Liver failure after Hydroxycut™ use in a patient with undiagnosed hereditary coproporphyria

We report the case of a young male presenting with cholestatic liver failure. After an extensive workup, the etiology of the liver failure was determined to be due to hereditary coprophorphyria (HCP). The inciting event was the use of Hydroxycut™, an over-the-counter supplement to promote weight loss that has been reported to cause oxidative liver injury in vulnerable populations. Although HCP is a rare cause of cholestatic liver failure, it is treatable if diagnosed correctly and in a timely manner. In this clinical vignette, we discuss a case that highlights the genetic susceptibility to disease that can be unmasked by environmental exposures. We also review the relevant literature on Hydroxycut™ and how it can affect hepatic function.

Protection of persons with mental disorders from research risk: a response to the report of the National Bioethics Advisory Commission

For the last several years, the National Bioethics Advisory Commission (NBAC) has considered several complex issues relating to biomedical research. Prominent among these considerations has been the protection of the rights and welfare of human research subjects, and the NBAC recently submitted to the president a report entitled Research Involving Persons With Mental Disorders That May Affect Decisionmaking Capacity. The importance of careful protection of vulnerable populations from undue or inappropriate risk in human subject research cannot be overemphasized, and the NBAC report includes recommendations that would strengthen such protection. However, the creation of workable mechanisms that allow appropriate risk-benefit judgments and that preserve respect for the autonomy of participating research subjects is challenging indeed. We believe that the NBAC has developed recommendations that strengthen protections for individual research participants. However, several key elements of the report are stigmatizing to persons with psychiatric disorders, and they could, if adopted as new federal regulations, inappropriately impede critical categories of psychiatric research.

Uninformed decisionmaking. The case of surrogate research consent

A New York court recently struck down state Office of Mental Health regulations governing research involving subjects with impaired decisionmaking capacity. The court held that neither incapacitated adults nor minors could participate in any research protocol that contained a nontherapeutic element, irrespective of possible benefits to the subject or the importance of the knowledge to be gained. Although the decision rested on a technical point of law and dealt only with psychiatric research, the court's holding has significantly broader implications.

HIV and the mentally ill: an approach to the legal issues

The epidemic of human immunodeficiency virus (HIV) requires mental health clinicians to make many decisions that present legal dilemmas, yet few clear rules of law exist that address HIV antibody testing, confidentiality of information about patients' HIV status, clinicians' duty to protect third parties, and discrimination against HIV-infected individuals in psychiatric settings. The author recommends a balance between the legal interests of infected and uninfected persons in addressing these issues. HIV antibody testing or disclosure of information about an individual's HIV status without informed consent should be strictly limited and done only when clinically necessary. Nondiscriminatory treatment for HIV-infected patients and protection of uninfected persons is best approached by use of universal infection control procedures and individualized clinical judgment.