Adjudicative Competence in the Context of a Defendant's Absence from Trial after a Suicide Attempt.

Defendants who are facing criminal charges in the United States have a constitutional right to be present at trial. This right can be voluntarily waived; for such a waiver to be valid, the defendant must be competent to waive the right to be present at trial. There have been several cases where a defendant is absent from trial because of a suicide attempt, and in these cases the courts must determine whether it is necessary to pause the criminal trial to allow for a competence hearing to take place. The U.S. Supreme Court offered guidance on this matter in its ruling in Drope v. Missouri; however, the Court did not clearly define the threshold for requiring a competence hearing when defendants attempt suicide during trial. Subsequent judicial rulings have provided insights into how courts might proceed when a criminal defendant is absent from trial following a suicide attempt. This topic has relevance to forensic psychiatry, as forensic psychiatrists may be called upon to participate in evaluations of adjudicative competence in these scenarios.

Clozapine Reduces Recurrent Suicidal and Self-Injurious Behavior in Treatment-Refractory Incarcerated Individuals.

This retrospective review examines clozapine's effects on treatment-refractory incarcerated individuals (N = 23) with recurrent thoughts of self-harm and/or self-injurious behavior. Emergent suicide risk assessments and days on suicide watch were assessed for the 3 months pre- and post-clozapine treatment. Total suicide assessments fell from 73 pre- to 14 post-clozapine, with a median of 2 assessments (interquartile range [IQR]: 1,5) pre-clozapine compared with 0 (IQR: 0,1) post-clozapine (p < 0.0001). Total days on suicide watch decreased from 104 days pre- to 32 post-clozapine, with a median of 3 days (IQR: 0,9) pre-clozapine compared with 0 (IQR: 0,0) post-clozapine (p = 0.0012). Emergency room visits and medical hospitalizations decreased substantially for all months of treatment. Clozapine treatment was associated with marked reductions in self-injurious thoughts and behaviors in high-risk incarcerated individuals.

Habitat aridity as a determinant of the trade-off between water conservation and evaporative heat loss in bats.

The maintenance of water balance in arid environments might represent a formidable challenge for Chiroptera, since they have high surface-to-volume ratios. In deserts, bats conserve water, for example, using daily torpor, but they also might experience episodic heat bouts, when they may need to increase total evaporative water loss (TEWL) to thermoregulate. We hypothesized that in bats, habitat aridity and its variability determine a trade-off between water conservation and thermoregulation via evaporative means. To test this hypothesis, we collated data from the literature of 22 species of bats on TEWL, body temperature and resting metabolic rate, in torpor and euthermy. We also collected data on ambient temperature (Ta) and precipitation of the locations where bats were captured, calculated an aridity index, and built an index of variability of the environment. After correcting for phylogeny, we found that, as aridity and variability of the environment increased, bats had lower values of TEWL, but the rate at which TEWL increases with Ta was higher, supporting our hypothesis. These results suggest that at high Ta there is a trade-off between water conservation and evaporative heat loss in bats. The evolution of physiological mechanisms that allow water conservation and tolerance to conditions of high Ta without access to free water might thus be crucial to explain the distribution of desert bats.

Effect of Clozapine on Time Assigned to Restrictive Housing in a State Prison Population.

This study examined the effect of clozapine on time assigned to restrictive housing (RH; i.e., solitary confinement), disciplinary infractions, and assaults on custody staff among patients treated within the North Carolina prison system. Records were reviewed for patients initiated on clozapine (n = 84) over a 3.5-year period. Fifty-nine patients completed at least three consecutive months of treatment and were included in data analysis. Assigned RH days and disciplinary infractions were assessed for the periods prior to and after treatment with clozapine. Patients accumulated 13,500 RH days pretreatment and 3,560 days postclozapine initiation. There was a significant reduction in RH days with clozapine treatment (P < .05). Patients with personality disorders (n = 36) had a significant decrease in RH days (P < .05), while those with psychotic disorders (n = 23) showed a decrease with borderline significance (P = .051). There were 253 disciplinary infractions pretreatment, including 27 assaults on custody staff, and 118 infractions posttreatment, including 7 assaults; the decrease in infractions was significant in the first three months of treatment (P < .05). The mean ± SD duration of treatment was 269 ± 102 days. Expanding clozapine use in state prisons should be a high priority, as these data are consistent with reports of clozapine's benefits in community settings.

Videoconferencing of Involuntary Commitment Hearings in the COVID Era.

Involuntary commitment hearings have been conducted utilizing videoconferencing technology for several years. There is limited information available in the published psychiatric literature pertaining to the use of this technology for commitment proceedings. The University of North Carolina Hospitals adopted a remote videoconferencing (tele-hearing) format for its civil commitment proceedings in response to the COVID-19 pandemic, and this provided us with the opportunity to investigate the use of such an arrangement. In this article, we review the use of videoconferencing for commitment hearings. We also review select case law related to the utilization of this technology for commitment hearings, which reveals that the courts have not been in full agreement about the legality of a virtual commitment tele-hearing format. Given that the general use of virtual platforms has expanded during the COVID-19 pandemic and many individuals and organizations are gaining confidence in operating this technology, more institutions may decide to shift to a virtual commitment scheme or make a commitment tele-hearing format permanent after the pandemic.

A Legal Right to Clozapine Therapy for Incarcerated Individuals With Treatment-Resistant Schizophrenia.

People with serious mental illnesses increasingly are being treated in jails and prisons, and during incarceration are afforded a constitutional right to medical care. This right pertains to both general medical and mental illnesses and both acute and chronic conditions. However, incarcerated patients with treatment-resistant schizophrenia (TRS) often are not offered clozapine, the only medication for this debilitating illness approved by the U.S. Food and Drug Administration. In this column, the authors argue that incarcerated individuals with TRS have a statutory and constitutional right to treatment with clozapine.

Resource Document for Electroconvulsive Therapy in Adult Correctional Settings.

ABSTRACT: Electroconvulsive therapy (ECT) has been used for decades for the treatment of mental illness. Despite its proven efficacy, ECT is rarely offered to individuals with psychiatric disorders who are incarcerated in jails and prisons. There are currently 2.2 million people confined in US correctional facilities. Research has demonstrated that the prevalence of serious mental illness among the US incarcerated population is 4 to 5 times what is observed in the community, and there can be no doubt that individuals currently exist within jails and prisons who would benefit from this treatment modality. One issue identified as a barrier to ECT being offered to this patient population is a lack of professional guidance on the administration of ECT to individuals who are incarcerated in correctional facilities. Indeed, very little information has been published on this subject in the medical literature. We offer this article as a resource document for the utilization of ECT within adult corrections. This resource document includes a protocol to assist correctional providers and administrators in navigating the ECT referral process, a review of options for delivery of ECT to adult inmate patients, and a discussion of topics related to correctional ECT that warrant special attention, such as informed consent, the perception of ECT use within corrections, ECT-associated cognitive impairment, involuntary ECT, and ECT for competence restoration. It is vital that this important therapy be made accessible to individuals in correctional settings who are experiencing mental illness.

Four-wave-mixing microscopy reveals non-colocalisation between gold nanoparticles and fluorophore conjugates inside cells.

Gold nanoparticles have been researched for many biomedical applications in diagnostics, theranostics, and as drug delivery systems. When conjugated to fluorophores, their interaction with biological cells can be studied in situ and real time using fluorescence microscopy. However, an important question that has remained elusive to answer is whether the fluorophore is a faithful reporter of the nanoparticle location. Here, our recently developed four-wave-mixing optical microscopy is applied to image individual gold nanoparticles and in turn investigate their co-localisation with fluorophores inside cells. Nanoparticles from 10 nm to 40 nm diameter were conjugated to fluorescently-labeled transferrin, for internalisation via clathrin-mediated endocytosis, or to non-targeting fluorescently-labelled antibodies. Human (HeLa) and murine (3T3-L1) cells were imaged at different time points after incubation with these conjugates. Our technique identified that, in most cases, fluorescence originated from unbound fluorophores rather than from fluorophores attached to nanoparticles. Fluorescence detection was also severely limited by photobleaching, quenching and autofluorescence background. Notably, correlative extinction/fluorescence microscopy of individual particles on a glass surface indicated that commercial constructs contain large amounts of unbound fluorophores. These findings highlight the potential problems of data interpretation when reliance is solely placed on the detection of fluorescence within the cell, and are of significant importance in the context of correlative light electron microscopy.

Behavioral Health Services in North Carolina's State Prison System: Challenges and Opportunities.

There has been a dramatic increase in the number of individuals incarcerated in the United States during the past several decades. Providing behavioral health care services to incarcerated people within North Carolina's prison system presents several challenges, and progress is being made to deliver care that is consistent with accepted community standards.

Clozapine Reduces Self-Injurious Behavior in a State Prison Population.

Self-injurious behavior (SIB) is a common, disruptive, and costly occurrence in U.S. prisons. In this study, we describe the use of clozapine to treat 10 offenders with chronic, repetitive self-injury refractory to other medications and behavioral therapies. The primary diagnosis for all 10 offenders was a personality disorder. Eight of the 10 inmates allowed weekly blood draws and took medication regularly (approximately 95% adherence), whereas two inmates discontinued treatment within the first two weeks. For these eight patients, we compared the number of in-house urgent care visits and outside emergency room visits related to SIB for the six-month periods before and after treatment with clozapine. After initiation of clozapine treatment, there were 66 fewer urgent care visits (94 versus 28) and 26 fewer emergency room visits (37 versus 11), a 70 percent reduction in each. As a secondary outcome, we assessed disciplinary infractions. There were 132 fewer infractions (197 versus 65), a 67 percent reduction. The median dose of clozapine used was 125 mg/day, substantially lower than doses typically used to treat schizophrenia. Clozapine appears to be a feasible and effective treatment for some patients with chronic, repetitive SIB for whom other treatments have failed.

Do Pregnant Inmates have a Constitutional Right to Opioid Replacement Therapy?

Changes in the national drug laws have resulted in a marked increase in the number of individuals who have been incarcerated in the United States over the past several decades; women have not been exempt from this trend. Incarcerated women who are pregnant and at risk of experiencing opioid withdrawal often lack access to opioid replacement therapy while in jails and prisons, although this treatment is necessary to prevent significant acute withdrawal that can be detrimental to maternal-fetal health. I contend that pregnant inmates who are at risk of experiencing opioid withdrawal possess a constitutional right to receive opioid replacement therapy while incarcerated and that failure to provide this treatment represents a violation of the Eighth Amendment's protection against cruel and unusual punishment.

Presence and persistence of a highly ordered lipid phase state in the avian stratum corneum.

To survive high temperatures in a terrestrial environment, animals must effectively balance evaporative heat loss and water conservation. In passerine birds, cutaneous water loss (CWL) is the primary avenue of water loss at thermoneutral temperatures and increases slightly as ambient temperature increases, indicating a change in the permeability of the skin. In the stratum corneum (SC), the outermost layer of the skin, lipids arranged in layers called lamellae serve as the primary barrier to CWL in birds. The permeability of these lamellae depends in large part on the ability of lipid molecules to pack closely together in an ordered orthorhombic phase state. However, as temperature increases, lipids of the SC become more disordered, and may pack in more permeable hexagonal or liquid crystalline phase states. In this study, we used Fourier transform infrared spectroscopy to monitor the phase state of lipids in the SC of house sparrows (Passer domesticus) at skin temperatures ranging from 25 to 50°C. As temperature increased, lipids became slightly more disordered, but remained predominantly in the orthorhombic phase, consistent with the small increase in CWL observed in house sparrows as ambient temperature increases. These results differ considerably from studies on mammalian SC, which find a predominantly hexagonal arrangement of lipids at temperatures above 37°C, and the increased order in avian SC may be explained by longer lipid chain length, scarcity of cholesterol and the presence of cerebrosides. Our results lend further insight into the arrangement and packing of individual lipid molecules in avian SC.

Interfacial properties of avian stratum corneum monolayers investigated by Brewster angle microscopy and vibrational sum frequency generation.

The outermost layer of skin, the stratum corneum (SC), contains a complex mixture of lipids, which controls the rate of cutaneous water loss (CWL) in reptiles, mammals, and birds. However, the molecular structure of SC lipids and how molecular configurations influence CWL is poorly understood. Here, the organization and structure of SC lipids extracted from birds were investigated by means of Langmuir films. Properties of lipids from the SC of arid and semi-arid adapted larks, known to have a low CWL, were compared with lipids extracted from the SC of mesic lark species with higher CWL to gain insight into how structure impacts CWL. Film properties were probed with surface pressure-area isotherms, Brewster angle microscopy (BAM), and vibrational sum frequency generation (VSFG). Results indicate organization and ordering of SC lipids in the arid-adapted hoopoe lark was vastly different from all other species, forming a miscible, rigid monolayer, whereas monolayers from semi-arid and mesic species were immiscible and disordered. Probing of interfacial water structure reveals that film morphology determines organization of water molecules near the monolayer; monolayers with a porous morphology had an increased population of water molecules that are weakly hydrogen-bonded. In general, CWL appears related to the miscibility and ordering of lipid components within the SC, as well as the ability of these lipids to interact with water molecules. From a broader perspective, CWL in larks appears linked to both the SC lipid composition and the aridity of the species' environment.

The cutaneous lipid composition of bat wing and tail membranes: a case of convergent evolution with birds.

The water vapour permeability barrier of mammals and birds resides in the stratum corneum (SC), the outermost layer of the epidermis. The molar ratio and molecular arrangement of lipid classes in the SC determine the integrity of this barrier. Increased chain length and polarity of ceramides, the most abundant lipid class in mammalian SC, contribute to tighter packing and thus to reduced cutaneous evaporative water loss (CEWL). However, tighter lipid packing also causes low SC hydration, making it brittle, whereas high hydration softens the skin at the cost of increasing CEWL. Cerebrosides are not present in the mammalian SC; their pathological accumulation occurs in Gaucher's disease, which leads to a dramatic increase in CEWL. However, cerebrosides occur normally in the SC of birds. We tested the hypothesis that cerebrosides are also present in the SC of bats, because they are probably necessary to confer pliability to the skin, a quality needed for flight. We examined the SC lipid composition of four sympatric bat species and found that, as in birds, their SC has substantial cerebroside contents, not associated with a pathological state, indicating convergent evolution between bats and birds.

Organization of lipids in avian stratum corneum: Changes with temperature and hydration.

In response to increases in ambient temperature (Ta), many animals increase total evaporative water loss (TEWL) through their skin and respiratory passages to maintain a constant body temperature, a response that compromises water balance. In birds, cutaneous water loss (CWL) accounts for approximately 65% of TEWL at thermoneutral temperatures. Although the proportion of TEWL accounted for by CWL decreases to only 25% at high Ta, the magnitude of CWL still increases, suggesting changes in the barrier function of the skin. The stratum corneum (SC) is composed of flat, dead cells called corneocytes embedded in a matrix of lipids, many of which arrange in layers called lamellae. The classes of lipids that comprise these lamellae, and their attendant physical properties, determine the rate of CWL. We measured CWL at 25, 30, 35, and 40 °C in House Sparrows (Passer domesticus) caught in the winter and summer, and in sparrows acclimated to warm and cold lab environments. We then used Fourier transform infrared spectroscopy to measure lipid-lipid and lipid-water interactions in the SC under different conditions of temperature and hydration, and correlated these results with lipid classes in the SC. As CWL increased at higher temperatures, the amount of gauche defects in lipid alkyl chains increased, indicating that lipid disorder is partially responsible for higher CWL at high temperatures. However, variation in CWL between groups could not be explained by the amount of gauche defects, and this remaining variation may be attributed to greater amounts of cerebrosides in birds with low CWL, as the sugar moieties of cerebrosides lie outside lipid lamellae and form strong hydrogen bonds with water molecules.