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December 1 Is World AIDS Day

This December 1, spare a thought for the estimated 33.2 million people around the world living with HIV/AIDS (95 per cent of them in the developing world). This year alone, some 2.5 million people will become newly infected with HIV (including countless children). The World AIDS Campaign's slogan in marking World AIDS Day is "Stop AIDS: Keep the Promise". Leadership is the theme for this year as a special plea towards governments and non-governmental organizations to provide the leadership needed to overcome ingrained resistance to strategies that have proven effective in preventing the spread of AIDS including condom distribution and providing retroviral drugs to prevent the transfer of HIV from mothers to their unborn children.

Despite numerous promises from industrialized nations to provide low-cost generic medications to combat AIDS, tuberculosis and malaria, they have routinely failed to deliver. Sadly, it does not appear to be a political priority as new causes crowd out old ones. In the meantime, people are dying and the resources in many Third World countries are strained to the breaking point trying to deal the patients and their families (this includes an estimated 14 million AIDS orphans). This problem isn't going away.

Click here for more information on how you can get involved.

After Disaster Strikes

While the 11 September 2001 terrorist attacks resulted in thousands of deaths and injuries, some injuries remain undiagnosed. The May 2008 issue of Prehospital and Disaster Medicine presents a research study examining incidence of traumatic brain injuries among persons hospitalized in New York City following the 11 September 2001 attacks. Using medical records of persons admitted to 36 hospitals in New York City with injuries or illnesses related to the attacks, individuals diagnosed with traumatic brain injuries (TBI) were identified using diagnosis codes from the International Classification of Diseases (9th Revision). Undiagnosed TBIs were identified by an adjudication team of TBI experts that reviewed the abstracted medical record information. Persons suspected of having an undiagnosed TBI were subsequently contacted and informed of the diagnosis of potential undetected injury.

The results indicate that, of the 282 records that were examined, fourteen cases of diagnosed TBIs and 21 cases of undiagnosed TBIs were identified for a total of 35 TBI cases (12% of all of the total). The leading cause of TBI was being hit by falling debris (22 cases) and one-third of the TBIs (13 cases) occurred among rescue workers. More than three years after the event, four out of six persons (66.67%) with an undiagnosed TBI who were contacted reported they were currently experiencing symptoms consistent with a TBI. The researchers conclude that not all cases of traumatic brain injury among hospitalized survivors of the 2001 attacks were identified at the time of acute injury care. Many individuals with undiagnosed cases were found to experience problems due to lack of effective diagnosis and treatment. The authors recommend additional clinical surveys be provided in-hospital for hospitalized survivors of mass-casualty incidents to help improve pre-discharge TBI diagnosis and refer patients to appropriate outpatient services. The use and adequacy of head protection for rescue workers also needs to be re-evaluated.

Click here for the abstract.

Car Fetishist Sentenced

A 45-year old Alberta man was sentenced to time served and two years probation for indecent exposure charges arising from an apparent sexual fetish for classic cars. The defendant (not named in the original news story) pleaded guilty to three counts of indecent exposure for repeatedly climbing on top of classic cars and masturbating in public. On March 22 of this year, he was caught masturbating on top of a $50,000 BMW Sedan at a Home and Garden show at the Northlands Agri Com. He was observed on two other occasions pleasuring himself on other cars in the Edmonton area.

A psychiatric evaluation report submitted at the time of his sentencing indicated that the man was sexually aroused by classic cars and also had a longstanding history of minor mental retardation due to a thyroid condition. While deemed to be a high risk for committing similar sexual offenses in future, he was not considered to pose an active risk to the public at large. In the submitted report, psychiatrist Curtis Woods indicated that the offender "announced that he is specifically sexually attracted to 'the roof top ... it's curved like a woman's body, the sex appeal, it felt good". He also reported a sexual attraction to motorcycles

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Casting Out The Djinn

Visitors to the countries of Western Africa (including Morocco, Algeria, and Senegal) can take in the exotic sights, sounds and smells associated with that part of the world but, for a real understanding of the religious life of the people, you need to learn about the marabouts. Meaning "saints" in the Berber language spoken in Morocco and Algeria, the marabouts act as spiritual leaders of the particular brand of Islam practiced throughout the West African nations. While the marabout tradition appears to predate Islam (and Islamic leaders often denounce the veneration attached to them), marabout worship can take many forms. The term marabout extends to the living spiritual leaders, known for their virtuous living and ability to act as agents between humans and divine forces, but also to the tombs where they are buried. Long after a marabout's death, the tomb can be a site for pilgrimages with each saint being judged by the miracles attached to his name and stories surrounding his life. Of all the marabouts who continue to attract pilgrims long after their death, there are few who are more revered than Bouya Omar.

Believed to have been born in 16th century Morocco, Bouya (Father) Omar developed a reputation for his ability to heal those suffering from mental illness. Much as in other parts of the world, mental illness was believed to be due to being possessed by evil spirits, in this case malign djinoun (djinn is the singular form). Although they are familiar figures in Western culture these days, djinoun (more commonly known as genies) are often perceived in West Africa as mischievous or vindictive spirits able to possess humans and cause illness. They were originally part of Arabian folklore but traditions concerning djinoun have been adopted in many countries in Western Africa, especially with respect to symptoms of mental illness. Bouya Omar's reputation stemmed from his ability to communicate with djinoun, learn what grievance they had against the one possessed, and persuading the djinn to leave. Long after his death, the tomb of Bouya Omar (near Marrakesh) continues to be the centre of veneration with families taking their mentally ill loved ones to the tomb to seek Bouya Omar's help. Physical restraints (including chains) are often used and ailing supplicants are kept near the tomb for months (if not years) to participate in complex rituals of prayer, animal sacrifice, or ritual fumigation with herbs administered by traditional healers (known as fquih or feki).

While modern psychiatry is slowly gaining acceptance in the larger cities, there is no real relationship between mainstream psychiatry and the traditional healers. Fquih have been known to recommend patients to psychiatrists when their rituals fail to help their patients but psychiatrists often view them as being little more than charlatans. Patients admitted to the few psychiatric hospitals available in the region tend to find themselves caught between medical and traditional views of healing with no real middle ground. Tempting as it is to consign the traditional healers to the fringes of African society, that is far from the case and they show no signs of going away, especially when psychiatric medication remains unaffordable for many Africans.

Is there a real solution? If so, feel free to share it with the ones at the tomb, waiting to be healed.

Remembering Washoe

There has been surprisingly little publicity concerning the recent death of Washoe, the first signing chimpanzee on October 30, 2007.  Washoe, matriarch of a research colony at Central Washington University's Chimpanzee and Human Interaction Institute, died of age-related causes at the ripe age of 42, far longer than she likely would have lived in the wild. Captured from her home in Africa in 1965, Washoe was originally sold to the United States Air Force are part of a group of "astrochimps". The ending of the space program led to Washoe being sent to live with Beatrix and Allen Gardner when she was 10 months old. They incorporated Washoe into their project on cross-species communication and began teaching her American Sign Language. Through careful work, Washoe was taught over 200 signs and observers at Central Washington University have reported the use of signing among the various members in the chimpanzee colony to which Washoe belonged.

The Washoe project came under criticism by Herbert Terrace, a psychologist at Colombia University, who began a series of experiments with a signing chimp affectionately named Nim Chimpsky. Although Nim learned 125 signs, Terrace concluded that he did not show any signs of the sequential use of signing that reflected human use of grammar. Nim simply used signs to obtain a desired end, not unlike what has been observed with other animals trained though operant conditioning. Terrace's conclusions, which he published in his 1979 Book Nim, placed him at odds with the Gardners who challenged his findings on methodological grounds. They considered the conditions under which Nim was taught to be too artificial and that the naturalistic setting in which Washoe and other signing chimps were raised was better suited to learning to communicate. Washoe also became notorious for biting off the middle finger of cognitive researcher, Karl Pribram, and essentially ending his career as a neurosurgeon.

Plans to assess whether Washoe passed on signing to her children were terminated when both of her offspring died as infants. Her death leaves only three other signing chimps in the small colony. It is uncertain whether additional chimpanzees will be added later.

Click here for the link.

Breaking the Cycle

The November 2007 issue of the Journal of the American College of Surgeons provides the results of a study evaluating whether, "Caught in the Crossfire," a hospital-based, peer intervention program for young victims of violence can be a cost-effective tool for reducing the impact of violence on later behaviour. The study used a retrospective design to examine patients admitted to a university-based urban trauma centre between January 1998 and June 2003 with an 18 month follow-up. The patients in the study were 12 to 20 years of age and were hospitalized for intentional violent trauma. The treatment group had a minimum of five interactions with an intervention specialist while a control group was selected from the hospital database. All patients were matched for age, socioeconomic status and ethnic background. The total sample size was 154 patients .

The results indicated that participating in the hospital-based program lowered the risk of later criminal justice involvement (relative risk=0.67; 95% CI, 0.45, 0.99; p=0.04) but there was no effect on risks of reinjury and death. Later violent criminal offending was reduced by 7% (p=0.15). Statistical analysis showed that age had a confounding effect on the association between program participation and criminal justice involvement (relative risk=0.71; p=0.043). When compared with juvenile detention center costs, the total cost reduction from the intervention program annually was $750,000 to $1.5 million. The researchers concluded that hospital-based peer intervention programming can meaningfully reduce the risk of criminal justice system involvement, is more effective with younger patients, and is cost effective. The potential of such programs for breaking the cycle of violence found in inner cities is self-evident.

Click here for the abstract.

When Victims Seek Help

For women who have been victimized by domestic violence, visiting a hospital emergency department can be an agonizing experience due to the problems in opening up to emergency staff. A study published in the November 2007 issue of Annals of Internal Medicine examining how female patients interact with emergency providers focuses on this issue. The study is based on an analysis of audio taped conversations made during a randomized, controlled trial of computerized screening for domestic violence in two emergency department (one urban and one sub-urban). Using a sample of 1281 English-speaking women age 16 to 69 years and 80 providers (30 attending physicians, 46 residents, and 4 nurse practitioners), 871 audiotapes, including 293 that included provider screening for domestic violence, were analyzed. Results indicated that providers typically asked about domestic violence in a routine manner during questioning concerning patient social history. Communication strategies that encouraged women to disclose abuse more openly included probing (defined as asking one or more additional topically related question), providing open-ended opportunities to talk, and being generally responsive to patient clues (any mention of a psychosocial issue). Chart documentation of domestic violence was present in one third of cases. While non-verbal communication was not directly examined, the results indicated that hectic and crowded clinical settings may obstruct candid reporting of domestic violence. Specific strategies designed to encourage meaningful discussion helped victims to open up about abuse. The researchers also identified common pitfalls and good practices in screening for domestic violence.

Click here for the abstract.

Does Child Abuse Affect Brain Development?

I was just attending the annual conference of the Association for the Treatment of Sexual Abusers that was held in San Diego this year. It was a stimulating experience with talks and workshops by some of the leading clinicians and researchers in the field. One of the high points of the conference was a presentation by Dr. Martin Teicher, Associate Professor at Harvard Medical School and director of the Clinical Biopsychiatry Research Program at McLean Hospital in Belmont, Massachusetts. The focus of Dr. Teicher's presentation was on the neurobiological affects of different types of stress on the developing brain, especially in terms of the short and long-term impact of child physical and sexual abuse on brain development. In particular, that early childhood maltreatment acts as a severe stressor that can produce various physiogical and hormonal reactions that leads to lasting alterations in patterns of brain development which, in turn, can manifest as different psychiatric disorders. Early stress can program the body's "fight or flight" systems to react more adversely to later stressors. There is also evidence for different periods during development when different regions of the brain are especially affected by early stress. Therefore, it isn't just the nature of the abuse but at when the abuse happens that can affect later development. Early neglect can also be as debilitating as physical or sexual abuse (a point that I have discussed before).

There also appear to be different abuse-related syndromes associated with particular ages of abuse and specific regional brain changes. Posttraumatic Stress Disorder, Major Depression, Borderline Personality Disorder, Impulse Disorders and aggression may be the result of abuse that only emerges at a much later stage of brain development (or even in adulthood). Even verbal abuse can impact later emotional and social development. Dr. Teicher concluded the presentation by arguing that society reaps what it sows in how children are nurtured. Early abuse can mold the brain to be more irritable, impulsive, and hypervigilant. He states that "maltreatment is a chisel that shapes a brain to contend with anticipated strife but at the cost of deep, enduring wounds. Early childhood stress isn't something you "get over". It is an evil that we must acknowledge and confront if we aim to do anything about the unchecked cycle of violence which often leads victims of abuse to become abusers".

Click here for the complete presentation.

Are Mental Health Courts Effective?

The September, 2007 issue of the American Journal of Psychiatry discusses the effectiveness of mental health courts in handling the increasing involvement of people with mental disorders in the criminal justice system. While many communities have created specialized mental health courts in recent years. there has been little research to date to the success such courts have had. A retrospective study was used to compare the occurrence of new criminal charges for 170 people who entered a mental health court after arrest and 8,067 other adults with mental disorders who were booked into an urban county jail after arrest during the same interval. Statistical analysis was used to rule out the influences of confounding variables such as demographic characteristics, clinical variables, and criminal history. The results indicated that participation in the mental health court program was associated with longer time without any new criminal charges or new charges for violent crimes. Successful completion of the mental health court program was associated with reduced recidivism and violence even after mental health court supervision ended. These results indicate that a mental health court can reduce recidivism and violence by people with mental disorders who are involved in the criminal justice system.

Click here for the abstract.

Does Tamiflu Cause Suicide?

Chugai Pharmaceutical Company the Japanese manufacturer and distributer of the antiviral drug, Tamiflu, has announced that it will curb supply of the drug following a warning by the Japanese government that Tamiflu use should be avoided in teenagers. Tamiflu was first developed by Gilead Sciences under the name Oseltamivir and is currently marketed by Hoffman-LaRoche. It is a prescription-only agent used in the prevention and treatment of influenzaviruses A and B and governments around the world have been stockpiling it due to pandemic fears. An estimated 50 million people have been treated around the world with the majority of cases being in Japan. The Japanese government issued the warning following reports that adolescents treated with Tamiflu have been experiencing delirium, seizures and self-harm attempts.

While concern has focused primarily on teenagers, patients in other age groups have reported problems as well. According to Japan's Health Ministry, between 2004 and 2007, fifteen people aged 10 to 19 have been injured or killed in apparent suicide attempts following Tamiflu use. Since 2001, approximately 128 patients reported abnormal behaviour after being treated with Tamiflu. While Hoffman-LaRoche denied a causal link, the U.S. Food and Drug Administration amended the warning label for Tamiflu to include possible delirium and psychiatric symptoms. Research is ongoing although Tamiflu is still viewed as part of a comprehensive front-line defense against future pandemics.

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