Phase I and pharmacokinetic study of 24-hour infusion 5-fluorouracil and leucovorin in patients with organ dysfunction.

BACKGROUND: Patients with hepatic or renal dysfunction are often treated with 5-fluorouracil (5-FU), but there are few data to confirm the safety of this practice. PATIENTS AND METHODS: Patients with solid tumors were eligible if they were able to fit into one of three organ dysfunction cohorts: I, creatinine >1.5 but < or =3.0 mg/dl and normal bilirubin; II, bilirubin >1.5 but <5.0 mg/dl with normal creatinine; or III, bilirubin > or =5.0 mg/dl with normal creatinine. 5-FU doses were escalated separately within each of the three cohorts. Leucovorin (LV) dosage was fixed at 500 mg/m(2). 5-FU was given as a 24-h infusion at 1000, 1800 or 2600 mg/m(2), and plasma concentrations were measured every 3 h during the first two infusions for each patient. RESULTS: Sixty-four patients were treated. Toxicities did not appear to be related to organ dysfunction cohort. A weekly dose of of 5-FU 2600 mg/m(2) produced dose-limiting toxicity (DLT) in six of 20 evaluable patients. These DLTs included grade 3 fatigue (n = 3), grade 2 neutropenia precluding weekly dosing (n = 1), grade 3 thrombocytopenia (n = 1) and grade 3 mental status changes (n = 1). There was no relationship between serum bilirubin or serum creatinine and 5-FU clearance. CONCLUSIONS: Patients with elevated bilirubin may be safely started on a weekly regimen of 5-FU 2600 mg/m(2) with leucovorin 500 mg/m(2) as a 24-h continuous infusion.

Interaction of the criminal justice system and psychiatric professionals in which civil commitment standards are prohibitive.

Three case studies are the basis for a discussion of the criminalization hypothesis as it may apply to psychiatric probationers and parolees in the criminal justice system. In each of these cases, the treating psychiatrist faced the problems of noncompliance with treatment and/or restrictive civil commitment standards. The patient's status as a probationer or parolee played a pivotal role in strategies for ensuring treatment through the criminal justice system as opposed to the mental health system or civil commitment process.

Jail recidivism and receipt of community mental health services.

OBJECTIVE: The authors' aim was to test the relationship between receipt of desired community mental health services by homeless mentally ill forensic clients and whether the clients returned to jail within six months. METHODS: Mentally ill homeless clients leaving jail were randomly assigned to three service conditions: intensive case management provided by an assertive community treatment team, intensive case management provided by individual case managers, and referral to a community mental health center. Data on whether clients' service needs were met were analyzed using discriminant function and chi square analyses. RESULTS: Thirty-two percent of the 105 clients interviewed at six months were reincarcerated during the six-month study period. Jail recidivism was related to receipt of fewer services that clients reported they needed, specifically to receipt of fewer services for developing independent living skills. Service condition was not significantly related to return to jail. CONCLUSIONS: Case management, a flexible community-based service that does not lend itself to clearly prescribed procedures, may easily deteriorate into providing monitoring rather than rehabilitative services for forensic clients and thus may facilitate reincarceration.

Predictors of reincarceration among patients who received psychiatric services in jail.

OBJECTIVE: The study sought to determine the proportion of patients treated in a jail psychiatric service who were jailed again within a year of release and to identify the factors that most effectively predicted jail recidivism in this population. METHODS: Clinical records for a random sample of 231 persons who received treatment at a jail psychiatric service were reviewed. Logistic regression analysis of 160 cases not transferred from jail to the state prison was used to identify factors, including demographic and clinical variables and prior jail detention, that predicted reincarceration within a year of release from jail. RESULTS: Younger age, a history of substance abuse, and prior jail detention were strong predictors of jail reincarceration. CONCLUSIONS: Return to jail is more likely for a subgroup of jail detainees for whom appropriate, effective treatment is less available in the community. Further research is needed to investigate the relationship between the course of substance abuse and jail reincarceration among younger psychiatric patients. Innovative treatments might be used to engage patients while in jail and follow them into the community after release.

Residents' treatment of clinic patients beyond graduation.

Twenty-one of 24 psychiatrists surveyed report that 51% (n=56) of their clinic patient panel entered their private care after they completed residency training. Patients with a DSM-III personality or depressive disorder were more likely than those with schizophrenia to continue in private treatment (p<.001). The practice of continued treatment of clinic patients beyond residency is reported to aid the professional development of the psychiatrist and the quality of patient care. Residency program directors may consider recommending this practice, if it is appropriate in their institution, to facilitate the psychiatrist's transition from training to career.

Lymphocyte function in major depressive disorder.

Lymphocyte stimulation by phytohemagglutinin, concanavalin A, and pokeweed mitogen was significantly lower in a group of hospitalized depressed patients than in matched controls. The absolute number of T and B cells was lower in the depressed group, but the percentage of these cell types did not differ between the groups. These findings may be related to the altered neuroendocrine function found in patients with depressive disorders.

What's new in aftercare? A review of recent literature.

With the deinstitutionalization movement has come the need to develop effective aftercare systems for chronic mental patients in the community. To assess the progress that has been made in aftercare, the authors conducted a review of the journal literature published since 1977. They summarize the major findings related to studies of aftercare in its various dimensions and conclude that, although numerous studies have reported more positive outcomes for patients involved in aftercare programs, none of the approaches used have been subjected to the kind of rigorous scientific investigation that would justify recommending their widespread application. They emphasize the need for further studies that attempt to define which type of treatment works for which type of patient.

The use of psychoanalytic concepts in crisis intervention.

Crises have a dynamic structure. Repressed neurotic conflicts and defects in ego organization determine vulnerability to specific stresses. Selection of focus in crisis intervention follows from the recognition of those rigid defensive patterns and adaptive incapacities which have either partially failed or been overwhelmed by the current stress. Aiming at the old problem in the new situation allows crisis work to go beyond symptom relief to improved conflict resolution and coping abilities. Therapeutic activity, rather than passivity, is the hallmark of crisis intervention and involves suggestion, abreaction, manipulation, clarification, and dynamic interpretation. Individuals in crisis are characteristically in a partially regressed state of transference readiness and availability, particularly as this involves intensified dependence wishes. Management of the transference requires recognition of negative, as well as positive, responses and the limitation of further regression that might lead to continual adaptive failure. A variety of specific countertransference responses are commonly evoked in crisis work. These must be recognized for effective treatment to proceed.

Influence of experience on major clinical decisions. Training implications.

We studied 779 walk-in psychiatric patients presenting to 32 first- or second-year residents and 772 patients presenting to 25 third-year residents or attending physicians as to the decision to admit to the hospital or to administer medication to those not admitted. There were no significant demographic or clinical differences between patients presenting to the two groups. The more experienced staff admitted half as many patients and treated serious depression with tricyclics twice as frequently. Inexperienced psychiatrists used hospitalization more frequently when these patients suffered from suicidal ideation, hallucinations, delusions, and inability to cope. When the training procedure was modified and second-year residents were introduced into a more structured setting, their decision-making quickly approached that of third-year residents and attending physicians. We suggest that specific training can modify decision-making, where general clinical experience may not. Implications for resident and medical student training are discussed.