The Final Years of Central State Hospital.

There is a rich literature on the deinstitutionalization movement in the US but few, if any, parallel histories of state mental hospitals. Under attack from the 1950s on, state hospitals dwindled in size and importance. Yet, their budgets remained large. This paper offers a case study of one such facility, Indiana's Central State Hospital, between 1968 and 1994. During these years, local newspapers published multiple stories of patient abuse and neglect. Internal hospital materials also acknowledged problems but offered few solutions. In 1984, the US Department of Justice intervened, charging Central State with having violated patients' civil rights, the first such action filed under the 1980 Civil Rights of Institutionalized Persons Act. Although Indiana signed a consent decree promising major reform, long-lasting change proved elusive. Civil and criminal lawsuits proliferated. In 1992, as Central State continued to attract negative attention, Indiana Governor Evan Bayh ordered the troubled hospital closed. His decision promised to save the state millions of dollars and won plaudits from many, but not all, mental health advocates. Even as the last patients left in 1994, some families continued to challenge the wisdom of eliminating Indiana's only large urban mental hospital, but to no effect.

Genotype-phenotype correlation in DTDST dysplasias: Atelosteogenesis type II and diastrophic dysplasia variant in one family.

Mutations in diastrophic dysplasia sulfate transporter (DTDST) cause a spectrum of autosomal recessive chondrodysplasias. In decreasing order of severity, they include processes designated as achondrogenesis type IB (ACG-1B), atelosteogenesis type II (AO2), diastrophic dysplasia (DTD), diastrophic dysplasia variant (DTDv), and recessively inherited multiple epiphyseal dysplasia (rMED). This is the first report of an extended family with unequivocally distinct phenotypes on the DTDST spectrum. Two siblings have DTDv and their first cousin had AO2. They all share the common Finnish mutation (IVS1 + 2C>T). The two patients with DTDv have the previously reported R279W extracellular domain missense mutation. The second mutation in the patient with AO2 is c.172delA, a deletion of one nucleotide causing a previously unreported frameshift mutation. This is the first published case of an individual with a frameshift mutation combined with the Finnish mutation. These three patients provide an opportunity, in concert with a review of previous literature, to further examine the genotype-phenotype correlation of DTDST. Analysis suggests that, while the DTDST family of disorders contains at least seven different conditions, mutations in the DTDST gene, in fact, appear to cause a phenotypic continuum. Furthermore, DTDST genotype alone is an imperfect predictor of clinical severity along this continuum.

Rare presentation of cutaneous cryptococcosis in advanced HIV.

Cryptococcus neoformans is an encapsulated yeast which causes opportunistic infection in the context of immunosuppression, including advanced HIV infection. Cryptococcal infection is systemic and can result in a fatal meningoencephalitis. Cutaneous lesions occur in 15% of those with systemic cryptococcosis and may be the first indicator of infection. Identification of these lesions may therefore expedite diagnosis and access to treatment. Cutaneous lesions typically present as papulonodular molluscum-like lesions; however, may vary significantly in appearance. We describe a rare case of extraneuronal cryptococcal infection manifesting as large subcutaneous tumours in a patient with advanced HIV-related immune deficiency.

Toxin-antitoxin (TA) systems are prevalent and transcribed in clinical isolates of Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus.

The percentage of bacterial infections refractory to standard antibiotic treatments is steadily increasing. Among the most problematic hospital and community-acquired pathogens are methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PA). One novel strategy proposed for treating infections of multidrug-resistant bacteria is the activation of latent toxins of toxin-antitoxin (TA) protein complexes residing within bacteria; however, the prevalence and identity of TA systems in clinical isolates of MRSA and PA has not been defined. We isolated DNA from 78 MRSA and 42 PA clinical isolates and used PCR to probe for the presence of various TA loci. Our results showed that the genes for homologs of the mazEF TA system in MRSA and the relBE and higBA TA systems in PA were present in 100% of the respective strains. Additionally, reverse transcriptase PCR analysis revealed that these transcripts are produced in the clinical isolates. These results indicate that TA genes are prevalent and transcribed within MRSA and PA and suggest that activation of the toxin proteins could be an effective antibacterial strategy for these pathogens.

Psychiatry and race during World War II.

Although the American literature on "war neuroses" expanded during World War II, psychiatrists remained more interested in dramatic instances of "combat fatigue" than in the problems of soldiers who broke down far from the field of battle. This bias in the medical literature shaped both diagnosis and treatment. It had an especially powerful effect on African American soldiers who, in the "Jim Crow" army of World War II, were assigned in disproportionate numbers to service units. When military neuropsychiatrists did write about troubled young African Americans, many revealed a racial conservatism that was surprising given the liberal environmentalist paradigm of the day. (Here, a particularly useful source is the two-volume history of Neuropsychiatry in World War II, produced by the Medical Department of the U.S. Army.) The major challenge to such views came from the National Medical Association (NMA). Despite its many criticisms of military medicine, the NMA argued that African American soldiers and veterans needed more, not fewer, psychiatric services. NMA members also joined their white counterparts in the campaign to diminish the stigma of mental illness, especially among the families of soldiers returning home. We need more investigation of the subsequent history of race and psychiatry, especially within the Veterans Administration.