RESUMEN

Mandatory outpatient treatment, or outpatient commitment, refers to court-ordered treatment for patients who suffer from severe mental illness and who are unlikely to be compliant with such treatment without a court order. Many states already have commitment statutes that permit mandatory outpatient treatment, and others are considering enacting new legislation or amending existing statutes. This Resource Document was prepared under the auspices of the American Psychiatric Association's Council on Psychiatry and Law to provide information to those who are drafting mandatory outpatient treatment legislation. It begins with a review of the history of mandatory outpatient treatment and recent empirical findings, followed by a detailed discussion of the salient issues in mandatory outpatient treatment. The document concludes with a statement of recommendations concerning key provisions in statutory schemes of mandatory outpatient treatment programs. This Resource Document endorses the view that mandatory outpatient treatment can be a useful intervention for a small subset of noncompliant patients with severe and chronic mental illness who go in and out of psychiatric hospitals through the so-called "revolving door."

Asunto(s)

RESUMEN

In this study, the utility of the cytomegalovirus antigen (CMV-AG) and the shell vial (SV) tests in the diagnosis and monitoring of posttransplant CMV infection were compared. Previous retrospective studies from the authors' center suggested that the CMV-AG test, which uses monoclonal antibodies to detect viral antigen in circulating peripheral blood leukocytes (PBL) may be both a more sensitive and specific test. A cohort of 32 renal transplant recipients was followed-up prospectively with serial CMV-AG testing, as well as conventional culture and SV for blood and urine and tests for immunoglobulin M (IgM) antibody. It was discovered that the CMV-AG test was not only more sensitive than the SV test in detecting CMV infection, but that the degree of antigenemia as expressed by the number of positive cells per 50,000 PBL correlated with the likelihood and degree of symptomatic infection. All patients with a count > 10 positive cells/50,000 PBL developed clinical symptoms; therefore, this threshold could be useful in deciding clinically whether fever is related to CMV infection. Alternatively, if antigenemia were monitored serially after transplant, the same threshold could be used as a trigger for instituting antiviral therapy, because it was often reached prior to the onset of symptoms and had a high specificity for subsequent symptomatic infection. Such an approach could obviate unnecessary treatment of patients not destined to become symptomatic. Based upon the findings in this study, the CMV-AG test is superior to the SV assay because the actual count helps determine the likelihood that symptoms are a result of the virus and the processing time is shorter, it can be used to monitor the response to therapy and as a guide to the institution of preemptive therapy.

Asunto(s)

Asunto(s)

RESUMEN

The clinical tolerance and pharmacokinetics of cyclosporine during a prolonged intermittent intravenous infusion (3.5 mg/kg/day three times) followed by an 8 mg/kg daily oral dose was evaluated in eight renal transplant recipients in the immediate postoperative period. Cyclosporine was analyzed from whole blood samples by HPLC. Despite peak drug concentrations of 1463 +/- 754 ng/ml during the infusion period, no adverse pulmonary effects were noted; renal function, urine output, and mean arterial pressure also appeared to have been unaffected. The mean trough cyclosporine concentration was 141 +/- 50 ng/ml; however, two patients had trough values below sensitivity. Kinetic analysis after the third dose of intravenous cyclosporine revealed a mean total body clearance of 0.31 +/- 0.1 L/min and a volume of distribution of 2.88 +/- 1.1 L/kg, whereas the elimination half-life was 12.8 +/- 3.8 hours and the mean residence time was 9.5 +/- 5.1 hours. After conversion to oral therapy the bioavailability ranged from 0.11 to 0.47, with a mean value of 0.27. Subsequently there was an unpredictable pattern of bioavailability within patients, with mean values of 0.27 +/- 0.13 and 0.30 +/- 0.25 during the second and third oral study periods, respectively. These data suggest that despite adjusting the intravenous cyclosporine dosage to account for acute changes in patient body weight, variable kinetics may result in subtherapeutic trough values, even when cyclosporine is administered by prolonged infusion. The clinical implications of fluctuating cyclosporine bioavailability and a potential alternative approach to dosing are discussed.

Asunto(s)

Asunto(s)

RESUMEN

A case of a pre-aortic left renal vein compression by the aorta is reported. The clinical presentation was characterized by the left flank pain varying with body body position. Renal venography was crucial for the diagnosis of this lesion. The left renal vein was successfully decompressed by ovarian vein-vena cava shunt surgery. The patient's left flank pain subsided after the surgery. This is the first reported case of a left renal vein compression syndrome by the aorta following the nephrotic syndrome.

Asunto(s)

RESUMEN

Sera from patients who had received renal allografts were studied for the presence of circulating immune complexes by using platelet aggregation technique combined with density gradient centrifugation. A simple and highly reproducible modification of the platelet aggregation technique, employing the use of relatively small amounts of blood from pretested donors as the source for platelets, is described. Immune complexes were detected in post-transplantation sera from 3 out of 16 patients. The development of a persistent immune complex state as a consequence of grafting was concluded in one patient.

Asunto(s)

RESUMEN

By means of double diffusion in gel reactions, "heterophile" antibodies were demonstrated in human renal transplantation sera. Of thirty-two recipients of renal allografts, 12 (37 per cent) had antibodies to extract of bovine erythrocyte stromata, and 5 (19 per cent) of 26 recipients produced antibodies to extract of sheep erythrocyte stromata. These antibodies became detectable 1-6 months after transplantation and persisted for several months or years. However, the strength of reactions given by individual serum samples from the same recipient varied considerably. Sera from the same recipient gave a reaction of identify, while sera from two different recipients frequently gave reactions of partial identity or nonidentity. The antibodies reacting with bovine stroma extract were distinct from those reacting with sheep stroma extract. Evidence was also presented that the heterophile antibodies in transplantation sera are different from Paul-Bunnell antibodies in infectious mononucleosis sera. Some of the HL-A typing sera were shown to contain antibodies against bovine stroma extract. The antigen recognized by these sera in the bovine stroma extract was not related to any HL-A specificity. Three of eight rabbits which received skin and renal allografts formed antibodies against bovine stroma extract. Absorption studies clearly demonstrated that these antibodies are directed against antigens present in the donor's, but not in the recipient's tissues.

Asunto(s)

Asunto(s)