior. Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. For example, in team management of outpatients with anorexia nervosa, one professional must be designated to consistently monitor weights so that this essential function is not inadvertently omitted from care. It is important to note that a significant number of patients are relegated to the heterogeneous diagnostic group referred to as eating disorders not otherwise specified because they have not been amenorrheic for 3 months and consequently do not meet current criteria for anorexia nervosa. These observations have important implications with respect to making clinical treatment decisions. They also imply that patients with continued menses who fulfill other criteria for anorexia nervosa should be eligible for the same levels of care as patients with anorexia nervosa. A clinician may also obtain useful information by sharing a meal with the patient or observing the patient eating a meal; in this way, the clinician can observe any difficulties the patient may have in eating particular foods, anxieties that erupt in the course of a meal, and rituals concerning food (such as cutting, separating, or mashing) that the patient feels compelled to perform. Treatment of Patients With Eating Disorders 25 Copyright 2010, American Psychiatric Association. Nonpurging type: During the current episode of bulimia nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Furthermore, blaming family members harms their psychological well-being and often impairs their desire, willingness, and capacity to be helpful to patients and to participate actively and constructively in treatment and recovery. Rather, the point is to identify family stressors whose amelioration may facilitate recovery. In the assessment of young patients, it is always helpful to involve parents and, whenever appropriate, school and health professionals who routinely work with children. Even when directly questioned, patients and their families may not initially reveal pertinent information about sensitive issues; important information may be uncovered only after a trusting relationship has been established and the patient is better able to accurately identify inner emotional states. Formal measures are available for the assessment of eating disorders, including self-report questionnaires and semistructured interviews. Clinical decisions about a diagnosis cannot be made on the basis of self-report screening instruments. Patients who are identified on initial screening as likely to have an eating disorder must be followed up in a second-stage determination by trained clinical interviewers. The instruments shown in Table 4, used by clinicians to interview patients in a structured format, are generally taken as "gold standards" to determine clinical diagnoses. An episode of binge eating is characterized by both of the following: (1) Eating, in a discrete period of time. The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. In Treatment of Patients With Eating Disorders 27 Copyright 2010, American Psychiatric Association. Except in individuals who are extremely under- or overweight, it is often not useful in estimating nutritional status. Commonly found signs, symptoms, and associated laboratory abnormalities for anorexia nervosa and bulimia nervosa are shown in Table 5 and Table 6, respectively. Although patients treated in outpatient practice may report few symptoms and show few obvious physical signs or abnormal laboratory test results, significant occult abnormalities may be present.

Among the 25 remaining patients, 13 are receiving an anti-depressant medication (all 13 have elevated serum folate levels), 9 receive a proton pump inhibitor (8 have elevated serum folate levels), and 3 receive a calcium channel antagonist (2 have elevated serum folate levels). Of these patients, 115 had serum folate and serum albumin levels obtained, and thus were included in this study. In these 115 patients, 68 had elevated serum folate and 36 of these had low serum albumin; 56 patients had normal serum folate and 28 of these had low serum albumin level (Chi-squared 2x2: p=0. In examination of serum folate levels compared to serum albumin levels, the correlation coefficient was ­0. The objective of this study was to compare visual findings to histology from chimney biopsies in asymptomatic and to more invasive ileal and jejunal biopsies in symptomatic patients. Methods: We analyzed the single experience of an experienced endoscopist over 12 months. The surveillance microscopic findings were divided into 3 subcategories: mucosal architecture (normal vs. Results: In surveillance, the positive predictive value of visualization for normal histology was 83. The correlation between visualization and the microscopic findings was significant overall for the 3 variables (Pearson Chi-Square; p<0. Purpose: Studies using enteroscopy have revealed that vascular ectasias are the leading cause of occult hemmorhage from the small intestine. These lesions typically reappear after localized therapy which causes the treatment of these lesions to be therapeutic challenge. Since vascular ectasias are known to form as a result of unregulated angiogenesis, inhibition of aberrant vascular formation with anti-angiogenic therapy in limited experience has shown to be successful. Methods: Three patients with evidence of recurrent, symptomatic anemia requiring multiple transfusions and hospitalizations underwent capsule endoscopy which revealed multiple vascular ectasias. It was determined that further endoscopy would not be helpful and systemic anti-angiogenic therapy would be more beneficial. After the capsule endoscopies were performed, all three patients were counseled on therapy and selected to receive bevacizumab. Results: the three patient that were treated(all men; age range 64-87 yrs) had suffered from recurrent bleeding related to multiple vascular ectasias over a period of 1-3 years. Among the three patients, a total of 26 units of blood were transfused prior to bevacizumab therapy, and the mean hemoglobin value was 9. Five months after bevacizumab therapy, none of the patients received transfusion therapy. Conclusion: All three patients were noted to have symptomatic anemias due to the presence of vascular ectasis not amenable to endoscopic therapy. This is the first case series demonstrating that bevacizumab may be useful in the treatment of vascular ectasias. If pts failed to respond to rifaximin treatment, additional combination antibiotics were administered. Weinstock, Salix, Speakers Bureau this research was supported by an industry grant from Support for preparation (review and editing) of the abstract by MedThink, Inc. Methods: We analyzed electronic data from Caris Diagnostics, a specialized gastrointestinal pathology group receiving specimens from endoscopy centers in 40 states. The database includes demographic and clinical information, a summary of the endoscopic findings, the site of origin, and the histopathologic report for each specimen. To identify the records for eligible duodenal biopsies, we extracted data from all cases with a sign-out date within the 12-month period from 4/01/07 to 3/31/08, and stored them in a Microsoft Access database. Results: There were 246,254 patient encounters with a total of 29,296 duodenal biopsies. The endoscopic impression of a duodenal polyp or nodule was reported in only 30 patients (6. Larazotide acetate treated patients did not have any change in these parameters and behaved similar to subjects not exposed to gluten, who received corn starch as placebo.

However, there was a dramatic increase in reports of attempted suicides between 1998 and 1999, from 54 to 98. Table 4 indicates the number of suicides and attempted suicides in Big Cove in the last year. While they may, in part, be due to differences in reporting periods, the huge variance in suicide attempts must have another explanation. It is well recognized that official records often underreport suicide because forensic, social, cultural, and religious factors can influence whether or not a death is classified as a suicide. The suicide literature reports distinct gender differences with respect to suicide and suicide attempts. In Canada as a whole, males are four times more likely than females to commit suicide. While the data presented here do not include a gender breakdown, it has been unofficially reported (but not confirmed) that all but one of the completed suicides in Big Cove involved males. Risk factors associated with suicide include a recent family or relationship breakup, facing criminal proceedings,12 previous attempted suicide, affective disorders, alcohol and drug dependency, and access to firearms. Half of the interviewees thought there was now an increased awareness and a greater willingness to talk about suicide. Others mentioned the ability of the project to respond immediately to a crisis and to provide ongoing support, prevention, and outreach-a proactive rather than reactive approach. This would include the multi-agency coordination taking place in the community and the shift away from crisis management. However, one person mentioned how people may have become immune to the rash of suicides, perhaps indicating hopelessness or frustration that comes with extensive and frequent loss. In addition to examining rates of suicide and attempted suicide in the follow-up study planned for 2003, it will be important to once again canvas the views of key informants on this issue. Data based on police reports are limited because they can be influenced by numerous outside factors, including police charging policies and recording practices (and changes in those policies and practices over time) as well as the willingness of victims to report to police. With respect to spousal violence, it is commonly noted that reported cases may represent as little as 10 per cent of actual cases. Similar claims have been made regarding child abuse; an estimated 90 per cent of cases may not be reported to child welfare agencies. Consequently, it is expected that the numbers reported below underestimate the real extent of the problem. In 1998 and 1999, there were 183 and 179 reports, respectively, with 30 reported in the first quarter of 2000. Level two assaults are summary convictions and range from spitting on someone to spousal assault. Spousal assaults are listed separately, although it was reported that officers do not always capture this additional information, so some of the reported cases under levels one and two may include spousal assault. In such circumstances, the views of key informants offer potential insights that may be invisible in the official statistics. When asked whether rates of physical abuse had changed over the past year, more than three-quarters (78. However, the interviews also captured observations on the most common crimes-assault-being committed by youth in the last year (64. On violent youth crimes, there was no consensus on whether rates had risen, decreased, or stayed the same. Interpretations will have to proceed with caution; however, an increase in reported rates of abuse may reflect an increased willingness on the part of victims to report or authorities to respond rather than an increase in the actual rate of physical abuse. It is understood that the objective of reducing levels of violence and abuse within the community speaks to real or actual rates and not simply a reduction in cases reported to authorities. Unfortunately, the police figures available do not provide a breakdown allowing for identification of how many were sexual assaults against a minor. Also, the number of child sexual abuse disclosures recorded does not represent total cases that made it to the court system, as some children were felt to be not psychologically ready for a court trial, or some made the initial disclosure but would not repeat the allegation during a later interview.

As regards the relationship between specific diagnoses and violence in the absence of concomitant substance use, the strongest association was that found with the bipolar disorder, followed by schizophrenia and major depression. Since the rates of violence seem to show no correlation with the severity of bipolar disease or with the various episodes of disease, the association between bipolar disorder and violent crime (including suicide) was largely mediated by substance abuse comorbidity - 83 - Heroin Addiction and Related Clinical Problems 14 (4): 81-94 [48]. Substance abusers were associated with increased odds of current and future violent behaviours in the schizophrenia spectrum disorder [18, 34, 46, 137]. Moreover, the trait impulsivity of bipolar subjects appears to show a positive correlation with substance abuse. Likewise, the episodic impulsivity of bipolar subjects increases during periods of symptom remission only for those with a history of substance abuse. This enhanced disposition to impulsivity even in the absence of full-blown mania, may be the reason for the increased risk of suicide and aggressive behaviours in bipolar substance abusers [132]. Aggressive behaviour of non-opiate substance abusers Substance use elicits aggressiveness and impulsivity, especially in those who have a biologically violent" disposition [70]. In drug addiction, the risk of violence also depends on the type of substance that is being abused; for example, heroin abusers are hardly ever violent under the influence of narcotics, but they can be aggressive during withdrawal, while those who use stimulants are likely to be violent under the effects of those drugs, even in cases of episodic exposure. Actually, violent crime is less frequent in heroin-dependent people than in alcohol an/or stimulant abusers [20, 41, 101]. People who consume alcohol often turn violent during intoxication, but alcohol withdrawal can also feature restlessness, agitation and irritability, especially as a result of hallucinations [40]. Alcohol consumption is associated with various types of violence, including but not limited to sexual aggression, family and marital violence, child abuse and suicide. Reports suggest a close link between acute alcohol intoxication and aggressive behaviour, whereby larger quantities of alcohol are associated with more severe aggressiveness [64, 111]. As regards benzodiazepines, the intake of high doses in non-tolerant individuals can lead to violent - 84 - outbursts, or escalations of anger, while chronic intoxication may cause an increase in hostile and aggressive tendencies [50]. Data gathered in psychiatric hospitals have proved that cannabis-positive acute bipolar psychoses display a characteristically violent clinical pattern [90]. Recent data showed that this trend also applies to ecstasy users undergoing acute psychotic episodes [119]. In comparing the rate of violent offences among heroin users and methamphetamine abusers, no differences emerged for life-time violence, whereas subjects on methamphetamine were significantly more likely to have committed violence in the past 12 months, so prompting the conclusion that regular methamphetamine use appears to be associated with an increased frequency of violent offences, probably with an earlier onset of violent behaviour within the history of substance use [37]. To our knowledge, few studies have focused on comparisons between the aggressiveness of heroin addicts and that displayed by the general population. Gerra and co-workers demonstrated that the enhancement of aggressive response in heroin-dependent patients on agonist treatment when faced by a laboratory task (Point Subtraction Aggression Paradigm) was higher than in the control group, independently of agonist treatment [59]. Also, heroin addicts who had undergone long-term opioid tapering regimens showed a higher degree of outwardly directed aggressiveness than healthy subjects [57]. Moreover, as long as we consider suicide to be a form of aggressive behaviour, heroin users are 14 times more likely than the general population to commit suicide, and the prevalence of attempted suicide too is far higher than it is among community samples [36]. Gender differences Male and female opioid-dependent patients differ in their antisocial attitudes and criminal history. A positive criminal record was much less likely among females than among males, and the recurrence of criminal acts was higher for males. Also, the pattern of criminality was different: in women, the onset of criminal behaviour occurred at a higher age, and their commitment was to drug deal- S. Nevertheless, women reported involvement in illegal activity more often during the year prior to treatment entry [144] and the incidence of incarceration had risen faster than that of men, by an average rate of 4. Gender differences in hostile attitude seem to influence treatment dropout, as women, who have greater levels of hostility at baseline, are more likely to drop out. Aggressive attitude before heroin use Common people are afraid of drug addicts, because of their violent and antisocial behaviour and their generally aggressive attitude, whether primary, or else induced by drug intoxication or withdrawal [76]. Aggressiveness and violence in heroin addicts before the onset of heroin use, is a poorly investigated issue; but at least one study identified marked premorbid traits of irritability [52]. Few studies shed light on the possible mechanism by which subjects choose between drugs and become attached to specific ones. On one hypothesis, drugs are not chosen randomly; on the other, the choice is the result of an interaction between psychopharmacological action and the dominant painful feelings, which were buffered as a result of drug self-administration. In line with this interpretation, addicts-to-be are likely to different substances for self-medication on the basis of their personality flaws [77].