Jerome Levine

Mycobacterium avium-intracellulare: A Cause of Disseminated Life-Threatening Infection in Homosexuals and Drug Abusers

Five men developed disseminated infection with Mycobacterium avium-intracellulare. These patients all lived in the New York City area and presented with their illnesses between January 1981 and September 1981; four were homosexual and one was an intravenous drug abuser. Four patients died. All five patients had defects in the cell-mediated immune response. The infections were characterized histopathologically by poor or absent granulomatous tissue reaction. Clinical isolates of M. avium-intracellulare from all five patients agglutinated commonly used antimycobacterial drugs. The spectrum of opportunistic infections among populations of homosexuals and drug abusers should be expanded to include disseminated disease due to M. avium-intracellulare.

Utilization of Valproate: Extent of Inpatient Use in the New York State Office of Mental Health

Objective: To describe the extent and type of use of valproate among hospitalized psychiatric patients. Method: A database containing patient information and drug prescription information for every in-patient within the adult civil facilities of the New York State Office of Mental Health was queried. Results: In 1994, 2,888 of 18,668 in-patients received valproate (15.5%). In 1996, 4,247 of 12,444 in-patients received valproate (34.1%). In 1996, approximately 50% of all patients diagnosed as bipolar or schizoaffective, and 28% of all patients diagnosed with schizophrenia, received valproate. Once started on valproate, over 90% remained on it after 2 weeks, with no difference found in the discontinuation rates between valproic acid or divalproex sodium at the end of the initial 14 day period. Patients received valproate for approximately two-thirds of their hospital stay, at a mean dose of 1400 mg/day. 95% also received concomitant antipsychotics, and 20% received concomitant lithium. Use of lithium and carbamazepine was less in 1996 than in 1994, but the magnitude of this change was much less than the increase in utilization of valproate. Conclusions: From 1994 to 1996 valproate use has more than doubled, and it is being used widely in patients with schizophrenia, an off-label indication for which there is only anecdotal support in the literature. Given the lack of difference in early discontinuation rates, there are probably no dramatic differences in side effects for the two preparations of valproate.

Treatment of schizophrenia with depot preparations of fluphenazine, haloperidol, and risperidone among inpatients at state-operated psychiatric facilities

BACKGROUND This study aimed to characterize the inpatient utilization of depot antipsychotics. METHOD The characteristics of adults with schizophrenia or schizoaffective disorder, hospitalized for at least 28 days, and who were prescribed depot antipsychotics were examined from 2004 to 2006 using a database from a large state-operated psychiatric hospital system. Demographic and clinical characteristics of patients receiving depot fluphenazine or haloperidol were compared to those prescribed depot risperidone. RESULTS We identified 2210 unique patients who initiated treatment with a depot antipsychotic (after receiving oral antipsychotics). Of these, 1484 (67.1%) received depot fluphenazine or haloperidol, and 726 (32.9%) received risperidone as their initial depot antipsychotic. Patients who received depot risperidone did not differ from those receiving depot fluphenazine or haloperidol with regard to demographics, diagnosis of schizoaffective disorder, number of comorbid psychiatric or medical diagnoses, or diagnosis of substance abuse. Patients started on depot risperidone during the observation period had a longer length of stay prior to initiation of depot than those started on depot fluphenazine or haloperidol (583 days vs. 237 days, t=5.489, p<.001). Patients who started on depot risperidone were less likely to be discharged on that medication than were patients who started on depot fluphenazine or haloperidol (odds ratio from Cox regression model=0.846 [95% CI 0.745-0.960]). CONCLUSIONS Patients initiated on depot risperidone had a longer length of stay prior to their first injection and were less likely to be discharged on that medication compared to patients initiated on depot fluphenazine or haloperidol, possibly indicating that patients initiating depot risperidone had a more severe or treatment-resistant course of illness and/or that there were reimbursement barriers for the outpatient utilization of depot risperidone, or that efficacy differences exist between the depot antipsychotics at the doses used in this population.

Case Report: Penicillin Sensitive Nutritionally Variant Streptococcal Endocarditis: Relapse After Penicillin Therapy

Studies to date have indicated that nutritionally-variant streptococci (NVS) causing bacterial endocarditis are frequently inhibited but not killed by low concentrations of penicillin. We report a patient with endocarditis due to a NVS strain which was killed in vitro by penicillin at a concentration of 0.09 microgram/ml. Despite therapy with intravenous penicillin for four weeks, the infection relapsed and was then cured by combined penicillin-gentamicin in therapy. In vitro studies demonstrated a synergistic effect of these two antibiotics. This experience suggests that combination therapy with penicillin and an aminoglycoside may be required for cure of all cases of nutritionally-variant streptococcal endocarditis regardless of in vitro susceptibility to penicillin.

Public-Academic Partnerships: Integrating State Psychiatric Hospital Treatment and Clinical Research

Collaboration between state clinical treatment services and academic research is fertile ground for clinical research opportunities. Such joint initiatives require careful planning, including provisions for joint training, integration of research staff into clinical activities, and integration of clinical treatment staff into research activities. The authors describe the planning and development of a 24-bed research unit at the Nathan S. Kline Institute for Psychiatric Research, colocated on the same campus as Rockland Psychiatric Center, each of which is an independent facility operated by the New York State Office of Mental Health.