[Involuntary patient admission and treatment against patient's will by emergency physicians]

INTRODUCTION

The treatment of acutely ill patients who presumably lack the insight or judgement to determine their need for medical treatment, is a difficult challenge for emergency physicians. We have carried out a study to assess the frequency and relevance of involuntary treatment and procedures in medical emergency services.

METHODS

Retrospective chart analysis for a 1-year period was performed for all treatment protocols of a medical emergency service unit and for all court-ordered treatments of a guardianship court. Cases of involuntary treatment by emergency physicians were identified and analysed.

RESULTS

In 10.4% of all emergency calls analysed a relevant and acute psychiatric condition was found. In 0.3% of the cases or 4.8% of the psychiatric cases, involuntary inpatient commitment was chosen by the emergency physician.

DISCUSSION

Involuntary inpatient commitment by emergency physicians was only necessary in relatively few cases. Nevertheless, in order to be able to correctly consider treatment and management options, emergency physicians should be aware of the basic conditions for treatment without a patient's consent.

A rare but life-threatening complication of ventriculo-atrial shunt

Insertion of ventriculoperitoneal and ventriculoatrial shunts is routinely performed. Infarction pneumonia and atrial thrombus formation are described as very rare complications of ventriculoatrial shunts. We present the case of a female patient with ventriculoatrial shunt insertion as long term treatment for aequeductal stenosis who presented with recurrent episodes of dyspnoea, chest pain, and unilateral pleural effusion. Diagnostic evaluation revealed a positive D-dimer test, bilateral basal infiltrates and pleural effusion. Transesophageal echocardiography established the diagnosis of a thrombus in the right atrium. Laboratory testing for thrombophilia revealed a homozygous factor V Leiden mutation. In the following, a shunt revision was performed.

TNFA promoter polymorphisms and narcolepsy

Narcolepsy is a debilitating sleep disorder that affects up to 0.05% of individuals in Caucasian populations. It is highly associated with the HLA-DR2 group antigen or the HLA-DRB1*1501-DQB1*0602 haplotype, respectively. However, the HLA association by itself cannot sufficiently explain the increased risk to family members, as HLA-DR2 is quite common in the general population and most people harboring the respective genotype do not develop any symptoms of narcolepsy. Situated in the HLA class II region, the TNFA gene is translated into the pro-inflammatory cytokine TNF-alpha. TNFA promoter polymorphisms have been linked to several inflammatory and autoimmune diseases. We analyzed three SNP of the TNFA promoter and one adjacent microsatellite in 103 patients and 96 controls. The T-allele of the C-857T polymorphism was strongly associated with narcolepsy in the subgroup of DRB1*15/16 (HLA-DR2 type) negative patients, but not in DRB1*15/16 positive patients. These results point towards an etiological influence of TNFA alleles in narcolepsy and support previous findings suggesting genetic heterogeneity and differences in pathophysiological characteristics of HLA-DR2 positive and negative narcolepsy.

Chemokines in the cerebrospinal fluid of patients with meningitis

Meningitis is accompanied by a differential immigration of leukocytes into the subarachnoid space. Since the mechanisms regulating leukocyte invasion are still incompletely understood, we studied the release of the neutrophil-attracting alpha-chemokines IL-8 and GRO-alpha and the mononuclear cell-attracting beta-chemokines MCP-1, MIP-1alpha, and RANTES during meningitis. In 48 paired CSF and serum samples from patients hospitalized for meningitic symptoms, high levels of IL-8, GRO-alpha, and MCP-1 were detected in the CSF during bacterial and abacterial meningitis. Elevated chemokine levels were not found in the blood serum samples taken in parallel. The release of MIP-1alpha or RANTES was below detection limits. The IL-8 and GRO-alpha levels significantly correlated with the number of immigrated granulocytes in the CSF of patients with bacterial meningitis. A similar correlation was found when MCP-1 levels and the mononuclear cell count were analyzed in abacterial meningitis. These findings suggest that the local production of the alpha-chemokines IL-8 and GRO-alpha and of the beta-chemokine MCP-1 represents the major chemoattractant stimulus for the differential recruitment of leukocytes into the subarachnoid space during meningitis.