Personality Disorder Diagnosis Among Justice-Involved Veterans: An Investigation of VA Using Veterans.

ABSTRACT: Justice-involved veterans are more likely to experience myriad mental health sequelae. Nonetheless, examination of personality psychopathology among justice-involved veterans remains limited, with studies focused on males within correctional settings. We examined Department of Veterans Affairs (VA) electronic medical records for 1,534,108 (12.28% justice-involved) male and 127,230 (8.79% justice-involved) female veterans. Male and female veterans accessing VA justice-related services were both approximately three times more likely to have a personality disorder diagnosis relative to those with no history of using justice-related services. This effect persisted after accounting for VA use (both overall and mental health), age, race, and ethnicity. Augmenting and tailoring VA justice-related services to facilitate access to evidence-based psychotherapy for personality psychopathology may promote optimal recovery and rehabilitation among these veterans.

Racial, ethnic, and sex differences in psychiatric diagnosis, mental health sequelae, and VHA service utilization among justice-involved veterans.

OBJECTIVE: Intervening in the cycle of symptom exacerbation and recidivism among justice-involved veterans is critical given elevated rates of psychiatric diagnoses and mental health sequelae. To responsively and effectively address justice-involved veterans' needs, it is essential to examine distinct groups who are at heightened risk (e.g., marginalized communities). Although racial and ethnic disparities within the justice system are well established, veteran-focused research remains limited. HYPOTHESES: We hypothesized that significant differences exist in service utilization, psychiatric diagnoses, and mental health sequelae among Black, Indigenous, and people of color (BIPOC) and White/non-Hispanic justice-involved veterans, for both male and female cohorts. METHOD: We examined a national data set of veterans accessing U.S. Department of Veterans Affairs (VA) justice-related services (i.e., justice-involved veterans) between 2005 and 2018 (N = 183,880; nBIPOC = 73,863, nWhite = 110,017) to elucidate racial and ethnic differences across clinical characteristics documented in the VA electronic medical record. Using linear and logistic analyses, we analyzed male (n = 173,487) and female (n = 10,393) justice-involved veterans separately to capture intersectionality. RESULTS: In general, BIPOC justice-involved veterans were more likely than White/non-Hispanic justice-involved veterans to be diagnosed with schizophrenia and other psychotic disorders and to use homeless services, p < .001. They were less likely to be diagnosed with mood, anxiety, personality, and opioid use disorders, p < .01. Separate examinations of Black and Hispanic justice-involved veterans, compared with their White/non-Hispanic counterparts, demonstrated some divergent trends (e.g., frequency of use of Veterans Health Administration [VHA] services). Our findings also revealed nuanced sex-related differences in terms of service use and diagnoses. Descriptive characteristics for each racial and ethnic category are reported. CONCLUSION: These findings provide support for race and ethnicity as a key social factor of health associated with distinct psychiatric diagnoses and mental health sequelae among justice-involved veterans. We discuss practice and policy implications, including how to adapt existing VHA programming and practices to meet the needs of BIPOC justice-involved veterans. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Trauma-Informed Training for Veterans Treatment Court Professionals: Program Development and Initial Feedback.

Background: Justice-involved veterans demonstrate greater mental health and psychosocial needs relative to justice-involved nonveterans and veterans without a criminal history. Veterans treatment courts (VTCs) serve as an alternative to incarceration for veterans whose criminogenic risk is believed to be related to mental health symptoms. Despite observed improvements in functioning and recidivism risk following successful VTC completion, little is known about factors that impede engagement with VTCs. This paper describes a trauma-informed training program that included psychoeducation, skills training, and consultation and was developed for court professionals to facilitate veteran engagement in VTCs. Observations: Needs assessments and court observations informed program development. Based on identified needs, the training incorporated skills from dialectical behavior therapy, acceptance and commitment therapy, and motivational interviewing. Two VTCs in the Rocky Mountain region participated in the pilot trauma-informed training, each lasting about 90 to 120 minutes. Feedback from attendees indicated that the focus on skills training-specifically, managing intense emotions, addressing ambivalence, and approaching sanctions and rewards-was uniquely helpful. The function of posttraumatic stress disorder symptoms and structure of evidence-based treatments were identified as useful educational components. Conclusions: Veterans Health Administration mental health professionals can serve an important role in facilitating effective practices for professionals working within VTCs. This pilot program provided preliminary support for skills-based training to bolster communication, motivation, distress tolerance, and engagement among veterans court participants. Future directions of this program may include expanding the training into a full-day workshop, conducting comprehensive needs assessments, and examining program outcomes.

Policy Changes as a Context for Moral Injury Development in the Wake of Dobbs v Jackson Women's Health Organization.

The U.S. Supreme Court's 2022 ruling in Dobbs v Jackson Women's Health Organization held that the U.S. Constitution does not confer the right to an abortion, which set into motion an overhaul of reproductive health care services in certain states. Health care professionals are now operating within a rapidly changing landscape of clinical practice in which they may experience conflict between personal and professional morals (eg, bodily autonomy, patient advocacy), uncertainty regarding allowable practices, and fear of prosecution (eg, loss of medical license) related to reproductive health care services. The ethical dilemmas stemming from Dobbs create a context for exposure to potentially morally injurious events, moral distress, and moral injury (ie, functional impairment stemming from exposure to moral violations) among health care professionals. Considerations related to clinical intervention and approaches to policy are reviewed. Early identification of health care professionals' potentially morally injurious event exposure related to restricted reproductive services is critical for preventing and intervening on moral injury, with implications for improving functioning and retention within the medical field.

Appraising Jackson-based unrestorability to competence to stand trial: The demonstration model.

Under United States law, criminal prosecution may not proceed against a defendant who is incompetent to participate in this process. The vast majority of defendants who are adjudicated incompetent to stand trial (IST) will subsequently regain sufficient capacities to be adjudicated competent to stand trial (CST). However, a small subgroup of defendants do not show sufficient improvement in clinical functioning and functional-legal capacities to regain CST. Under Jackson v. Indiana (1972), such individuals should be adjudicated unrestorably IST, with associated actions (e.g., dropping of criminal charges, civil commitment, transfer to a less restrictive environment or released) specified under the particular jurisdictional statutes. But the present practices associated with the evaluation of unrestorability do not appear well supported by research. In particular, statutorily specified evaluative procedures are overly dependent on prediction in some instances and allow an unnecessarily long restoration period in others. In the present article, we propose and describe an alternative approach-the Demonstration Model-that would address both challenges, providing a more consistent and standard approach to assessing CST and the possibility that a defendant may not recover needed capacities within the foreseeable future. Implementation of this approach can potentially guide restoration planning and intervention, decrease unsupported reliance upon prediction in favor of observing and documenting the results of selected interventions, and provide legal decision-makers with clearer and more transparent evidence, while acknowledging the liberty interests of IST defendants set forth in Jackson. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Military sexual trauma among Veterans using and not using VA justice-related programing: A national examination.

Veterans accessing Department of Veterans Affairs (VA) Veterans Justice Program (VJP) services have high rates of depression, substance misuse, and posttraumatic stress disorder. Although factors that may confer risk for mental health sequelae among these Veterans have been identified (e.g., childhood abuse, combat exposure), limited research has examined report of military sexual trauma (MST) among Veterans accessing VJP services. As survivors of MST experience myriad chronic health conditions which necessitate identification and referral to evidence-based care, identifying MST survivors among those accessing VJP services may facilitate referral to appropriate services. We examined whether MST prevalence differed between Veterans with and without a history of VJP service use. Sex-stratified analyses were conducted with 1,300,252 male (13.34% accessing VJP) and 106,680 female (10.14% accessing VJP) Veterans. In crude models, male and female Veterans accessing VJP services were significantly more likely to screen positive for MST (PR = 3.35 and 1.82 respectively). Significance was maintained in models that adjusted for age, race/ethnicity, VA service use, and VA mental health use. VJP service settings may serve as a critical intercept for identifying male and female survivors of MST. Using a trauma-informed approach to screen for MST in VJP settings is likely warranted. Moreover, integration of MST programing into VJP settings may be beneficial.

The Current Landscape for METex14 Skipping Mutations in Non-Small Cell Lung Cancer.

Capmatinib and tepotinib received US Food and Drug Administration (FDA) approval for mesenchymal-epithelial transition (MET) exon 14 (METex14) skipping alteration in 2020 and 2021, respectively. Capmatinib was FDA approved in May 2020 under accelerated approval for the treatment of patients with metastatic non-small cell lung cancer (NSCLC) whose tumors have a mutation that leads to METex14 skipping. Accelerated approval was based on overall response rate and response duration to capmatinib, and it was granted orphan drug and breakthrough therapy designation. Capmatinib is a potent selective kinase inhibitor of the MET receptor, crosses the blood-brain barrier, and has shown low-grade adverse events. Based on phase II data, capmatinib demonstrated an overall response rate (ORR) of 41% and a median duration of response (DOR) of 9.7 months in those who previously received one or two lines of therapy. In treatment-naive patients, capmatinib demonstrated a 68% ORR with a median DOR of 12.6 months. The FDA also granted accelerated approval to tepotinib for adult patients with metastatic NSCLC harboring METex14 skipping alteration. Accelerated approval for tepotinib was based on an ORR of 43% with a median DOR of 10.8 months in treatment-naive patients. Among previously treated patients, the ORR was 43% with a median DOR of 11.1 months. Continued approval for capmatinib and tepotinib is contingent upon confirmatory trials. Both agents are now considered first-line therapy or a subsequent therapy option in patients with metastatic NSCLC who are positive for METex14 skipping alterations.

Understanding the Intersection of Homelessness and Justice Involvement: Enhancing Veteran Suicide Prevention Through VA Programming.

BACKGROUND: Veterans with a history of homelessness and justice involvement are at greater risk for mental health sequelae, including suicide. OBSERVATIONS: A bidirectional relationship exists between criminal justice involvement and housing instability (ie, the institutional circuit). Homelessness and justice involvement often represent a vicious cycle that is difficult to escape. The US Department of Veterans Affairs (VA) has a number of programs focused on connecting homeless and justice-involved veterans to health and social services. This paper reviews existing programing and initiatives within such services to detect risk for suicide and connect these veterans to appropriate evidence-based mental health care. CONCLUSIONS: The VA currently has several programs focused on enhancing care for homeless and justice-involved veterans, many of which currently incorporate suicide prevention initiatives. Understanding of factors that may impact health service delivery of suicide risk assessment and intervention may be beneficial in order to enhance veteran suicide prevention efforts.

Forensic Mental Health Assessment as a Critical Intercept for Enhancing Mental Health Care.

Rates of psychiatric diagnosis, medical morbidity, and suicide risk are notably high among incarcerated individuals. However, engaging these individuals in community-based health care settings can be a challenge. Among justice-involved individuals who do access services, community-based health care settings may lack available resources to effectively conduct comprehensive assessments that inform evidence-based conceptualization. We propose forensic mental health assessment (FMHA) as a critical opportunity to enhance service delivery for this at-risk population. In particular, within the scope of their role, forensic mental health evaluators are able to conduct a comprehensive review of records across health (eg, inpatient and outpatient health care settings), social (eg, homeless shelter), and correctional (eg, jail or prison) settings. Moreover, FMHA often includes specialized batteries that are able to assess and differentially diagnose myriad clinical presentations that may have overlapping symptomatology. We present 2 case vignettes to illustrate the utility of FMHA for enhancing service delivery. Finally, we conclude by noting challenges to integrating FMHA into conceptualization and necessary next steps in research and programing.

The Role of Social Determinants of Health in Moral Injury: Implications and Future Directions.

Purpose of Review: Exposure to potentially morally injurious events (PMIEs) and the development of moral injury have yet to be conceptualized as they relate to social determinants of health (SDoH).Recent Findings.In this paper, the extant literature on moral injury and SDoH is reviewed. Specific individual-level SDoH, including gender, sex, sexual orientation, race, and ethnicity, are explored relative to PMIEs and moral injury. The relationship among environmental SDoH, including childhood environment, justice involvement, and homelessness, is described. Summary: Assessment and treatment implications are discussed, and future research directions highlighting the need for additional work addressing health inequities in moral injury are presented.

Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes.

Background: The overlap between justice system involvement and drug use is well-documented. Justice-involved people who misuse opioids are at high risk for relapse and criminal recidivism. Criminal justice policymakers consider opioid-specific medication-assisted therapies (MATs) one approach for improving outcomes for this population. More research is needed that explores the impacts of opioid-specific MATs for justice-involved people. Objectives: This study sought to assess the effects of opioid-specific MAT for reducing the frequency and likelihood of criminal justice and overdose outcomes for current or formerly justice-involved individuals. Search Methods: Records were searched between May 7, 2021 and June 23, 2021. We searched a total of sixteen proprietary and open access databases that included access to gray literature and conference proceedings. The bibliographies of included studies and relevant reviews were also searched. Selection Criteria: Studies were eligible for inclusion in the review if they: (a) assessed the effects of opioid-specific MATs on individual-level criminal justice or overdose outcomes; included (b) a current or formerly justice-involved sample; and (c) a randomized or strong quasi-experimental design; and c) were published in English between January 1, 1960 and October 31, 2020. Data Collection and Analysis: We used the standard methodological procedures as expected by The Campbell Collaboration. Main Results: Twenty studies were included, representing 30,119 participants. The overall risk of bias for the experimental studies ranged from "some" to "high" and for quasi-experimental studies ranged from "moderate" to "serious." As such, findings must be interpreted against the backdrop of less-than-ideal methodological contexts. Of the 20 included studies, 16 included outcomes that were meta-analyzed using mean log odds ratios (which were reported as mean odds ratios). Mean effects were nonsignificant for reincarceration (odds ratio [OR] = 0.93 [0.68, 1.26], SE = .16), rearrest (OR = 1.47 [0.70, 3.07], SE = 0.38), and fatal overdose (OR = 0.82 [0.56, 1.21], SE = 0.20). For nonfatal overdose, the average effect was significant (OR = 0.41 [0.18, 0.91], SE = 0.41, p < 0.05), suggesting that those receiving MAT had nearly 60% reduced odds of a nonfatal overdose. Implications for Policy Practice and Research: The current review supports some utility for adopting MAT for the treatment of justice-involved people with opioid addiction, however, more studies that employ rigorous methodologies are needed. Researchers should work with agencies to improve adherence to medication regimens, study design, and collect more detailed information on participants, their criminal and substance use histories, onset, and severity. This would help clarify whether treatment and control groups are indeed comparable and provide better insight into the potential reasons for participant dropout, treatment failure, and the occurrence of recidivism or overdose. Outcomes should be assessed in multiple ways, if possible (e.g., self-report and official record), as reliance on official data alone may undercount participants' degree of criminal involvement.

Patients' perspectives on initiating treatment with extended-release naltrexone (XR-NTX).

BACKGROUND: The National Drug Abuse Treatment Clinical Trials Network (CTN) multisite comparative-effectiveness study ("X:BOT") by Lee et al. (2018) found that, once initiated, extended-release naltrexone (XR-NTX) is as similarly safe and effective as sublingual buprenorphine-naloxone (BUP-NX) for the treatment of opioid use disorder (OUD). However, the detoxification hurdle makes XR-NTX much more difficult to initiate than BUP-NX. This hurdle highlights the need to better understand how patients transition from active opioid use to XR-NTX treatment. OBJECTIVE: To explore patient-identified barriers and facilitators to initiating antagonist treatment (XR-NTX) within the context of an inpatient hospital setting and to reflect postdischarge experiences of those who did and did not initiate XR-NTX treatment. METHOD: We used a convenience sampling strategy to identify study candidates, with the intention of recruiting approximately an equal number of medication-initiated and noninitiated patients. Study participants (N = 14) included 13 males and 1 female with OUD randomized to the XR-NTX arm of the X:BOT study at 1 of the 8 study sites. Seven participants in this sample initiated XR-NTX treatment, and seven did not. Each participant completed one semistructured qualitative interview. We analyzed transcripts using deductive and inductive approaches to conventional content analysis. RESULTS: Although the majority of participants viewed opioid blockade, once-monthly dosing, and no dependence or withdrawal as favorable attributes of XR-NTX, participant ambivalence and lack of familiarity with antagonist treatment were barriers to treatment initiation. The long duration of action and the perceived "commitment" to the medication (e.g., "At the time, a month sounded like a year") compounded the patients' concerns and ambivalence. The majority of those who initiated XR-NTX described it as an effective treatment for OUD, with treatment satisfaction and sustained abstinence emerging as central themes among this population. Some participants who did not successfully initiate XR-NTX expressed regret and a willingness to try XR-NTX in the future. CONCLUSION: Achieving full opioid detoxification is one, but not the only, barrier to initiating treatment with XR-NTX. Additional participant-identified barriers to XR-NTX initiation include fears and ambivalence regarding antagonist treatment. Once initiated, participants perceive XR-NTX to be an effective treatment for maintaining abstinence from opioids. XR-NTX appealed to participants due to the autonomy it affords with once-monthly dosing and no physical dependence.

PROTOCOL: Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes.

Background: The overlap between criminal justice system involvement and drug use is well-documented, and criminal justice agencies have been particularly overwhelmed by the recent opioid epidemic. Treating opioid (and other substance) addiction as a means to reduce risk for future criminality and improve public safety is inherently a responsibility for the criminal justice system. In turn, the criminal justice system has a responsibility to manage and treat addiction among the individuals under its purview.  Policy recommendations place emphasis on the use of medication-assisted treatments (MAT) as a front-line defense among correctional populations, because its efficacy and effectiveness has been well-established in other contexts.  Despite this, criminal justice agencies have been reluctant or slow to do so. Objectives: The current review will provide criminal justice and substance use treatment decision-makers with information regarding the efficacy and effectiveness of opioid-specific MAT on offending and overdose outcomes. Specifically, the authors will address the following research questions: Do opioid-specific MATs reduce the frequency or likelihood of criminal justice outcomes, as defined by official or self-reported indices of criminal reconviction or rearrest, revocation of community supervision, mandated treatment failure, and specialized court docket failure? Do opioid-specific MATs reduce the frequency of opioid overdose among individuals with current or prior self-reported or official record of criminal justice system involvement? Inclusion Criteria: Studies were required to use strong quasi-experimental or randomized experimental designs. All studies used individual level unit of analysis and examined adults and adolescents who are male, female, or nonbinary and racially/ethnically diverse, with current opioid use and who have current or prior criminal justice involvement. Studies had to prospectively test the effects of heroin and methadone maintenance, buprenorphine, or naltrexone on criminal conviction, arrest, revocation of community supervision, technical probation or parole violation, mandated treatment failure, and specialized court docket failure. Overdose outcomes were also examined for samples in criminal justice settings such as jails, prisons, probation, and parole. Search Strategy and Data Collection: This review builds upon a prior review conducted by Egli et al. (2009) and examined studies meeting the inclusion criteria above published between 1960 and October 31, 2020. The following platforms and databases (in parentheticals) were used: EBSCOhost (Criminal Justice Abstracts, SocINDEX with Full Text, Legal Collection, Wilson Omnifile, PsycINFO, Social Work Abstracts, and Women's Studies International [includes grey literature]); ProQuest (Criminal Justice Database, PAIS [includes grey literature], Dissertations and Theses Global [includes grey literature]); Gale (Expanded Academic ASAP, Opposing Viewpoints Resource Center); FirstSearch (GPO Monthly Catalog, PapersFirst [includes grey literature]); ISI Web of Knowledge (Web of Science Core Collection); Office of Justice Programs (National Criminal Justice Reference Service); Summon; and Nexis Uni. The following open access platforms and databases will also be consulted: Elsevier (Scopus [includes grey literature]); Science.gov; ClinicalTrials.gov; WHO International Clinical Trials Registry Platform (ICTRP) portal; and Google Scholar. Search terms were harvested according to their demonstrated success in drawing out relevant and complete results for studies regarding the effectiveness of opioid-specific medication-assisted therapies (MATs). From this process 5 core search strings were created, each one with the same general base terms, but unique outcome measure(s). Analysis: For binary offending outcomes (e.g., arrest, conviction, incarceration, specialty court failure, mandated treatment failure, or community supervision failure) and overdose outcomes, odds ratios were computed, and for continuous or quasi-continuous outcomes (e.g., total number of arrests), a standardized mean difference type effect size was computed and then transformed into an odds ratio. We used the χ 2 test that goes with the forest plot and computed the I 2 statistic to assess heterogeneity. Risk of bias was assessed with (1) the revised Cochrane risk-of-bias tool for randomized trials; and (2) the risk of bias in non-randomized studies of interventions assessment tool.

Facilitating Successful Reentry Among Justice-involved Veterans: The Role of Veteran and Offender Identity.

Reentry courts facilitate successful offender reintegration into the community following release from incarceration, and many justice-involved veterans may benefit from such services given their elevated risk for deleterious outcomes postrelease. However, effectively engaging court participants is a crucial foundation to achieve the goals of recidivism reduction and global psychosocial improvement. This conceptual article presents an overview of factors that may interfere with a veteran's engagement in reentry court through the lens of both veteran and offender identity. Recommendations for reentry court personnel based on justice-involved veterans' experiences, identity, and unique needs are presented. Careful consideration of these factors and associated practice adaptations may facilitate rapport between reentry court personnel and veteran participants, foster engagement, and ultimately improve outcomes among this unique, at-risk population.

Association of lifetime homelessness and justice involvement with psychiatric symptoms, suicidal ideation, and suicide attempt among post-9/11 veterans.

Both homelessness and criminal justice involvement can impact mental health symptoms and increase risk for suicide. Despite this, few studies have examined their cumulative impact. Moreover, no studies to date have examined the impact of these social determinants of health on post-9/11 veterans, a population with high rates of housing insecurity and justice involvement. The current study sought to better understand the adverse impacts of homelessness and justice involvement on mental health symptoms and suicide risk among post-9/11 veterans. We carried this out by conducting a secondary analysis of cross-sectional data from a 2018 national survey of men and women post-9/11 veteran users and non-users of Veterans Health Administration (VHA) services (N = 15,067). Gender-stratified Poisson and multivariate regressions examined mental health symptoms and suicide risk based on history of homelessness and justice involvement. Models adjusted for sociodemographics, military-related variables, and trauma exposure. Homelessness and justice involvement were both independently associated with more severe posttraumatic, depressive, and substance use symptoms as well as increased rates of suicidal ideation and attempt relative to those with no history of homelessness or justice involvement. Veterans with a history of both homelessness and justice involvement reported the most severe mental health symptoms and suicide risk. This study found consistent positive associations with mental health symptoms for homelessness and justice-involved veterans. Enhancing and increasing access to services that address complex mental health presentation among those with histories of justice involvement and housing instability remain necessary.

Serial Swept-Source Optical Coherence Tomography Features of Gentamicin Macular Toxicity: A Glimpse Into the Injury Cascade.

The early clinical manifestations of macular infarction secondary to subconjunctival gentamicin (Gentak; Akorn, Lake Forest, IL) use in an aphakic eye were documented sequentially on swept-source optical coherence tomography (OCT) and fundus fluorescein angiography. The first recorded event after drug toxicity was macular detachment, along with disorganization of outer retinal layers in about 12 hours. The changes in inner retinal layers occurred after 36 hours had elapsed. OCT-documented initial damage to outer retinal layers could be due to the susceptibility of first order retinal neurons, followed by subsequent inner retinal layer involvement and ischemia. This helps in understanding pathogenesis of a catastrophic complication of subconjunctival gentamicin injection commonly used for endophthalmitis prophylaxis. [Ophthalmic Surg Lasers Imaging Retina. 2018;49:456-459.].

Ultrasensitive Quantification of Cytokine Proteins in Single Lymphocytes From Human Blood Following ex-vivo Stimulation.

In this study we demonstrate the feasibility of direct, quantitative measurement of cytokine proteins in single human CD8 lymphocytes from fresh peripheral blood of healthy donors following a brief ex vivo stimulation. Cytokine-secreting cells were identified using cell surface "catch" reagents and single cell data were obtained by sorting of individual cytokine-secreting cells into 96 well plates containing lysis buffer followed by analysis using ultrasensitive immunoassays for interferon gamma (IFN-γ) and tumor necrosis factor alpha (TNF-α). CD8 cells negative for cytokine production, as determined by the cell surface catch reagents were used as negative controls. Furthermore, studies were undertaken to compare the mean fluorescence intensity (MFI) values of cytokine staining by flow cytometry with the quantification of cytokines using the current method. This study demonstrates that it is feasible to quantify cytokines from individual primary cells. A shift from qualitative to quantitative determinations of cytokine protein levels in single cells will permit more precise and reproducible studies of heterogeneity in the immune system and can be accomplished with readily available instrumentation.

Pythium Insidiosum Keratitis: Histopathology and Rapid Novel Diagnostic Staining Technique.

PURPOSE: To elucidate the histopathology of Pythium insidiosum keratitis and to describe a novel, simple, and rapid staining technique for identification of oomycete Pythium insidiosum and to differentiate it from fungi. METHODS: This is a laboratory investigation study of 38 nonconsecutive cases (37 ocular samples and 1 colonic biopsy); 14 microbiologically diagnosed as Pythium insidiosum keratitis and 24 as fungal keratitis. Review of clinical, demographic details, microbiological results, and identification of cases that necessitated evisceration was performed. Reevaluation of histopathology slides was done using stains such as hematoxylin-eosin, Gomori methenamine silver (GMS), periodic acid-Schiff (PAS), potassium iodide-sulfuric acid (IKI-H2SO4). Morphology, degree, and nature of inflammation and load, distribution, and staining results of Pythium insidiosum and its comparison with fungi were studied. RESULTS: Delay in zoospore formation, failure of growth, and delay in identification of Pythium were the main cause of evisceration. Corneal pythiosis showed epithelial ulceration, stromal destruction, and varying inflammation; load and distribution of Pythium were inversely proportional to inflammation. The filaments were commonly wide, with admixed narrower structures and uncommonly involved Descemet membrane. The oomycete was not discretely discerned with PAS stain and stained distinctly with GMS stain and IKI-H2SO4 stain (100% sensitive). In comparison, fungal organisms stained well with PAS and GMS stain, but not with IKI-H2SO4 stain (100% specific). CONCLUSIONS: Pythium insidiosum keratitis is perhaps not more devastating than fungal keratitis but late diagnosis, misdiagnosis, and treatment as fungal infection are major heralds. Early diagnosis may markedly improve the patient outcome. IKI-H2SO4 is a cost-effective, simple, sensitive, and specific stain for the diagnosis of oomycete Pythium.