Differentiation between monomorphic ventricular tachycardia and sinus tachycardia based on the right ventricular evoked potential

The differentiation between ventricular tachycardia (VT) and sinus tachycardia (ST) is problematic in some patients with implantable defibrillators and/or antitachycardia pacemakers. The integral of the ventricular endocardial evoked response, or paced depolarization integral (PDI), has been demonstrated to undergo characteristic changes with a variety of stimuli including catecholamines, pacing rate, and exercise. We hypothesized that the PDI recorded from a unipolar transvenous right ventricular endocardial catheter would differentiate VT from ST. The PDI was calculated from a unipolar pacing stimulus, delivered via a cathode in the right ventricular apex, and the reference electrode, a quadripolar catheter positioned in the superior vena cava. PDIs were measured in 22 patients during VT and sinus rhythm. The PDI measured during sinus rhythm was 579 +/- 240 microV-sec and the PDI during VT was 894 +/- 411 microV-sec (P < 0.001). In a subset of seven patients, PDIs were measured during VT, sinus rhythm, and ST induced by catecholamine infusion or exercise. In this subset, the PDI during sinus rhythm was 645 +/- 295 microV-sec, during ST 588 +/- 308 microV-sec (9% decrease from sinus, P = 0.05), and during VT 863 +/- 342 microV-sec (33.9% increase, P = 0.01). These data indicate that the measurement of the PDI is potentially useful in differentiating VT from ST.

Cloning of an Erwinia herbicola gene necessary for gluconic acid production and enhanced mineral phosphate solubilization in Escherichia coli HB101: nucleotide sequence and probable involvement in biosynthesis of the coenzyme pyrroloquinoline quinone

Escherichia coli is capable of synthesizing the apo-glucose dehydrogenase enzyme (GDH) but not the cofactor pyrroloquinoline quinone (PQQ), which is essential for formation of the holoenzyme. Therefore, in the absence of exogenous PQQ, E. coli does not produce gluconic acid. Evidence is presented to show that the expression of an Erwinia herbicola gene in E. coli HB101(pMCG898) resulted in the production of gluconic acid, which, in turn, implied PQQ biosynthesis. Transposon mutagenesis showed that the essential gene or locus was within a 1.8-kb region of a 4.5-kb insert of the plasmid pMCG898. This 1.8-kb region contained only one apparent open reading frame. In this paper, we present the nucleotide sequence of this open reading frame, a 1,134-bp DNA fragment coding for a protein with an M(r) of 42,160. The deduced sequence of this protein had a high degree of homology with that of gene III (M(r), 43,600) of a PQQ synthase gene complex from Acinetobacter calcoaceticus previously identified by Goosen et al. (J. Bacteriol. 171:447-455, 1989). In minicell analysis, pMCG898 encoded a protein with an M(r) of 41,000. These data indicate that E. coli HB101(pMCG898) produced the GDH-PQQ holoenzyme, which, in turn, catalyzed the oxidation of glucose to gluconic acid in the periplasmic space. As a result of the gluconic acid production, E. coli HB101(pMCG898) showed an enhanced mineral phosphate-solubilizing phenotype due to acid dissolution of the hydroxyapatite substrate.

Faking specific disorders: a study of the Structured Interview of Reported Symptoms (SIRS)

An untested assumption of malingering research is that persons who feign mental illness will not attempt to fake a particular disorder, but will be content to fabricate non-specific and possibly global psychiatric impairment. We tested the effectiveness of the Structured Interview of Reported Symptoms (SIRS) to detect feigning of three diagnostic groupings: schizophrenia, mood disorders, and PTSD on 45 psychologically knowledgeable correctional residents. We found that the SIRS maintained its powers of discrimination with respect to clinical samples. Similar research on faking specific disorders is needed on the MMPI-2 and other psychological measures.

Diversion of mentally disordered offenders: a legitimate role for clinicians?

Consultations to the courts often extend beyond criminal competencies and may include implicit statements regarding the diversion of mentally disordered offenders to treatment facilities. Arguments for diversion are based on humanitarian interests and treatment needs. Arguments opposing diversion recommendations emphasize (a) the variability of opinions regarding treatability, (b) the lack of sufficient outcome data, and (c) the potential for negative consequences in offering unsolicited opinions on diversion. Initial data from 271 pretrial evaluations underscore the range in psychiatric use of diversion recommendations, although inpatient referrals in particular appear to be based on clinical status.

The future of refugee flows and policies

"The number of forced migrants...is estimated today to exceed 40 million [worldwide]. The changed international climate of the 1990s...has shifted the focus from the asylum and resettlement countries to the countries of origin: there is today a greater willingness to intervene in other countries' affairs either to avert the creation of new flows of focused migrants or to assist internally displaced populations, and there is the expectation of large-scale voluntary returns of refugees in asylum. This article discusses these and other policy issues concerning forced migration in this new international environment."

Validity of the M Test: simulation-design and natural-group approaches

The utility of the M Test (Beaber, Marston, Michelli, & Mills, (1985) as a screening measure for malingering was assessed using simulation-design (subjects asked to fake mental illness) and natural-group (forensic assessment cases suspected of malingering) approaches. A total of 318 subjects from community, clinical, and correctional settings completed the M Test under instructions to respond honestly or to simulate a major mental disorder. A factor analysis of the M Test items supported the original rationally based scale assignment, and the scales were found to have adequate internal reliability. To examine the predictive validity of the M Test, results revealed that sensitivity using the cutting scores suggested by Beaber et al. (1985) was much higher for simulating subjects (79.8%) than for the suspected malingerers (40.0%). The findings emphasize the danger of exclusive reliance on simulation studies for validating measures of malingering. It was concluded that, in its present form, the M Test does not constitute a good screening measure for assessing malingering.

Utility of adenosine administration during intraoperative mapping in a patient with the Wolff-Parkinson-White syndrome

Adenosine is an endogenous nucleoside that is administered intravenously and has potent chronotropic and dromotropic effects. This drug is distinguished from verapamil by its very short half-life. This makes it an ideal agent for use in the operating room where long lasting electrophysiological effects may not be desirable. A 61-year-old man with preexcited atrial fibrillation was referred for surgical ablation of his accessory pathway. Preexcitation was minimal or absent on arrival in the operating room. Intravenous adenosine was given causing AV nodal block, and resulted in marked preexcitation, thus allowing computerized mapping to localize the site of the accessory pathway. Adenosine may be a useful agent for rapid and precise localization of accessory pathway(s) in a select group of patients with minimal preexcitation at the time of surgery. Its short half-life allows additional mapping without sustained electrophysiological effects on the AV node, or accessory pathway.

The role of Canadian psychiatry in dangerous offender testimony

Psychiatrists and psychologists who participate in dangerous offender hearings are accorded "expert status" by the courts for the long term prediction of violent recidivism. The clinical and judicial bases for such involvement are reviewed and critiqued. Given the frailties of our predictive abilities, the most prudent course would be for mental health experts to eschew dangerous offender determinations. Since this alternative appears unlikely, tentative guidelines are offered to reduce grave errors in testimony given at dangerous offender hearings.

A prospective comparison of four insanity defense standards

OBJECTIVE

Controversy about the formulation of the insanity defense has been intense, but little empirical work is available regarding how different standards affect court findings. The major aims of the present study were to determine if different standards for determining insanity produced different judgments and to provide a broad descriptive picture of those cases in which the standards appeared to make a difference.

METHOD

Four forensic psychiatrists were asked to indicate whether they thought 164 defendants met any or all of four insanity tests: 1) the American Law Institute (ALI) cognitive criterion, 2) the ALI volitional criterion, 3) the APA test, and 4) the M'Naghten rule.

RESULTS

The four psychiatrists determined that 97.5% of the defendants met the ALI volitional criterion, 73.9% met the APA criterion, 70.3% met the M'Naghten rule, and 69.5% met the ALI cognitive criterion. Nearly two-thirds of the defendants met all four insanity tests, and 24.4% met only the ALI volitional test. Few defendants met cognitive tests without also meeting the ALI volitional test. Elimination of the volitional test for insanity reduced the rate of psychiatric recommendations of acquittal by 24.4%.

CONCLUSIONS

These findings highlight the fact that the primary logical division between volitional and cognitive standards appears to be powerful but that distinctions between types of cognitive standards are not terribly powerful. In addition, the variation among individual raters must be viewed as an important determinant of how any insanity standard is applied.

The clinical presentation of command hallucinations in a forensic population

In a forensic population, patients with command hallucinations (N = 25) were compared to two groups of psychotic patients: those with noncommand hallucinations (N = 24) and those without hallucinations (N = 16). The three groups did not differ in overall impairment as measured by the Global Assessment Scale and the Social Behavior Rating Schedule. However, the group with command hallucinations differed in the content of their hallucinations (more aggression, dependency, and self-punishment themes), and nearly one-half did not report or denied their command hallucinations to the assessment team. Many patients (N = 11, 44%) reported that they frequently responded to hallucinatory commands with unquestioning obedience.

Information exchange

I am currently collating information on positive monitoring systems developed for use in the field of community nursing.

Nutritional requirements in the elderly

Nutritional management of elderly persons can be difficult because of illness, drug-nutrient interactions, socioeconomic factors, and lack of precise information regarding nutrient requirements. Dietary intake and requirements, nutritional assessment, and guidelines for nutritional management of the elderly population are reviewed.

Pain clinic #14. Fibromyalgia and myofascial pain: either, neither, or both?

Musculoskeletal pain syndromes and the accompanying physical and emotional sequelae are frequent reasons for self-medication and physician visits. Most musculoskeletal pain syndromes are self-limited, periodically flaring up and subsiding. Fibrositis and myofascial pain syndromes, which affect a significant number of patients with musculoskeletal pain, should be clinically differentiated to reduce unnecessary work-ups and improve patient management at reduced costs. The more common pain locations are reviewed, and a cost-effective, comprehensive approach to management is outlined.

Diagnostic legitimacy of factitious disorder with psychological symptoms

The authors question the clinical status of factitious disorder with psychological symptoms as a mental disorder. In particular, they argue that unresolved issues regarding the motivational basis of this disorder and the lack of clearly delineated inclusion, exclusion, and outcome criteria seriously compromise its diagnostic legitimacy. Two case reports are presented to illustrate these difficulties. Future studies should consider these empirical and conceptual difficulties in refining the diagnosis of factitious disorder with psychological symptoms for DSM-IV.

Guidelines for selecting a nursing model for practice

Nursing models can provide direction to the practicing nurse. In this article, the process of selecting a nursing model is outlined. Noteworthy is the need for administrative support in this process in terms of providing release time, adequate coverage of the unit, scheduling, secretarial support, praise, and encouragement. It is suggested that nurses from various levels form an ad hoc committee so that there be representatives from both management and staff nurses as well as those who have been exposed to the use of models on the committee. Initially, the committee members should examine beliefs about nursing, the client, and the environment so that the model selected will reflect the beliefs and goals of the staff. Factors to consider in model selection are outlined so that the selected model will provide direction to each phase of the nursing process. Once a model is selected, it is recommended that individuals with experience in using it be approached to share their successes and difficulties. It is imperative that staff nurses be involved in the decision-making process.

Pharmacological characterization of conduction over a Mahaim fiber: evidence for adenosine sensitive conduction

The presence of a nodoventricular pathway (Mahaim fiber) has been invoked to explain certain distinctive electrocardiographic and electrophysiological observations. The presence of an atrioventricular or atriofascicular fiber with decremental conduction properties has been documented in many of these patients. We report the case of a patient with a Mahaim fiber and the response to conduction over this pathway after adenosine, procainamide, encainide, verapamil, edrophonium, phenylephrine and isoproterenol. Conduction over the Mahaim fiber was blocked by adenosine, but not verapamil. The time course of adenosine induced block over the Mahaim fiber differed from adenosine induced AV nodal block. Mahaim fibers are decrementally conducting pathways that are adenosine sensitive. These findings support the concept that conduction in accessory pathways manifesting decremental properties is not mediated by the calcium channel.

Forensic psychiatrists' and psychologists' understanding of insanity: misguided expertise?

The ability of mental health experts to consult on insanity cases is highly dependent on their accurate understanding of the current Canadian standard. The study surveyed experienced forensic psychiatrists and psychologists and found the majority (88%) had erroneous beliefs regarding the insanity standard. Results of a discriminant analysis suggest that experience with insanity evaluations and courtroom testimony may improve experts' understanding. Implications of these results are discussed with respect to professional training and public policy.

Increased circulating atrial natriuretic factor (ANF) release during induced ventricular tachycardia

During sustained ventricular tachycardia (VT), there is usually a rise in mean atrial pressure. Atrial natriuretic factor (ANF) is a peptide released by the atria in response to increased atrial pressure or distension. ANF causes arterial vasodilation and natriuresis in man, and may contribute to the polyuria noted during tachycardia. We hypothesized that induction of sustained VT would cause elevation of right atrial pressure and lead to increased release of ANF. We measured mean arterial pressure, right atrial pressure, VT cycle length, atrial cycle length, plasma norepinephrine, and central ANF in 11 patients during 20 episodes of VT. The mean cycle length of induced tachycardia was 335 +/- 15 msec, with a mean atrial cycle length of 547 +/- 43 msec. Baseline plasma ANF was 70 +/- 11 femtomoles per milliliter and increased to 133 +/- 22 fmol/ml (p less than 0.001) after 4 minutes of VT. There was a decrease in mean arterial pressure from 87 +/- 3 to 66 +/- 3 mm Hg, and a rise in mean right atrial pressure from 4.0 +/- 0.8 to 11 +/- 1 mm Hg (p less than 0.001). The change in plasma ANF was quite variable among individual patients and was correlated with changes in mean right atrial pressure but poorly correlated with changes in mean arterial pressure, plasma norepinephrine, and atrial cycle length. Our data demonstrate that significant increased in ANF levels occur during sustained VT and are associated with increased right atrial pressure.

Nursing by degrees

What's the point of a degree in nursing? Nursing graduates themselves are apparently in no doubt as to its benefits, although the gap between their ideals and reality can be wide. Their non-graduate peers, however, often remain to be convinced.

Multiple schedule of affective disorders and schizophrenia (SADS) in the assessment of criminal defendants

Psychiatric and psychological assessment of criminal defendants is often complicated by the retrospective nature requiring an overreliance on self-reported data and the need to achieve a high degree of certainty in formulating the diagnosis and subsequent expert opinion within the context of an adversarial evaluation. The Multiple Schedule of Affective Disorders and Schizophrenia (SADS) evaluation involves the application of an extensive diagnostic interview that has demonstrated a high degree of reliability and satisfactory validity in making current and lifetime diagnoses. The multiple SADS entails sequential administrations of the SADS, first to the defendant and later to significant others regarding the defendant's functioning during the time period in question. This comprehensive approach allows for the systematic examination of individual symptoms and the clear delineation of disparities and areas of agreement. Usefulness of the multiple SADS evaluation is exemplified in a case study involving criminal responsibility.

Use of the SADS diagnostic interview in evaluating legal insanity

Examined clinical usefulness of the SADS diagnostic interview in evaluations of criminal responsibility. Findings, based on 78 SADS evaluations from a specialized forensic clinic, indicated that SADS successfully differentiated between sane and insane evaluatees. These differences were found primilarily in the severity of psychotic symptoms and overall level of psychological impairment. In addition, preliminary data on institutionalized and outpatient Ss suggested the potential applicability of the SADS for assessing the general psychological functioning of insane patients in treatment.

Identification of random responders on the MMPI: an acturial approach

Actuarial methods were tested on 80 random profiles and 80 forensic evaluatees for discriminating between random and nonrandom MMPI profiles. Both a discriminant analysis approach and clinical decision rules were highly accurate (90% or better) at correctly classifying random profiles with findings consistent with previous research.

Identification of random responders on MMPI protocols

In clinical practice, indicators of random or irrelevant responses on MMPI protocols are typically not examined, and, if obtained, assumed to be the result of either gross psychopathology or attempts to malinger. A sample of 40 computer-generated random profiles and 40 profiles of forensic outpatients were compared on validity scales, clinical scales, and scales specially designed to detect randomness (TR index and Carelessness Scale). Results of discriminant analysis indicated differentiating patterns of responses with random profiles generally elevated. Further, the accuracy of several clinical decisions rules were evaluated. The "F greater than 80 and TR greater than 4" rule was found to have the greatest clinical utility at correctly classifying random responders.

The RCRAS and legal insanity: a cross-validation study

Examined the RCRAS as an empirically based approach to insanity evaluations. Previous research has been encouraging with regard to the RCRAS' interrater reliability and construct validity. The present study, with a larger data base (N = 111), sought to cross-validate these findings. Results from five forensic centers established satisfactory reliability for the RCRAS (mean kappa r = .80 for decision variables for criminal responsibility) and differentiating patterns for four of the five scales between sane and insane patient-defendants. Results further suggested that the RCRAS was generalizable across age, sex, criminal behavior, and location of the forensic evaluation. These findings were discussed with respect to the potential clinical utility of the RCRAS.

The resistance to re-infection of cats repeatedly inoculated with infective larvae of Brugia pahangi

Seven microfilaraemic and five amicrofilaraemic cats which had been repeatedly infected with Brugia pahangi were challenged along with normal cats 28, 14 and 1 day before autopsy. The lymphatics of the amicrofilaraemic cats contained no female adult worms originating from the repeat infections and only two adult males (both from the same cat). Only 5.2% of the worms in the control cats were recovered from the amicrofilaraemic cats. Most of the challenge worms were killed in the first 24 h. The microfilaraemic cats all contained fertile adult male and female worms derived from the repeated infection but in such low numbers as to indicate considerable resistance to infection. Compared to their controls 26.4% of the challenge worms were recovered. Analysis of the life-cycle stages recovered showed that in both groups there was attrition of all stages and that although a number of worms reached L5 these were all killed later in the amicrofilaraemic cats.

Accuracy of MMPI decision rules in establishing DSM III diagnoses

The usefulness of MMPI decision rules in identifying corresponding DSM III diagnosis was explored. A study of 118 outpatient evaluations yielded a low degree of accuracy for both the Meehl-Dahlstrom and Henrichs decision rules. Given those results, a discriminant analysis was performed for three DSM III diagnostic categories (schizophrenic disorders, affective disorders, and no mental disorders); this analysis suggested potential usefulness for multivariate-based MMPI decision rules.

A computerized assessment program for forensic science evaluations: a preliminary report

The development of the innovative use of an on-line, computer-assisted evaluation program is discussed, with a brief review of pertinent literature. The particular applications within a forensic psychiatric center of the Tandem 16 computer system, utilizing both "canned psychological tests" and specialized assessment techniques, are examined and highlighted with a case vignette. A highly relevant problem within forensic psychiatry, malingering or exaggeration of symptoms, is examined in more detail as it relates to computer assessments. The advantages and limitations of a computer-assisted evaluation are described relative to both its clinical and research application.

Scientific inquiry in forensic psychiatry

Forensic psychiatry and psychology, with an extensive history of clinical practice, is only recently emerging as a new scientific specialty. It is confronted with both general scientific-methodological issues, as well as unique, empirically-based psycholegal applications. Aimed towards a broader, more flexible paradigm for understanding the basis of our scientific inquiry, the paper examines various research and methodological issues. As a model for connecting and understanding these complicated and interrelated issues, Holton's explicit and useful model of scientific structure is provided. The methodology, logical and statistical analysis, and themata are explored with regards to their potential impact on scientific inquiry in forensic psychiatry. This paper argues for several considerations in furthering research. From a methodological basis, the prospective researcher has to consider (1) whether the methodology is, in part, predetermining the results; (2) whether the results are a prediction of the inclusion criteria rather than an independent finding; (3) what balance between specificity and generalizability is designed within the research study; and (4) what is the impact of various methodological artifacts on the results and conclusions of forensic psychiatric research (e.g., demand characteristics, evaluation apprehension, experimenter bias, systems influence). Further, the forensic psychiatric researcher is asked to consider the basis of the "validity" of his research findings in comparison with "objective reality" from the perspective of logical and statistical analysis. Scientists within forensic psychiatry are asked to consider (1) whether to employ "best fit" or complementarity in understanding their results; (2) how to make explicit the steps in data transformation and redefinition within their study; (3) what are the implications of exclusive use of null hypothesis testing in establishing research results; and (4) what is the comparative utility of non-parametric and multivariate statistical procedures in studying and understanding experimental variables. Finally, in acknowledging the non-linear and sometimes self-justifying aspect of science, researchers are invited to examine their basic assumptions, and the self-perpetuating and constraining nature of unacknowledged themata, as well as their impact on forensic psychiatry. This paper is conceptualized as a movement towards articulating both general methodological issues and their unique application to forensic psychiatry. The brief exposition of Holton's model and review of illustrative research in forensic psychiatry constitutes one attempt to strengthen the scientific rigor of forensic psychiatric research.

Schedule of Affective Disorders and Schizophrenia, a diagnostic interview in evaluations of insanity: an exploratory study

The Schedule of Affective Disorders and Schizophrenia (SADS) is described, including its potential applicability to insanity evaluations. A small sample ( N = 28) of evaluations are examined with significant differences observed between sane and insane groups on over-all psychopathology, delusions and hallucinations.

An empirical approach to insanity evaluations

Described the development of the Rogers Criminal Responsibility Assessment Scales (RCRAS) as an empirically based testing procedure specifically designed for use in insanity evaluations. A pretest of the RCRAS that employed 10 case vignettes and a preliminary study of 25 patients are reported. Initial results indicated that the RCRAS has satisfactory interrater reliability and successfully discriminated between those patients evaluated as sane and insane. Results of the discriminant analysis, MANOVA, and factor analysis are discussed with reference to the RCRAS' construct validity and the need for further extensive studies.

Biosynthetic human insulin: effect in healthy men on plasma glucose and non-esterified fatty acids in comparison with highly purified pork insulin

Biosynthetic human insulin (BHI) produced by recombinant DNA technology was administered subcutaneously and intravenously at two dose levels to two groups, each consisting of six normal men. Responses were compared with those for purified pork insulin (PPI) given by the same routes at the same dose levels to the same two groups. The glycemic response to the insulins was similar with a suggestion (seen both with intravenous and subcutaneous administration) that the glycemic depression with BHI was slightly greater at low dose and less at high dose. No significant difference between insulin types was found in the depression of non-esterified fatty acid (NEFA) concentrations, although significant differences between types with low-dose subcutaneous injection emerged during the later phases of the experiment. After termination of high-rate infusion with both insulins, NEFA concentrations rose more rapidly with some overshoot, suggesting that the rate and depth of blood glucose fall in these experiments might have triggered a brisker counterregulatory response. The small differences found between human and pork insulins, although in some cases significant, are unlikely to be of clinical importance.

Aggressive and socially disruptive behavior among maximum security psychiatric patients

The study examines retrospectively selected environmental variables and the frequency of aggressive and socially disruptive behaviors within a 42-bed maximum security psychiatric setting. Perceived “violent” patients showed a low incidence of aggressive behavior in a controlled setting. Significant variables associated with these behaviors were the time of day and availability of professional staff.

Successful vaccination of cats against Brugia pahangi with larvae attenuated by irradiation with 10 krad cobalt 60

Cats were vaccinated by the inoculation on 10 occasions of approximately 300 larvae of Brugia pahangi which had been irradiated with 10 krad cobalt 60. They were challenged on 3 occasions with normal larvae of either B. pahangior B. patei. The vaccinated cats were resistant to challenge as demonstrated by either longer pre-patent periods or failure to become microfilaraemic and by having fewer third, fourth or adult worms than normal controls. Although the vaccination procedure was unpractically heavy these results lend encouragement to the possibility of developing vaccines against filarial infections.