Neuroleptic malignant syndrome can occur in patients given atypical antipsychotics and resembles "classical" neuroleptic malignant syndrome. However, side effect profiles overlap considerably with neuroleptic malignant syndrome criteria, and atypical antipsychotics may cause neurotoxicities unrelated to (but misattributed as) neuroleptic malignant syndrome. Insufficient evidence exists for "atypical" neuroleptic malignant syndrome with novel antipsychotics.

BackgroundRising rates of infectious diseases in international migrants has reignited the debate around screening. There have been calls to strengthen primary-care-based programmes, focusing on latent TB. We did a cross-sectional study of new migrants to test an innovative one-stop blood test approach to detect multiple infections at one appointment (HIV, latent tuberculosis, and hepatitis B/C) on registration with a General Practitioner (GP) in primary care.MethodsThe study was done across two GP practices attached to hospital Accident and Emergency Departments (A&E) in a high migrant area of London for 6 months. Inclusion criteria were foreign-born individuals from a high TB prevalence country (>40 cases per 100,000) who have lived in the UK ≤ 10 years, and were over 18 years of age. All new migrants who attended a New Patient Health Check were screened for eligibility and offered the blood test. We followed routine care pathways for follow-up.ResultsThere were 1235 new registrations in 6 months. 453 attended their New Patient Health Check, of which 47 (10.4%) were identified as new migrants (age 32.11 years [range 18–72]; 22 different nationalities; time in UK 2.28 years [0–10]). 36 (76.6%) participated in the study. The intervention only increased the prevalence of diagnosed latent TB (18.18% [95% CI 6.98-35.46]; 181.8 cases per 1000). Ultimately 0 (0%) of 6 patients with latent TB went on to complete treatment (3 did not attend referral). No cases of HIV or hepatitis B/C were found. Foreign-born patients were under-represented at these practices in relation to 2011 Census data (Chi-square test −0.111 [95% CI −0.125 to −0.097]; p < 0.001).ConclusionThe one-stop approach was feasible in this context and acceptability was high. However, the number of presenting migrants was surprisingly low, reflecting the barriers to care that this group face on arrival, and none ultimately received treatment. The ongoing UK debate around immigration checks and charging in primary care for new migrants can only have negative implications for the promotion of screening in this group. Until GP registration is more actively promoted in new migrants, a better place to test this one-stop approach could be in A&E departments where migrants may present in larger numbers.Electronic supplementary materialThe online version of this article (doi:10.1186/s12879-014-0657-2) contains supplementary material, which is available to authorized users.

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Clarithromycin-Induced ManiaTO THE EDITOR: This letter presents a case of clarithromycin-induced mania.Ms. A, a 52-year-old woman with a history of three depressive episodes, was admitted for hyperenergetic, loud, and unfocused behavior. She was also elated and delusional. Two days earlier, she had been prescribed a regimen of clarithromycin, 500 mg b.i.d., and prednisone, 60 mg q.i.d., followed by a taper, for severe sinusitis. Results of a neurologic examination were within normal limits; laboratory data were also within normal range. The results of a drug-of-abuse screen were negative; Ms. A's blood alcohol concentration was zero. Her clarithromycin was discontinued; the prednisone taper continued. Within 1 week, Ms. A responded to haloperidol and lithium treatment. She was tentatively diagnosed as having steroid-induced psychosis. Lithium was discontinued after 4 months because of the appearance of hypothyroidism, probably induced by lithium. Two years later, again 2 days after starting treatment with clarithromycin for an acute episode of sinusitis, Ms. A became agitated and acutely delusional. She believed she was "Jesus Christ," a singer and a superstar. She would scream intermittently. She had an expansive mood, flight of ideas, an intense affect, and looseness of associations, but no hallucinations. Her physical examination and laboratory results were unremarkable. Clarithromycin was discontinued, and Ms. A was started on a regimen of haloperidol and lithium. An unequivocal improvement was noted the next day with mildly pressured speech and an expansive mood, but a denial of delusions. Ms. A was discharged 6 days after her admission. Ms. A had two similar episodes with clear evidence of mania and psychosis. During the first episode, she was taking both clarithromycin and prednisone; the mania and psychosis were thought to be due to the prednisone. Before the second episode, Ms. A was taking clarithromycin alone. We think that Ms. A's case represents clarithromycin-induced mania. Her dose of clarithromycin in both episodes was 500 mg b.i.d. as opposed to the relatively high doses (1000 mg b.i.d.) described in the treatment of disseminated Mycobacterium avium-complex infections in two AIDS patients who developed manic episodes (1), similar to the results reported by Cone et al. (2). Clarithromycin has excellent CSF penetration (3), but no reports of possible interaction with central neurotransmitters were found in the literature, although such interaction is a plausible assumption. There have been several reports of CNS side effects of clarithromycin: dizziness, lightheadedness, confusion, and insomnia (4), as well as visual hallucinations (5). 2. Cone LA, Sneider RA, Nazemi R, Dietrich EJ: Mania due to clarithromycin therapy in a patient who was not infected with human immunodeficiency virus. Clin Infec Dis 1996; 22:595-596 3. Schmidt T, Froula J, Tauber MG: Clarithromycin lacks bactericidal activity in cerebrospinal fluid in experimental meningitis. J Antimicrob Chemother 1993; 32:627-632 4. Wallace RJ, ...

Mental distress in medical learners and its consequent harmful effects on personal and professional functioning, a well-documented concern, draws attention to the need for solutions. The authors review the development of a comprehensive mental health service within a large and complex academic medical education system, created with special attention to offering equitable, accessible, and responsive care to all trainees. From the inception of the service in January 2017, the authors placed particular emphasis on eliminating obstacles to learners’ willingness and ability to access care, including concerns related to cost, session limits, privacy, and flexibility with modality of service delivery. Development of outreach initiatives included psychoeducational programming, consultation services, and cultivation of liaison relationships with faculty and staff. Significant utilization of clinical services occurred in the first year of the program and increased further over the course of 4 academic years (2017–2021); with a 2.2 times increase in trainees served and a 2.4 times increase in visits annually. In the 2020–2021 academic year, 821 medical learners received services (for a total 5,656 visits); 30% of all medical students and 25% of house staff and fellows sought treatment in that year. In 2021, 38% of graduating medical school students and 27% of graduating residents and fellows had used mental health services at some point in their training. Extensive use of services combined with very high patient satisfaction ratings by medical learners within this system demonstrate the perceived value of these services and willingness to pursue mental health care when offered a resource that is cognizant of, and responsive to, their unique needs. The authors reflect on potential factors promoting utilization of services—institutional financial support, outreach efforts, and design of services to increase accessibility and reduce barriers to seeking treatment—and propose future areas for investigation.