A Qualitative Analysis of Suicide Notes to Understand Suicidality in Older Adults.

OBJECTIVE: Suicide is a complex multifactorial process influenced by a variety of biological, psychological, and social stressors. Many older adults face a characteristic set of challenges that predispose them to suicidal ideation, suicide-related behavior, and death by suicide. This study explored the subjective experience of suicidality through the analysis of suicide notes from older adults. DESIGN: Qualitative study analyzing written suicide notes. SETTING: Written notes for suicide deaths in Toronto, Canada, between 2003 and 2009 were obtained from the Office of the Chief Coroner for Ontario. PARTICIPANTS: The analysis comprised 29 suicide notes (mean words per note: 221; range: 6-1095) written by individuals 65 years and older (mean ± SD age: 76.2 ± 8.3). MEASUREMENTS: We employed a constructivist grounded theory framework for the analysis, conducted through line-by-line open coding, axial coding, and theorizing of data to establish themes. RESULTS: Suicide notes elucidated the writers' conception of suicide and their emotional responses to stressors. Expressed narratives contributing to suicide centered on burdensomeness or guilt, experiences of mental illness, loneliness or isolation, and poor physical health or disability. Terms related to pain, poor sleep, apology, and inability to go on were recurrent. CONCLUSIONS: Suicide notes enrich our understanding of the thoughts and emotions of those at highest risk of suicide, and they inform potential interventions for reducing suicide risk in older adults.

Susceptibility to Undue Influence: The Role of the Medical Expert in Estate Litigation.

OBJECTIVES: Medical experts are increasingly asked to assist the courts with Will challenges based on the determination of testamentary capacity and potential undue influence. Unlike testamentary capacity, the determination of undue influence has been relatively neglected in the medical literature. We aim to improve the understanding of the medical expert role in providing the courts with an opinion on susceptibility to undue influence in estate litigation. METHOD: Medical experts with experience in the assessment of testamentary capacity and susceptibility to undue influence collaborated with experienced estate litigators. The medical literature on undue influence was reviewed and integrated. The lawyers provided a historical background and a legal perspective on undue influence in estate litigation and the medical experts provided a clinical perspective on the determination of susceptibility to undue influence. Together, they provided recommendations for how the medical expert could best assist the court. RESULTS: Susceptibility to undue influence is frequently used in estate litigation to challenge the validity of Wills and is defined as subversion of the testator's free will by an influencer, resulting in changes to the distribution of the estate. While a determination of undue influence includes the documentation of indicia or suspicious circumstances under which the Will was drafted and executed, medical experts should focus primarily on the susceptibility of the testator to undue influence. This susceptibility should be based on a consideration of cognitive function, psychiatric symptoms, physical and behavioural function, with evidence derived from the medical documentation, the medical examination, and the history. CONCLUSIONS: The determination of undue influence is a legal one, but medical experts can help the court achieve the most informed legal decision by providing relevant information on clinical issues that may impact the testator's susceptibility to undue influence.

Patterns of Perceived Stress Throughout the Migraine Cycle: A Longitudinal Cohort Study Using Daily Prospective Diary Data.

OBJECTIVES: To describe patterns of perceived stress across stages of the migraine cycle, within and between individuals and migraine episodes as defined for this study. METHODS: Individuals with migraine aged ≥18 years, who were registered to use the digital health platform N1-HeadacheTM , and completed 90 days of daily data entry regarding migraine, headache symptoms, and lifestyle factors were eligible for inclusion. Perceived stress was rated once a day at the participant's chosen time with a single question, "How stressed have you felt today?" with response options graded on a 0-10 scale. Days were categorized into phases of the migraine cycle: Ppre  = pre-migraine headache (the 2 days prior to the first day with migraine headache), P0  = migraine headache days, Ppost  = post-migraine headache (the 2 days following the last migraine day with migraine headache), and Pi  = interictal days (all other days). Episodes, defined as discrete occurrences of migraine with days in all 4 phases, were eligible if there was at least 1 reported daily perceived stress value in each phase. Individuals with ≥5 valid episodes, and ≥75% compliance (tracking 90 days in 120 calendar days or less) were eligible for inclusion in the analysis. RESULTS: Data from 351 participants and 2115 episodes were included in this analysis. Eighty-six percent of the sample (302/351) were female. The mean number of migraine days per month was 6.1 (range 2-13, standard deviation = 2.3) and the mean number of episodes was 6.0 (range 5-10, standard deviation = 1.0) over the 90-day period. Only 8 (8/351, 2.3%) participants had chronic migraine (defined as 15 or more headache days per month with at least 8 days meeting criteria for migraine). Cluster analysis revealed 3 common patterns of perceived stress variation across the migraine cycle. For cluster 1, the "let down" pattern, perceived stress in the interictal phase (Pi ) falls in the pre-headache phase (Ppre ) and then decreases more in the migraine phase (P0 ) relative to Pi . For cluster 2, the "flat" pattern, perceived stress is relatively unchanging throughout the migraine cycle. For cluster 3, the "stress as a trigger/symptom" pattern, perceived stress in Ppre increases relative to Pi , and increases further in P0 relative to Pi . Episodes were distributed across clusters as follows: cluster 1: 354/2115, 16.7%; cluster 2: 1253/2115, 59.2%, and cluster 3: 508/2115, 24.0%. Twelve participants (12/351, 3.4%) had more than 50% of their episodes fall into cluster 1, 216 participants (216/351, 61.5%) had more than 50% of their episodes fall into cluster 2, and 25 participants (25/351, 7.1%) had more than 50% of their episodes fall into cluster 3. There were 40 participants with ≥90% of their episodes in cluster 2, with no participants having ≥90% of their episodes in cluster 1 or 3. CONCLUSIONS: On an aggregate level, perceived stress peaks during the pain phase of the migraine cycle. However, on an individual and episode basis, there are 3 dominant patterns of perceived stress variation across the migraine cycle. Elucidating how patterns of perceived stress vary across the migraine cycle may contribute insights into disease biology, triggers and protective factors, and provide a framework for targeting individualized treatment plans.

The Role of the Medical Expert in the Retrospective Assessment of Testamentary Capacity.

OBJECTIVES: Physicians and other mental health experts are increasingly called on to assist the courts with the determination of testamentary capacity. We aim to improve the understanding of the retrospective assessment of testamentary capacity for medical experts in order to provide more useful reports for the court's determinations and to provide a methodology for the retrospective assessment of testamentary capacity. METHOD: Medical experts with experience in the retrospective assessment of testamentary capacity collaborated with lawyers who practice estate litigation. The medical literature on the assessment of testamentary capacity was reviewed and integrated. The medical experts provided a clinical perspective, while the lawyers ensured that the case law and legal perspective were integrated into this review. RESULTS: The focus and limitations of the medical expert are outlined including the need to be objective, nonpartisan, and fair. For the benefit of the court, the medical expert should describe the nature and severity of relevant medical, psychiatric, and cognitive disorders, and how they may impact on the specific criteria for testamentary capacity as defined by the leading case of Banks v Goodfellow. Medical experts should opine only on the issue of vulnerability to influence and defer to the court to determine the facts of the case regarding any influence that may have been exerted. CONCLUSIONS: Although the ultimate determination of testamentary capacity is a legal one, medical experts can help the court achieve the most informed legal decision by providing relevant information on clinical issues that may impact the criteria for testamentary capacity.

Piloting the global capacity education e-tool: can capacity be taught to health care professionals across different international jurisdictions?

Determining decision-making capacity is part of everyday business for health care professionals working with older adults. We used a modified Delphi approach to develop an inclusive curriculum for a capacity education e-tool with global application and clinical relevance to a range of disciplines. The tool comprised: (i) 25 questions forming a "pre-test" for the adaptive and personalized e-Learning platform; (ii) a learning module based on the participant's response to the "pre-test"; (iii) a "post-test" (the same baseline 25 questions) to test knowledge translation. The tool was tested on 31 health care professionals across Israel (8), Canada (15), and Australia (8) from the following disciplines: General Practitioners (GP) (19), Internal Medicine (1), Palliative Care GP (2); Palliative Care Physician (2), Geriatrician (2); and one of each: Psychologist, Occupational Therapist, Psychiatrist, Aged Care Researcher, and Aged Care Pharmacist. The mean baseline pre-test score was 19.1/25 (S.D. =1.61; range 15-22) and post-test score 21.7/25 (S.D.= 1.42; range 18-24); with a highly significant improvement in test scores (paired t-test P < 0.0001; t=10.81 on 30 df). This is the first such pilot study to demonstrate that generic capacity principles can be taught to health care professionals from different disciplines regardless of jurisdiction.

Cutaneous T-cell lymphoma mimicking palmoplantar pustular psoriasis: A rare variant.

The development of pustular cutaneous T-cell lymphoma (CTCL) on the palms and soles is rare. Without confirmatory biopsy and molecular studies, CTCL can be misdiagnosed as many benign inflammatory skin diseases. We present a case of cutaneous T-cell lymphoma (CTCL) that mimicked palmoplantar pustular psoriasis, a rarely reported manifestation of the disease. We stress the importance of biopsy to confirm diagnoses, especially when preliminary diagnoses do not respond to empiric treatment.

Delphi survey of maintenance lithium treatment in older adults with bipolar disorder: An ISBD task force report.

OBJECTIVES: Despite the growing numbers and proportion of older adults with bipolar disorder (OABD), there are very limited guidelines for the use of lithium with its double-edged potential for effectiveness and toxicity in this population. The primary aims of this Delphi survey were: (a) To determine the place of lithium among the preferred choices for maintenance treatment of OABD. (b) To provide detailed clinical guidelines for the safe and effective use of lithium in OABD. METHODS: In the face of limited evidence, the Delphi survey method was used to achieve consensus by a group of 25 experts in OABD from nine countries. An oversight committee monitored and analyzed the results of each survey and formulated more focused questions with each subsequent iteration. RESULTS: A 100% response rate was achieved for all three iterations of the survey. Lithium was the preferred choice for maintenance monotherapy in OABD. Serum levels of 0.4-0.8 mmol/L were recommended for ages 60-79 and serum levels of 0.4-0.7 mmol/L were recommended for ages 80 and over. Specific recommendations achieved consensus for second line monotherapy as well as for other drugs to be used in combination with lithium if necessary. Guidelines for routine monitoring of lithium in OABD were provided for laboratory investigations and clinical assessments. CONCLUSIONS: Lithium remains the preferred choice for maintenance monotherapy in OABD. Laboratories should report the therapeutic range for serum levels of lithium separately for older adults.

Evaluating Mean Level and Within-Person Consistency in Migraine Pain Intensity and Migraine-Related Disability for AVP-825 vs Oral Sumatriptan: Results from the COMPASS Study, A Randomized Trial.

BACKGROUND: Consistency of response across multiple attacks is typically measured as the proportion of study participants who achieve a categorical endpoint over a specified number of attacks (ie, 2-hour pain-free response in 2 of 3 attacks). We applied a novel analytic approach for measuring consistency of response in the acute treatment of episodic migraine using data from the COMPASS study. METHODS: The COMPASS study (NCT01667679) was a multiple attack crossover study which compared AVP-825, a Breath Powered® intranasal delivery system for low-dose sumatriptan powder (22 mg), with 100-mg oral sumatriptan tablets in the acute treatment of migraine. Participants were 18-65 years old, met ICHD-2 criteria for migraine with or without aura, and had migraine for ≥1 year prior to screening. They were instructed to treat up to 5 migraine attacks with each treatment and recorded migraine pain intensity and disability data at pre-dose and 10, 15, 30, 45, 60, 90, and 120 minutes post-dose for each attack. We explored the mean level and within-person variability (WPV; a measure of consistency) in migraine pain intensity and migraine-related disability across multiple attacks after treatment with AVP-825 (22 mg) vs oral sumatriptan (100 mg) using location scale mixed-effects models (LSMEMs). LSMEMs controlled for pre-dose pain/disability, demographics, treatment sequence, and treatment period. RESULTS: The mean age was 40 and the sample was 84.6% women. Participants (N = 259) treated an average of 6.8 attacks each during the course of the study. Attacks treated with AVP-825 showed significantly lower mean pain intensity and mean disability from 10 to 90 minutes post-dose (effect sizes ranged from -0.09 to -0.29 and P values ranged from P < .0001 to P = .01). WPV was significantly greater at 10-15 minutes (WPV ratios ranged from 1.20 to 1.58 and P values ranged from P < .0001 to P = .04) but significantly reduced from 45 to 120 minutes for attacks treated with AVP-825 compared to oral sumatriptan (WPV ratios ranged from 0.67 to 0.81 and P values ranged from P < .0001 to P = .03). CONCLUSIONS: LSMEMs demonstrate that treatment with AVP-825 is associated with lower average migraine pain intensity and disability from 10 to 90 minutes and greater within-person consistency across multiple migraine attacks (reduced WPV) from 45 to 120 minutes post-dose compared to oral sumatriptan. These findings may reflect the more rapid and consistent absorption of sumatriptan using AVP-825. Increased WPV with AVP-825 in the first 15 minutes likely reflects the earlier onset of treatment effects with the device compared to oral sumatriptan. LSMEMs show promise as a novel approach for assessing and comparing consistency of treatment response in migraine trials.

Clock drawing and neuroanatomical correlates: A systematic review.

OBJECTIVE: The popular clock drawing test (CDT) is easy to administer, acceptable to patients, and has excellent psychometric properties. Although it has been used primarily as a cognitive screening test, many studies have attempted to establish the CDT's ability to localize specific brain lesions or pathology. This systematic review aimed to summarize the evidence on the neuroanatomical correlates of the CDT. METHODS: Using PRISMA guidelines, the authors systematically reviewed the evidence on neuroanatomical correlates of clock drawing by a systematic search in six databases (Pubmed, CINHL, PsychINFO, HealthStar, Embase, and Web of Science) until January 2018. Studies were included if they reported CDT correlations with anatomical brain lesions documented by neuroimaging. RESULTS: Forty-five papers met inclusion criteria. Thirty-one studies identified distinct areas of neuroanatomical correlates of CDT utilizing different scoring methods and imaging techniques. Nine articles reported on the degree of white matter hyperintensities that correlated with lower scores on CDT and the severity of cognitive deficits. Five articles focused on postacute cerebrovascular accidents correlated with CDT performance. A variety of different anatomical lesions, located in all areas of the brain, were associated with abnormalities on the CDT. CONCLUSIONS: The CDT, regardless of scoring method and population studied, was not associated with any consistent, specific brain localization. This systematic review supports the use of the CDT as a cognitive screening test rather than a method of localizing brain lesions.

AVP-825 (Sumatriptan Nasal Powder) Reduces Nausea Compared to Sumatriptan Tablets: Results of the COMPASS Randomized Clinical Trial.

BACKGROUND: Migraine-related nausea is associated with significant disability, increased burden of disease, and personal distress. Nausea can lead to delays or avoidance of initiating oral migraine treatment, sometimes resulting in treatment failures and poor outcomes. Nausea is often a symptom of migraine, but nausea may also be a consequence of treatment (ie, treatment emergent nausea [TEN]). Relieving nausea and minimizing TEN are important goals in acute migraine therapy. METHODS: We analyzed data from the COMPASS study, a randomized, double blind, double-dummy, comparative efficacy study that contrasted two active treatments, AVP-825 (breath-powered intranasal delivery of powdered sumatriptan 22 mg) and oral sumatriptan tablets (100 mg). Three-level logistic multilevel models were used to examine longitudinal changes in nausea from three distinct perspectives across multiple attacks. Model 1 (Overall Nausea) examined longitudinal change in nausea from pre-dose through 120 minutes post-dose for the entire sample, independent of baseline nausea. Model 2 examined TEN from 10 minutes through 120 minutes post-dose in attacks free of nausea at baseline to investigate whether or not nausea developed following treatment. Model 3 examined Nausea Relief from 10 minutes through 120 minutes post-dose in eligible attacks with nausea at baseline to examine whether or not nausea was relieved over the first 2 hours post-dose. Models tested for differences in rate of change in nausea over time and odds of nausea at specific time-points. RESULTS: Longitudinal nausea trajectories differed for AVP-825 and oral sumatriptan in the Overall Nausea model (Model 1) and TEN model (Model 2), but were more comparable across treatments for the Nausea Relief (Model 3). More specifically, in the Overall Nausea model (Model 1), an individual treating an attack with AVP-825 had a significantly faster decrease in nausea through the first 60 minutes post-dose and reduced odds of nausea at each time-point from 30 minutes through 120 minutes post-dose compared to oral sumatriptan. In Model 2, an individual's risk for TEN increased at a significantly faster rate through the first 45 minutes post-dose when treating an attack with oral sumatriptan, with significantly greater odds of experiencing TEN at 45, 60, and 90 minutes post-dose compared to AVP-825. The Nausea Relief model (Model 3) showed similar rates of change in nausea over time for the two treatments, but there was a constant difference in nausea level leading to reduced odds of nausea when treating with AVP-825 compared to oral sumatriptan. CONCLUSIONS: All three longitudinal models showed that AVP-825 had more favorable nausea outcomes compared to oral sumatriptan. AVP-825 treatment led to more rapid early reductions in Overall Nausea rates during the first hour, reduced odds of nausea from 30 minutes to 2 hours following treatment and reduced risk of TEN compared to oral sumatriptan. These results highlight the importance of separately assessing TEN and Nausea Relief in acute treatment trials of migraine.

The test of time: a history of clock drawing.

OBJECTIVE: The clock drawing test (CDT) has become one of the most widely used cognitive screening instruments in clinical and research settings. Its effectiveness, acceptability, and quick and easy administration have made it a staple for cognitive screening in dementia and a wide range of brain disorders. Despite a spike in popularity since the 1990s, its origins are relatively unknown. The goal of this review is to chronicle its saga and chart its usage over time. METHODS: PsycInfo, Medline, and PubMed literature searches were performed from earliest record to June 2016, in addition to manual cross-referencing of bibliographies, with a focus before 1990. Summary of relevant articles and books up until 1989 is included, as well as clinical applications and surveys that track CDT usage over time. RESULTS: While MacDonald Critchley's well-known textbook from 1953, The Parietal Lobes, is often cited as the first mention of the CDT, its recorded use actually stretches back more than a century to 1915. A review of the literature shows that the CDT began as a test for aphasia-related disorders and constructional apraxia until its entry into contemporary cognitive screening in the 1980s when it primarily became a cognitive screen. Its usage took off in 1989 with over 2000 publications since. CONCLUSIONS: Despite a fairly obscure existence for decades, the CDT has emerged as an effective and ideal cognitive screening instrument for a wide range of conditions. Its use continues to increase, and it has been incorporated into several widely used cognitive screening batteries. Copyright © 2017 John Wiley & Sons, Ltd.

The association between cognitive fluctuations and activities of daily living and quality of life among institutionalized patients with dementia.

OBJECTIVE: Cognitive fluctuations (CFs) occur commonly in dementia of all types. While it is generally accepted that CFs can affect the clinical rating of dementia severity and neuropsychological performance, little is known about their impact on patients' activities of daily living (ADLs) and quality of life (QOL). Our study aims to explore the impact of CFs on ADLs and QOL among institutionalized patients with dementia. METHODS: The present study examined the nature and frequency of CFs in 55 institutionalized dementia patients. We used the Dementia Cognitive Fluctuation Scale (DCFS) to assess the presence and severity of CFs. The Alzheimer's Disease Functional Assessment of Change Scale (ADFACS) was used to assess patients' ADLs, and the Quality of Life in Late Stage Dementia scale (QUALID) was used to assess QOL. Linear regression models were used to assess the relationships between CFs, ADLs, and QOL. RESULTS: The mean age of the patients was 90.41 years (SD = 2.84). Their mean Aggressive Behavior Scale score was 1.13 (SD = 1.59), mean Severe Impairment Battery total score was 86.65 (SD = 13.77), and mean DCFS score was 10.07 (SD = 3.04). The mean ADFACS-ADL score was 10.88 (SD = 6.37), mean ADFACS-IADL score was 16.61 (SD = 9.54), and mean QUALID total score was 18.25 (SD = 5.70). DCFS significantly predicted ADFACS-ADL score (R2  = 0.39, ß = 0.30, P = .011) although the relationship between ADFACS-IADL score and DCFS score was not significant (R2  = 0.16, P = .111). DCFS significantly predicted QUALID score (R2  = 0.08, ß = 0.29, P = .033). CONCLUSION: More severe CFs in patients with dementia were significantly associated with impaired ability to engage in ADLs and poorer QOL.

Rapidly Enlarging Malignant Proliferating Trichilemmal Tumor in a Young Female

Malignant proliferating trichilemmal tumors are rare adnexal neoplasms that most commonly occur on the scalp in elderly women. These tumors are associated with recurrence and even nodal or distant metastatic spread. Here we describe a 38-year-old patient who presented with a scalp nodule that was diagnosed as a high-grade malignant proliferating trichilemmal tumor. J Drugs Dermatol. 2018;17(12):1325-1327.

Faster Improvement in Migraine Pain Intensity and Migraine-Related Disability at Early Time Points with AVP-825 (Sumatriptan Nasal Powder Delivery System) versus Oral Sumatriptan: A Comparative Randomized Clinical Trial Across Multiple Attacks from the COMPASS Study.

BACKGROUND: Fast relief of migraine pain, associated symptoms, and migraine-related disability are priorities in the acute treatment of migraine. Efforts to improve the pharmacokinetic profiles of acute migraine treatments with the aim of providing faster relief include the development of non-oral routes of administration. AVP-825 (ONZETRA® Xsail® ) is a delivery system containing 22 mg sumatriptan powder that uses a patient's own breath to deliver medication intranasally, targeting the upper posterior nasal cavity beyond the narrow nasal valve, an area lined with vascular mucosa conducive to rapid drug absorption into the systemic circulation. While most studies comparing treatments measure differences in proportions of patients achieving a dichotomous endpoint at fixed time intervals, in this study we compare trajectories of migraine pain and disability over time for AVP-825 versus 100 mg oral sumatriptan tablets. METHODS: We used data from the COMPASS study (NCT01667679, clinicaltrials.gov), a double-blind, double-dummy, active-comparator, cross-over study of people with a diagnosis of migraine. Participants treated up to five qualifying migraine attacks within 1 hour of onset with either AVP-825 plus placebo tablets or 100 mg oral sumatriptan tablets plus placebo delivery system during the first of two 12-week treatment periods, and then switched treatment sequences to treat up to five more attacks in the second treatment period. Patients recorded ordinal migraine pain intensity and migraine-related disability before dosing (predose), and at 10, 15, 30, 45, 60, 90 and 120 minutes. Three-level ordinal multilevel models accounted for unique data structure (repeated measures nested within attacks for each patient) and tested for treatment differences in migraine pain and migraine-related disability through the first 2 hours of attacks post dose. RESULTS: Among 259 study participants (mean age 40.0 years, 84.6% female, 78.4% white), there was significant between and within person variability in migraine pain intensity and migraine-related disability. A typical individual showed significantly faster reductions in migraine pain over the first 30 minutes and migraine-related disability over the first 45 minutes when treating with AVP-825 compared with oral sumatriptan. Overall levels of pain and disability also favored AVP-825 over 2 h following treatment. Model-based odds ratios (OR) comparing AVP-825 to oral sumatriptan ranged from 0.38 to 0.76 for pain and 0.37 to 0.65 for disability, with OR <1 indicating reduced pain/disability in the AVP-825 condition. CONCLUSIONS: Compared with 100 mg oral sumatriptan, treatment with AVP-825 was associated with faster reductions in migraine pain intensity and migraine-related disability starting at 10 minutes postdose and continuing through the first 30 minutes for migraine pain intensity and the first 45 minutes for migraine-related disability, resulting in lower overall pain intensity and disability that lasted through the first 2 h following treatment. Both migraine pain intensity and disability varied substantially both across subjects and within subjects across attacks.

Current psychotropic medication prescribing patterns in late-life bipolar disorder.

OBJECTIVE: Many patients with bipolar disorder are reaching old age, but whether they are receiving evidence-based psychotropic treatment remains unclear. Our objective was to describe current psychotropic prescribing patterns in a large Canadian late-life bipolar sample. METHODS: Population-based cross-sectional study of 1443 bipolar disorder patients aged ≥ 66, discharged from a psychiatric hospitalization in Ontario, Canada from 1 April 2006 to 31 March 2012. We described psychotropic medication prescribing within 30 days post-discharge. RESULTS: Prescription of ≥2 psychotropic medications was highly prevalent (81.5%). The most common medications were atypical antipsychotics (75.3%), benzodiazepines/zopiclone (42.3%), and antidepressants (38.5%), with less frequent use of valproate (35.4%) and lithium (23.4%). Only 1.4% of patients were on lithium monotherapy, while 4.4% and 15.7% of patients were on antidepressant or atypical antipsychotic monotherapy; 8.9% of all patients were using ≥2 atypical antipsychotics. CONCLUSIONS: In clinical practice, older adults hospitalized with bipolar disorder are often prescribed multiple psychotropic medications upon discharge. In many instances, practices did not reflect bipolar treatment guidelines and may be putting patients at risk for poor physical health and psychiatric outcomes. One such example is the very infrequent use of lithium monotherapy. Future research should examine whether health system-wide protocolized late-life bipolar treatment may optimize prescribing to improve effectiveness and safety. Copyright © 2016 John Wiley & Sons, Ltd.

Differentiating regressed melanoma from regressed lichenoid keratosis.

BACKGROUND: Distinguishing regressed lichen planus-like keratosis (LPLK) from regressed melanoma can be difficult on histopathologic examination, potentially resulting in mismanagement of patients. OBJECTIVE: We aimed to identify histopathologic features by which regressed melanoma can be differentiated from regressed LPLK. METHODS: Twenty actively inflamed LPLK, 12 LPLK with regression and 15 melanomas with regression were compared and evaluated by hematoxylin and eosin staining as well as Melan-A, microphthalmia transcription factor (MiTF) and cytokeratin (AE1/AE3) immunostaining. RESULTS: (1) A total of 40% of regressed melanomas showed complete or near complete loss of melanocytes within the epidermis with Melan-A and MiTF immunostaining, while 8% of regressed LPLK exhibited this finding. (2) Necrotic keratinocytes were seen in the epidermis in 33% regressed melanomas as opposed to all of the regressed LPLK. (3) A dense infiltrate of melanophages in the papillary dermis was seen in 40% of regressed melanomas, a feature not seen in regressed LPLK. CONCLUSIONS: In summary, our findings suggest that a complete or near complete loss of melanocytes within the epidermis strongly favors a regressed melanoma over a regressed LPLK. In addition, necrotic epidermal keratinocytes and the presence of a dense band-like distribution of dermal melanophages can be helpful in differentiating these lesions.

Getting clocked: screening for TBI-related cognitive impairment with the clock drawing test.

PRIMARY OBJECTIVE: Undetected cognitive impairment resulting from Traumatic Brain Injuries (TBIs), particularly the 75-95% classified as mild (mTBI), poses a significant public health challenge as untreated symptoms, can persist and cause lasting disability. These cognitive deficits are often missed by standard screening tests, creating a need for alternative cognitive screening tools. The Clock Drawing Test (CDT), a popular, brief cognitive screening instrument, was used to evaluate cognition in persons with TBI. DESIGN: The effectiveness of the CDT was assessed on its own and in tandem with a validated computerised screening battery, including the Stroop Test, Symbol Digit Modalities Test (SDMT), and Paced Visual Serial Addition Test 2-second trials (PVSAT-2). METHODS AND PROCEDURES: The clock drawing component of the Montreal Cognitive Assessment (MoCA) of 223 subjects attending an outpatient TBI clinic was scored using two different methods. MAIN OUTCOMES AND RESULTS: The CDT screened for cognitive impairment most effectively when scored using the Clock Drawing Interpretation Scale (CDIS). Cognitive impairment was detected in 19.4% of the elusive cohort of persons with mTBI. CONCLUSIONS: The results of this study suggest that the CDT is effective at screening for cognitive impairment in persons with TBI. The CDT could be a valuable supplementary tool in TBI clinics as well as an effective cognitive screening instrument in busy primary care settings.

Clinical and Pathological Evaluation of Mycobacterium marinum Group Skin Infections Associated With Fish Markets in New York City.

BACKGROUND: From December 2013 through May 2014, physicians, dermatopathologists, and public health authorities collaborated to characterize an outbreak of Mycobacterium marinum and other nontuberculous mycobacterial skin and soft tissue infections (SSTIs) associated with handling fish in New York City's Chinatown. Clinicopathologic and laboratory investigations were performed on a series of patients. METHODS: Medical records were reviewed for 29 patients. Culture results were available for 27 patients and 24 biopsy specimens were evaluated by histopathology, immunohistochemistry (IHC) staining for acid-fast bacilli (AFB), and mycobacterial polymerase chain reaction (PCR) assays. RESULTS: All patients received antibiotics. The most commonly prescribed antibiotic regimen was clarithromycin and ethambutol. Of the 29 patients in this case series, 16 (55%) received surgical treatment involving incision and drainage, mass excision, and synovectomy. Of these, 7 (44%) had deep tissue involvement. All patients showed improvement. For those with culture results, 11 of 27 (41%) were positive for M. marinum; the remainder showed no growth. Poorly formed granulomas (96%), neutrophils (75%), and necrosis (79%) were found in 24 biopsies. Of 15 cases that were culture-negative and analyzed by other methods, 9 were PCR positive for M. marinum group species, 8 were IHC positive, and 3 were positive by AFB stains. CONCLUSIONS: A multidisciplinary approach was used to identify cases in an outbreak of M. marinum infections. The use of histopathology, culture, and IHC plus PCR from full thickness skin biopsy can lead to improved diagnosis of M. marinum SSTIs compared to relying solely on mycobacterial culture, the current gold standard.