Faculty Bibliography

BACKGROUND:We examine the performance of the Diagnostic and Statistical Manual of Mental Disorders-fifth edition (DSM-5) persistent complex bereavement-related disorder (PCBD) criteria in bereaved adults to identify prolonged grief cases determined prospectively. METHODS:Bereaved adults (n = 138) were assessed at 8, 21, 32, 67, and 90 months after the sudden death of a spouse or close relative. We used latent class growth analysis to identify the longitudinal trajectories of grief assessed using the Inventory for Complicated Grief. To validate the trajectory that corresponded to prolonged grief, we examined the baseline predictors of these trajectories and their relationship with functional impairment. RESULTS:We found three distinct trajectories of grief reactions. One of these trajectories (13.8%) showed high and sustained grief reactions that persisted for almost 7.5 years after the death. Participants with prolonged grief showed greater functional impairment [relative risk ratio (RRR) = 0.82, 95% confidence interval (CI): 0.70 to -0.97; p = 0.02] and higher self-reported depression (RRR = 1.21, 95% CI 1.09 to 1.96; p = 0.001) than participants whose grief reactions subsided over time. The original PCBD (requiring 6 criterion C symptoms) criteria correctly identified cases (57.9-94.7%) with perfect specificity (100%) but low to high sensitivity (5.6-81.3%); however, its sensitivity increased when revising criterion C to require ⩾3 (45.5-94.1%). The dimensional approach showed high sensitivity (0.50-1) and specificity (0.787-0.97). CONCLUSIONS:We recommend revisions to the PCBD criteria, which are overly restrictive and may exclude cases with clinically significant grief-related distress and impairment. In the meantime, clinicians need to monitor grief symptoms over time using available dimensional approaches to reduce the burden of grief.

OBJECTIVE/UNASSIGNED:Title I of the Americans with Disabilities Act (ADA) provides protection against discrimination on the basis of disability. This article explores how the courts have dealt with provisions limiting these protections for persons with substance use disorders. Specifically, the ADA allows employees with substance use disorders to be held to the same standards as other employees, suggesting that employers may not be required to provide reasonable accommodations. Moreover, employees "currently engaging in the illegal use of drugs" are excluded from ADA coverage. METHODS/UNASSIGNED:This article reviewed all published federal appellate court opinions involving cases in which a substance use disorder was the basis for a claim of employment-related discrimination in violation of the ADA. RESULTS/UNASSIGNED:In 26 cases identified, the lower courts ruled in favor of the employer 25 times, and the appellate courts reversed four of these rulings. The cases highlight three important limitations of ADA protections for persons with substance use disorders: the dilemma of needing to prove that one's substance use disorder limits major life activities while simultaneously arguing that one is qualified for the job; expansive interpretations of "current" drug use and the period of sobriety needed to qualify for ADA protections; and restrictions on the extent to which a qualifying disability can serve as a legal excuse for substance use-related misconduct. CONCLUSIONS/UNASSIGNED:The protections afforded by the ADA for individuals with substance use disorders are restricted by what appears to be the statute's moralizing on drug and alcohol use and those who use these substances.

This column describes the Internet System for Tracking Over-Prescribing (I-STOP), New York State's prescription monitoring program, and its compatibility with HIPAA and Part 2 of Volume 42 of the Code of Federal Regulations (CFR). The authors review use of information that is permitted by I-STOP and CFR for health care operations, including disclosure, and present information from the state Bureau of Narcotics Enforcement about appropriate use of the program. Physicians are permitted, for example, to contact other prescribers in I-STOP, even without explicit permission from the patient, an area in which physicians need more training. Common clinical scenarios encountered while navigating I-STOP are described.

AIMS/OBJECTIVE:A few studies have suggested a relationship between thyroid hormones and alcohol dependence (AD) such as a blunted increase of thyroid stimulating hormone (TSH) in response to thyrotropin-releasing hormone (TRH), lower levels of circulating free triiodothyronine (fT3) and free thyroxine (fT4) levels and down regulation of the TRH receptors. The current study aimed to explore the relationship between the hormones of the thyroid axis and alcohol-seeking behaviors in a sample of alcohol-dependent patients. METHODS:Forty-two treatment-seeking alcohol-dependent individuals enrolled in a 12-week treatment study were considered. The Timeline Follow Back (TLFB) was used to assess the number of drinks consumed during the 12-week period. Blood levels of thyroid hormones (TSH, fT3 and fT4) were measured prior to and at the end of treatment. Questionnaires were administered to evaluate craving for alcohol [Penn Alcohol Craving Scale (PACS) and the Obsessive Compulsive Drinking Scale (OCDS) and its two subscales ODS for obsessions and CDS for compulsions] as well as anxiety [State and Trait Inventory (STAI)], depression [the Zung Self-Rating Depression Scale (Zung)] and aggression [the Aggressive Questionnaire (AQ)]. RESULTS:At baseline, we found significant positive correlations between fT3 and OCDS (r = 0.358, P = 0.029) and CDS (r = 0.405, P = 0.013) and negative correlations between TSH levels and STAI (r = -0.342, P = 0.031), and AQ (r = -0.35, P = 0.027). At the end of the 12-week study period, abstinent patients had a greater change in TSH than those who relapsed (-0.4 vs. -0.25, F(1,24) = 5.4, P = 0.029). CONCLUSION/CONCLUSIONS:If confirmed in larger samples, these findings could suggest that the thyroid axis might represent a biomarker of alcohol craving and drinking.

Over the past several decades, nontraditional drugs of abuse, including bath salts, synthetic cannabinoids, and salvia, have increased in popularity and use. Despite this fact, they remain unfamiliar to many healthcare providers. Commonly marketed as "legal highs," these substances are being used for their desired neuropsychiatric effects, taking advantage of their accessibility, low cost, variable legality, and limited detection on traditional urine drug screens. Similar to traditional drugs of abuse, these substances have varying degrees of toxicity and may lead to potentially adverse effects, ranging from benign to life threatening. This paper offers a review of three of the more widely-used emerging drugs (or classes of drugs): bath salts, synthetic cannabinoids, and salvia. For each we review its history and development, the neurochemical basis for its clinical effects, the nature and route of ingestion, the range of desired effects, potential toxicities, diagnostic and therapeutic approaches, as well as social and legal considerations. [Full text available at http://rimed.org/rimedicaljournal-2014-06.asp, free with no login].

Although the use of recombinant activated factor VII (rFVIIa) to control intractable bleeding in nonhemophiliac patients is expanding, several issues pertinent to its potential thrombotic complications and effect on patient mortality are still of concern. We herein describe our experience at a developing country tertiary care center over a period of 4 years. A total of 49 patients were identified of whom 28.6% belong to the pediatric age group. The most common bleeding settings were intracerebral hemorrhage, abdominal aortic surgery, general surgery, and disseminated intravascular coagulopathy. All patients achieved cessation or significant reduction in bleeding. Only 1 patient had a documented postuse thrombotic complication. Of the whole group, 12 patients (24.4%) eventually died with only 1 death having a possible association to rFVIIa use. There was a statistically significant reduction in the need for blood product transfusion after the use of rFVIIa. The use of rFVIIa was in accordance with the hospital's algorithm (identifying salvageable patients, preconditioning, blood product replacement, and dosing) in 30 (61.2%) patients. We conclude that rFVIIa should continue to be considered in nonhemophiliac patients failing to respond to conventional measures of bleeding control. However, this off-label use should be coupled with strict adherence to the treatment algorithms, which remains essential in developing countries with limited health care resources.