Demoralisation, depression and desire for death: problems with the Dutch guidelines for euthanasia of the mentally ill

OBJECTIVE

Given the recent publication of Dutch guidelines for euthanasia of the mentally ill, our aim in this paper is to review the clinical role of the psychiatrist in assessing patients who seek euthanasia or physician-assisted suicide.

METHOD

Three areas are examined that are informative of the role of the psychiatrist in assessing patients who desire death: recent surveys of psychiatrists' attitudes, empirical and clinical studies, and treatment issues.

RESULTS

Demoralisation and depression emerge as pertinent clinical issues worthy of psychiatric intervention. The role of the psychiatrist is complex and includes issues of assessment, systems, countertransference and treatment.

CONCLUSIONS

Dutch guidelines for physician-assisted suicide in the mentally ill generate serious concern given the uncertainty of prognosis, potential range and variability of outcome of treatments of suicidality and the boundary violations that are involved for the psychiatrist. The guidelines have the potential to dangerously alter the practice of psychiatry and should be condemned.

Cisplatin-based therapy: a neurological and neuropsychological review

The present paper reviews research in the area of the broad-spectrum chemotherapeutic agent cisplatin (cis-diamminedichloro-platinum II) and examines the implications for clinical neuropsychology arising from the neurological disruption associated with cisplatin-based therapy. The paper begins with a brief review of cisplatin treatment in terms other than survival alone, and examines the side-effects and the potential central nervous system (CNS) dysfunction in terms of neurological symptoms and concomitant implications for neuropsychology. Two main implications for clinical neuropsychology arising from cisplatin therapy are identified. First, cisplatin therapy impacts upon the psychological well-being of the patient, particularly during and in the months following treatment. It is suggested that during this time, a primary role for neuropsychology is to focus upon the monitoring and the active enhancement of the patient's social, psychological and spiritual resources. Second, with regard to neurocognitive changes, the review suggests that (1) neurocognitive assessment may not yield stable results within 8 months following treatment and (2) while perceptual, memory, attentional and executive dysfunction may be predicted following cisplatin treatment, little systematic research has been carried out to investigate such a possibility. Future research might profitably address this issue and also specifically examine the effects of low dosage cisplatin-based therapy and the effects of recently developed neuroprotective agents. Finally, there is some evidence to suggest that women may be more susceptible to neurotoxicity during cisplatin therapy, but no gender-related cognitive effects are reported in the cisplatin literature. Future research could usefully investigate gender differences in association with cisplatin chemotherapy.

Progression in acute stroke: value of the initial NIH stroke scale score on patient stratification in future trials

BACKGROUND AND PURPOSE

The objective was to determine the occurrence of neurological changes during the first 48 hours after acute stroke as it relates to initial stroke severity.

METHODS

The National Institutes of Health Stroke Scale (NIHSS) was performed serially for the first 48 hours on 127 consecutive ischemic stroke patients (129 strokes) admitted to the neuroscience intensive care unit. Incidence of stroke progression (a >/=3-point increase on the NIHSS) was recorded and analysis performed to determine its association with initial stroke severity and other demographic and physiological variables. Deficit resolution by 48 hours, defined as an NIHSS score of 0 or 1, measured the frequency of functional recovery predicted by the initial deficit.

RESULTS

Overall progression was noted in 31% of events (40/129). Applying Bayes' solution to the observed frequency of worsening, the greatest likelihood of predicting future patient progression occurs with stratification at NIHSS scores of </=7 and >7. Patients with an initial NIHSS of </=7 experienced a 14.8% (13/88) worsening rate versus a those with a score of >7 with a 65.9% (27/41) worsening rate (P<0.000005). Forty-five percent (40/88) of those with an initial score of </=7 were functionally normal at 48 hours, whereas only 2.4% (1/41) of those with scores of >7 returned to a normal examination within this period (chi2, P<0.000005).

CONCLUSIONS

This study suggests that the early clinical course of the neurological deficit after acute stroke is dependent on the initial stroke severity and that a dichotomy in early outcome exists surrounding an initial NIHSS score of 7. These findings may have significant implications for the design and patient stratification in treatment protocols with respect to primary clinical outcome.

Managing HIV. Part 7: Professional issues. 7.7 HIV care: the impact on the doctor

Managing patients with HIV raises complex clinical, ethical and personal challenges. "Burnout" threatens the overcommitted doctor who is not prepared to take preventive measures.

Assisted suicide and euthanasia: what about the clinical issues?

This paper aims to address the clinical issues involved in a patient's request for assisted suicide. The psychiatric and broader psychosocial issues for the dying patient, their family and their treating doctor have been largely unaddressed in the debate concerning euthanasia to date. A range of the clinical issues that need to be incorporated in the ethical and legal considerations are reviewed. The reasons for a patient seeking suicide as a treatment are complex and go beyond questions of a patient's right to die. The request for euthanasia needs to be seen in the context of the patient's circumstances, including relationships with and attitudes of carers and health professionals, along with patterns of psychiatric disorder and psychiatric symptoms in the medically ill. The clinical issues involve not only the diagnosis or management of psychiatric disorder but also the acknowledgment of the factors influencing an individual's adjustment to the threat of illness and death. The dynamics of family interactions and doctor-patient relationships in this setting are factors that may impinge upon a request for assistance to die. These factors may be more important than the severity of a person's illness or their quality of life, and are less likely to be recognised and addressed in situations of professional isolation. There are critical issues facing psychiatry in new legislative developments.

Changes in acetylcholine receptor number in muscle from critically ill patients receiving muscle relaxants: an investigation of the molecular mechanism of prolonged paralysis

OBJECTIVE

Previous reports have described prolonged paralysis after the administration of muscle relaxants in critically ill patients. The purpose of this study was to examine possible pathophysiologic causes for this paralysis by measuring muscle-type, nicotinic acetylcholine receptor number in necropsy muscle specimens from patients who had received muscle relaxants to facilitate mechanical ventilation before death.

DESIGN

Prospective laboratory study of human muscle collected at autopsy.

SETTING

Medical and surgical intensive care units (ICUs) at a university hospital and a research laboratory.

PATIENTS

Fourteen critically ill patients, with a variety of diagnoses, all of whom required mechanical ventilatory support before their deaths in the ICU and who underwent post mortem examination. Patients were arbitrarily divided into three groups, according to their total vecuronium dose and number of days mechanically ventilated before death. Three patients were in the control group (defined as dying within 72 hrs of initiation of ventilatory support and receiving a total dose of < 5 mg of vecuronium). Six patients were in the low-dose group (defined as requiring ventilatory support for > 3 days before death and receiving a total vecuronium dose of < or = 200 mg). Five patients were in the high-dose group (defined as requiring ventilatory support for > 3 days before death and receiving a total vecuronium dose of > 200 mg).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Nicotinic acetylcholine receptor numbers as measured by specific 125I-alpha-bungarotoxin binding to human rectus abdominis muscle obtained at autopsy were determined. In general, receptor number reflected the clinical requirements for the muscle relaxants of each patient. Patients who had increasing requirements for muscle relaxants before death had increases in receptor number, as compared with control values.

CONCLUSIONS

The increase in nicotinic acetylcholine receptor number in muscle from patients with an increasing requirement for muscle relaxants before death suggests that nicotinic acetylcholine receptor up-regulation may underlie the increased requirements for muscle relaxants seen in some patients. Furthermore, these findings suggest that muscle relaxant-induced, denervation-like changes may at least be partially responsible for prolonged muscle paralysis after the long-term administration of muscle relaxants. This study may provide the first information into the molecular mechanisms underlying prolonged paralysis.

Prevalence and severity of neurologic dysfunction in critically ill patients. Influence on need for continued mechanical ventilation

OBJECTIVE

The relative importance of neurologic dysfunction in critically ill mechanically ventilated patients has not been well studied. This study investigates the prevalence of neurologic dysfunction in critically ill mechanically ventilated patients and its influence on preventing the discontinuation of mechanical ventilation and patient outcome.

DESIGN

Prospective study.

SETTING

University-based, tertiary care center.

PATIENTS

All eligible adult patients mechanically ventilated for more than 48 h were included. A total of 66 patients were evaluated.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Two independent questionnaires, one completed by the critical care attending physician documenting the major clinical factors necessitating continued mechanical ventilation, and a second questionnaire, completed by a critical-care trained neurologist documenting neurologic status and objective cardiopulmonary status formed the basis for outcome measurements. Respiratory and physiologic data, the patient's clinical conditions, and outcome (mortality) were also included in the database.

RESULTS

Pulmonary factors were the major reason for prolonged ventilation in only 51 percent of the patient evaluations. Neurologic status was the major factor necessitating continued mechanical ventilation in 32 percent of the patient evaluations and a significant contributing factor in an additional 41 percent. Of the neurologic factors, diminished level of consciousness was the major cause of continued ventilatory support. This was usually due to a systemic illness, rather than a primary central nervous system disorder. Mortality was significantly lower in patients who continued to require mechanical ventilation after 48 h because of neurologic factors as opposed to pulmonary factors (15 percent vs 72 percent, p = 0.002).

CONCLUSIONS

There is a high prevalence of neurologic dysfunction in critically ill patients and this problem plays a significant role in preventing the discontinuation of mechanical ventilation. Altered mental status is a major factor necessitating continued mechanical ventilation in combined medical-surgical intensive care units.

Attention deficits in children and adolescents with hearing loss. A survey

OBJECTIVES

To determine the prevalence of reported attention deficits in a sample of children who are deaf or hard of hearing and to examine associated variables.

DESIGN

Cross-sectional survey.

SETTING

Residential school for the deaf.

PARTICIPANTS

All students attending the school (n = 238; median age, 16.0 years; range, 4 to 21 years). Subjects were subgrouped by cause of deafness for further analyses.

INTERVENTION

None.

MEASUREMENTS/MAIN RESULTS

School personnel completed questionnaires that are commonly used in the assessment of attention problems. Teachers completed the Attention Deficit Disorder With Hyperactivity (ADD-H) Comprehensive Teacher Rating Scale (ACTeRS) and an abbreviated version of the Attention-Activity section of the ANSER (Aggregate Neurobehavioral Student Health and Education Review) System Questionnaires. Dormitory supervisors rated students on the Conners' Parent Rating Scale and the ANSER System Questionnaires. The mean factor scores for the total sample of deaf and hard-of-hearing students on the Attention and Hyperactivity scales of the ACTeRS and Conners' questionnaires did not differ from the normative data. The 64 students with hereditary deafness received significantly better ratings than the 75 with an acquired cause of deafness such as bacterial meningitis or congenital rubella. Raw scores on the ACTeRS were converted to percentile equivalents based on the normative sample. On the Attention Scale, 38.7% of those with acquired deafness were rated below the 20th percentile (indicative of problems); only 14.1% of the students with hereditary deafness were in this range (P = .002).

CONCLUSIONS

Ratings of attention for students with hearing loss, attending a residential school, did not differ from the normative data. However, the subgroup of children with acquired sensorineural deafness appear to be at increased risk for attention problems.

Current concepts in cerebral protection

In the past, physicians viewed ischemic injury as an irreversible event. Modern science has shown that this view is incorrect and that ischemic neuronal damage is an ongoing, active process that might be amenable to various therapies. Figure 2 illustrates some of the possible sites where these therapies might be active. Pending evidence of their effectiveness, cerebral protection can best be achieved by maintaining adequate CPP and CBF during periods when patients are at risk for cerebral ischemia, restoring perfusion after ischemia occurs, and optimizing the metabolic milieu of the ischemic penumbra.

Evaluation of techniques for the elimination of "hot" bladder artifacts in SPECT of the pelvis

The purpose of this study was to validate the usefulness of two digital filtering techniques used to eliminate the artifacts caused by rapid bladder filling during SPECT of the pelvis. A dynamic phantom model was used containing two hips and a bladder. The phantom was studied under three conditions--bladder empty, filling, and full. The ability of the pixel truncation and interpolative background replacement techniques to eliminate bladder artifacts was assessed. Both techniques gave similar results and resulted in significant (but not complete) recovery of activity in the hips. Quantitative analysis of pixel counts over each hip shows that the measured activity was variable and approximately 20%-30% less than that seen in the empty bladder study. The use of left/right ratio to quantitate differences in hip activity was highly inaccurate despite the use of these filtering techniques. In summary, while these techniques significantly improve image quality, caution should be exercised, particularly in the evaluation of the medial aspects of the hips.

Turkey muscle growth and focal myopathy

Muscle structure and blood enzyme activity were studied to 16 wk of age in lines of turkeys selected for rapid growth. The body and carcass weights were measured, frozen sections of breast and leg muscles examined, and plasma creatine kinase (CK) levels determined. Muscle weights were usually proportional to BW except for the relatively larger superficial pectoralis (SP) muscles in the most rapidly growing line. Damaged muscle fibers were found in all muscles examined, especially in the SP of the breast, the gastrocnemius (GA), and other muscles of the leg; these damages became more common from 10 to 16 wk of age. There were more degenerating muscle fibers and higher levels of plasma CK in the rapidly growing lines than in a slower growing unselected line. The findings support the idea that a focal myopathy, unrelated to deep pectoral myopathy or to inherited muscular dystrophy of the chicken, is associated with rapid growth of turkeys.

Some parental views on the Community Dental Service

A sample of 220 adults accompanying children to Community Dental Service (CDS) clinics in two adjacent health districts in the North Western Health Region of England were questioned to gain insight into their views about the service. Seventy-five per cent reported that they had a dentist of their own; 82% of these claimed to have visited him/her in the previous 12 months. They had chosen the CDS for four broad reasons: 51% saw it as providing a specialised service, 27% came as a result of a school inspection, 15% used it because it was convenient, and 7% had been unhappy with the care provided by a general dental practitioner. Seventy-six per cent thought that the CDS should be allowed to treat adults. There were no significant differences between those with dentists of their own and those without, or between those who gave the specialised nature of the CDS as the reason for attending and those who did not. Those who came by car were significantly less likely to believe that the CDS should treat adults; nevertheless, 69% of these were in favour.

Unilateral pursuit-induced congenital nystagmus

We describe two patients with a lifelong history of oscillopsia only when following objects moving toward their left side. Neurologic examination was normal except for eye movements. The patients showed nystagmus during any tasks that required visual following toward the left (ie, smooth pursuit, optokinetic nystagmus, and vestibulo-ocular-reflex-suppression), but had no nystagmus during fixation of stationary targets or visual following tasks to the right. Eye-movement recordings showed waveforms during pursuit to the left that were typical of congenital nystagmus.

Effect of tampon wraps on production of toxic shock syndrome toxin 1

The influence of tampon wraps on the production and distribution of toxic shock syndrome toxin 1 (TSST-1) was investigated with use of a disk-membrane-agar method. Filter membranes (45 micron) overlaying agar medium in 50-mm petri dishes were spread-inoculated with a TSST-1-producing strain of Staphylococcus aureus and covered with 0.5 mL of whole citrated rabbit blood. Disks of tampon core materials with and without wraps were placed on the inoculated membranes and incubated at 37 degrees C in 5% CO2 in air. Eight wraps with each of 14 tampon core materials were tested to determine the amount of toxin in the agar layer, a quantity considered an indicator of the relative amounts of toxin available for absorption in vivo. The average level of toxin in the agar layer with any particular wrap compared with that in the agar layer with no wrap was higher with five wraps, lower with two wraps, and essentially the same with one wrap. The lower levels of toxin were obtained with one wrap that had a starch binder and with one that contained the surfactant Standamul 1414-E. Standamul 1414-E has been reported to be an inhibitor of growth of and production of TSST-1 by S. aureus.

Abnormal gallium uptake in anticardiolipin syndrome: an unexplained phenomenon

A case of asymmetrical gallium uptake in the musculature of a young woman with anticardiolipin syndrome is reported. The patient was asymptomatic in the areas of involvement, muscle biopsy was normal, and the abnormal gallium accumulation was unchanged on repeat evaluation 7 months later. Possible causes for the abnormal gallium uptake are proposed, but the mechanisms of uptake in this case remain unclear. Nuclear physicians should be aware of this disorder and the potential for abnormal gallium uptake with this syndrome.

Pasteurella anatipestifer infection in commercial meat-type turkeys in California

A disease outbreak characterized by respiratory signs, occasional neurologic signs, and increased mortality in commercial meat turkeys from four separate companies in central California was investigated in the late summer and early fall of 1986. The disease syndrome affected turkeys from 6 to 15 weeks of age and caused a severe fibrinous pericarditis, perihepatitis, and airsacculitis. Bacteriologic and serologic examinations as well as virus- and chlamydia-isolation attempts initially failed to implicate an etiologic agent. Eventually culture attempts were made in a 5% CO2 incubator, resulting in isolation of Pasteurella anatipestifer. The disease syndrome was reproduced in young turkeys and broiler chicks inoculated with the organism.

Clinical outbreak of Bordetella avium infection in two turkey breeder flocks

An acute upper respiratory disease was observed in two broad-breasted white (BBW) turkey primary breeder flocks. Associated clinical signs included sneezing, depression, and a deep dry cough originating from large conducting airways. Morbidity reached approximately 15-20% of the hens in an affected house. None of the turkeys died, and total feed consumption was not affected. A minimal effect upon egg production was noticed. Sera from an acutely affected flock exhibited a marked rise in titer to Bordetella avium compared with preinfection sera samples. In Case 1, B. avium was isolated in pure culture from affected birds. In Case 2, B. avium was diagnosed by serological results and clinical signs; bacteriological examination was not attempted. The findings presented here are consistent with an acute clinical outbreak of B. avium-induced turkey rhinotracheitis (turkey coryza) in BBW turkey breeder hens.

Hemorrhagic enteritis of turkeys in California: serologic study of hemorrhagic enteritis virus antibody with an enzyme-linked immunosorbent assay

The incidence of hemorrhagic enteritis (HE) infection in California turkeys was studied by testing 2220 turkey blood samples from 173 flocks for HE virus (HEV) antibody by the enzyme-linked immunosorbent assay (ELISA). Maternal antibody was detected at 1 day of age in all flocks tested, and it vanished after 3 weeks. Acquired HEV antibody appeared at 8 to 10 weeks, and 100% of the meat and breeder turkey flocks were positive after 11 weeks of age. HEV infection occurred earlier in the meat flocks than in the breeder flocks, and it also occurred earlier during summer than during the fall and winter months.

Paramyxovirus type 3 (PMV-3) in California turkeys: serologic study of PMV-3 antibody with an enzyme-linked immunosorbent assay

An enzyme-linked immunosorbent assay (ELISA) was developed for detecting paramyxovirus type 3 (PMV-3) antibody. This test had a higher sensitivity than the hemagglutination-inhibition test, and no cross-reactivity with various paramyxoviruses or avian pathogens was detected when the sera were tested diluted 1:200. The incidence of PMV-3 infection in California was studied by testing 2037 turkey sera from 174 meat and breeder flocks for the presence of PMV-3 antibody using the ELISA. The age at which the infection occurs was around 5 to 8 weeks for meat flocks and 10 to 12 weeks for breeder flocks. Infection with the PMV-3, as determined serologically, was more frequent than manifested cases of disease, and 95.2% of the flocks aged over 11 weeks had PMV-3 antibody. No typical manifestations of PMV-3 disease (respiratory disease plus drop in egg production) were observed, probably because of the early infection which occurred before laying age.

Factors affecting the reporting of symptoms by hypertensive patients

Patients diagnosed as hypertensive have a high complaint rate, both on and off treatment and this has been postulated to be due to either their disease process, their being labelled as hypertensive, or to their treatment. Data from 6637 hypertensive patients being entered into clinical trials in general practice have been analysed to determine the relationship between the patient's age, sex, concurrent illnesses, concurrent medication, whether they were on antihypertensive treatment and the frequency of their reporting symptoms. The analysis was conducted using a multivariate technique. The frequency of reporting symptoms was greater in females than males. Those receiving antihypertensive therapy reported more symptoms than those who were not. This was notable with those receiving a beta-adrenoceptor blocker (47% of such patients complaining). Patients receiving concurrent medication were more likely to report a symptom than those not (48 compared to 37%). This was particularly noticeable if central nervous system-acting drugs were prescribed where the prevalence of symptoms was 52%. Patients already on antihypertensive treatment were more likely to be taking other medication for other conditions (37 vs 31%) than those not receiving antihypertensive treatment. Females were more likely to be taking other tablets than males (38 compared to 30%). The only symptoms which were less prevalent in those receiving treatment were headache, dizziness and breathlessness. All other symptoms were increased or unchanged in patients on antihypertensive therapy. This study indicates that present treatment for hypertension produces a high complaint rate from patients and that, when patients so complain, the possibility of their symptoms being due to their concurrent medication should be considered.

R plasmid-mediated gentamicin resistance in salmonellae isolated from turkeys and their environment

Gentamicin-resistant salmonellae were isolated from turkey poults, hatching eggs, and litter on three unrelated farms and from a scrub jay (Aphelocoma coerulescens) on a fourth farm unrelated to the other three. The isolates were Salmonella arizonae from three of the farms (poults, eggs, scrub jay) and S. thompson (litter) from the fourth farm. The genes responsible for gentamicin resistance were located on the same conjugal plasmid. This plasmid also encoded resistance to kanamycin, streptomycin, ampicillin, and sulfadiazine.

Immunization of turkey breeder hens against fowl cholera by combined oral and wing-web administration of attenuated (CU) pasteurella multocida

Turkey breeder candidates were exposed to attenuated Pasteurella multocida (Clemson University strain) via both mouth (one or three times) and wing-web stick (one or two times). Significant protection lasting to 25-30 weeks post-vaccination was conferred under such immunization programs. The best protection with the fewest adverse effects of vaccination was established when orally vaccinated turkeys were subsequently vaccinated via wing-web at 20 and 25 weeks of age. High doses of attenuated P. multocida via wing-web produced lameness (synovitis and osteomyelitis) and severe wing lesions in growing turkeys.

Piezoelectric ceramic implants: in vivo results

The suitability of barium titanate (BaTiO3) ceramic for direct substitution of hard tissues was evaluated using both electrically stimulated (piezoelectric) and inactive (nonpolarized) test implants. Textured cylindrical specimens, half of them made piezoelectric by polarization in a high electric field, were implanted into the cortex of the midshaft region of the femora of dogs for various periods of time. Interfacial healing and bio-compatibility of the implant material were studied using mechanical, microradiographical, and histological techniques. Our results indicate that barium titanate ceramic shows a very high degree of biocompatibility as evidenced by the absence of inflammatory or foreign body reactions at the implant-tissue interface. Furthermore, the material and its surface porosity allowed a high degree of bone ingrowth as evidenced by microradiography and a high degree of interfacial tensile strength. No difference was found between the piezoelectric and the electrically neutral implant-tissue interfaces. Possible reasons for this are discussed. The excellent mechanical properties of barium titanate, its superior biocompatibility, and the ability of bone to form a strong mechanical interfacial bond with it, makes this material a new candidate for further tests for hard tissue replacement.

Piezoelectric ceramic implants: a feasibility study

A piezoelectric ceramic has been investigated as a direct substitute for hard tissues. Barium titanate (BaTiOz) power was slipcast and fired at 1430 degrees C for 2 hr, then made piezoelectric by polarizing. After 16 and 86 days of implantation in the cortex of the femoral midshafts, the femora with test specimens were sectioned into about 4-cm lengths. Their voltage outputs were measured under cyclic load at 1 Hz. The present results show that the voltage gradient at the implant surface is 0.15 mV/mm for the 16-day implantation with a 445-N (100-lbs.) load. This in turn can give rise to about 0.01 microA current flow in the adjacent area of the 16-day implant. The 86-day implant showed an order of magnitude higher voltage output compared to the 16-day implant with the same magnitude of loads. This is probably due to the "load-transfer" efficiency through the implants, since the voltage output is directly proportional to the actual load transferred to the implant. The more bone implant interface matures, the better the load transfer occurs through the implant, resulting in higher voltage output.