[Questionable procedures in environmental medicine using an example of "multiple chemical sensitivity"]

"Multiple Chemical Sensitivity" (MCS) has to be regarded as a merely subjective concept without etiological and pathological background or objective criteria for diagnosis. Most of the "MCS" patients suffer from various psychiatric disorders; in a small minority somatic diseases can be found. The data recently won in the German multicenter study on MCS underline this point of view. The informal German "MCS network" consisting of patients' self-help groups, "therapists" with or without medical background and law firms specialised in compensation claims nevertheless strictly denies any psychogenic model. They do, however, propose a whole range of diagnostic and therapeutic procedures based on different theoretical concepts. Some of the procedures are derived from scientifically based medicine, others have an unconventional and esoteric background. Most of them are logically incompatible; however, they are applied in a polypragmatic manner. None of these so-called diagnostic or therapeutic procedures or health technologies can be regarded as evidence-based. Some of them, however, are extremely expensive and/or pose significant risks for patients' health. In any case, wrong subjective disease concepts are perpetuated iatrogenically. Additionally, those procedures make effective help for the real underlying medical and/or psychiatric conditions impossible.

[Ethical conflicts in involuntary treatment of schizophrenic patients; decision-making and in influential factors in three prototype cases]

Three case reports of patients with schizophrenia were presented to a sample of 520 persons (25.1% psychiatrists, 3.7% psychologists, 8.1% social workers, 14.6% nurses, and 48.6% others). The decisions for involuntary admission to a psychiatric hospital and involuntary treatment were questioned. In case 1 (young man, first episode, delusions, extreme social withdrawal), 71.7% supported admission to hospital and 62.7% were in favor of neuroleptic treatment. In case 2 (woman with disorganized syndrome beating her 74-year-old mother), 84.6% supported hospitalization and 78.8% neuroleptics. In case 3 (relapsed multi-episode patient, increasingly neglected, delusional, and socially withdrawn), 56.3% supported hospitalization and 52.7% neuroleptics. Generally, psychiatrists' decisions were very similar to those of other professionals and laypersons, while social workers more often rejected involuntary treatment. After professional status, multivariate analyses revealed older age as the most significant variable for support of involuntary treatment. Frequency of experience with mentally ill persons were only weak predictors or not significant.

["Lex Kendra" in New York, United States. Homicide, "revolving door psychiatry" and political response]

OBJECTIVE AND METHODS

The history, motivation and consequences of the New York State "Kendra's Law" as of August 1999 are reviewed.

RESULTS

"Kendra's Law" was the consequence of the killing of a young woman, Kendra W., by a schizophrenic patient later convicted for second degree murder. Before, he had been repeatedly rejected when he sought treatment in state-run psychiatric facilities and was expelled several times from long-term hospitals despite a long history of violent behaviour when untreated. "Kendra's Law" now entitles physicians, case workers, roommates and families of untreated mentally ill persons to seek a court order forcing a patient to comply with treatment and, at the same time, compelling mental health institutions to grant this treatment. Additionally, the law and another bill signed in November 1999 provided for additional funding for the underfinanced state-run mental health system.

CONCLUSION

"Kendra's Law" illustrates a bidirectional attempt to cope with the revolving door treatment situation of mentally ill in the State of New York by additional funding and additional possibilities to enforce treatment. The law illustrates the fundamental conflict between individual autonomy and the need for treatment of people suffering from severe mental illness.

[Acute psychiatric symptoms as the initial manifestation of HIV-infection: differential diagnosis, therapy and medico-legal issues]

The prevalence of psychiatric symptoms and disorders in HIV-infected patients is high. The differential diagnosis includes psychoreactive disorders, acute psychiatric symptoms of an HIV-associated encephalopathy, and symptomatic psychotic illnesses due to secondary neurologic manifestations such as opportunistic central nervous infections and intracerebral lymphoma. Clinical aspects and psychopathological findings are not sufficient for differential diagnosis and identification of primarily psychiatric disorders. Secondary neurologic manifestations causing a symptomatic psychosis must be excluded as soon as possible by brain imaging (CT, MRI) and analysis of the cerebrospinal fluid. In emergency situations, however, German law imposes strict regulations, especially in the case of sectioned patients. These medical and medicolegal questions are illustrated by case reports and propositions for an effective strategy are made.

[Cryptococcal meningoencephalitis in HIV infected immigrants. Diagnostic and therapeutic aspects with reference to evidence-based medicine"--an overview]

Cryptococcal meningitis is one of the most frequent forms of meningoencephalitis in AIDS patients. Before the introduction of triazole antibiotics like difluconazole, the frequency of this meningitis among AIDS patients was 5-10%, yet declined during the last years. Clinically, nonspecific signs of a meningeal inflammation predominate while focal neurological signs are rare. Rapid institution of high-dose antimycotic therapy is the keystone to improve prognosis and decrease mortality. Antimycotics of choice are amphotericin B, fluconazole, and flucytosin. Diagnosis is established by detection of cryptococcal antigen in cerebrospinal fluid, microscopic demonstration of cryptococci using India-ink, and cryptococcal cultures. Recent developments aim to improve antimycotic therapies. During the last years, lifelong secondary prevention with difluconazole was established. Cryptococci which are resistant against fluconazole and amphotericin B are a special challenge, yet fortunately are rare. Longterm outcome of patients is determined by the progression of the underlying immunosuppression. Therefore, combination of secondary prophylaxis with modern antiviral substances is important. Clinical decision analysis in patients with suspected cryptococcal meningitis is presented using methods from evidence-based medicine.

[Commitment and treatment of psychiatric patients in Great Britain and Germany. Comparison of legal principles and medical practice]

PURPOSE AND METHODS

The legal provisions concerning the admission to hospital, holding powers and compulsory treatment of mentally ill persons in Great Britain and Germany are compared and the underlying medicolegal conceptions analysed.

RESULTS

Whereas British law gives key powers to multiprofessional decision making and relatives, German law requests formal court decisions even in routine issues. This reflects a different understanding of individual rights and their protection. The German mental health law is motivated by the experiences of the totalitarian National Socialist regime. It tries to protect the patient's rights by restricting physicians, hospitals and family members' influence. British law, on the other hand, assumes that experts as well as family members act benevolently in the patient's interest, prefers less formal mechanisms and expresses trust in professional ethics.

CONCLUSION

Further research is necessary to analyse the situations in other countries and to investigate which of these approaches is the better one from the point of view of the mentally ill. This is even more important as in the long view European integration will touch these questions and will result in convergence of medicolegal issues.

Cycling S-phase cells in animal and spontaneous tumours. I. Comparison of the BrdUrd and 3H-thymidine techniques and flow cytometry for the estimation of S-phase frequency

Evaluation of the proliferative activities of cell populations has mainly been restricted to the use of autoradiography and flow cytometric measurements. The introduction of a new BrdUrd specific antibody makes it possible to determine exactly the DNA synthesizing cells. The BrdUrd technique is safe with respect to handling and the results are obtained within five hours. The suitability of the BrdUrd labelling procedure has been studied in different cell lines and compared with 3H-thymidine autoradiography and flow cytometry.