The dangerous psychiatric patient. Part III: Long-term treatment and management and responsibility considerations

Physicians from various medical specialties have the opportunity to encounter once in a while a dangerous psychiatric patient, an encounter which in many cases generates confusion and embarrassment. An attempt is made to identify the typical characteristics of such a patient, and to give some practical guidance to the physician 'in the field'. A number of examples of management of dangerous or even violent patients is presented. The objective of this contribution is to increase awareness of this issue, even among non-psychiatric medical personnel. Part III deals with long-term treatment and management of dangerous psychiatric patients and responsibility issues.     

The dangerous psychiatric patient. Part I: Epidemiology, etiology, prediction

Physicians from various medical specialties have the opportunity to encounter once in a while a dangerous psychiatric patient, an encounter which in many cases generates confusion and embarrassment. An attempt is made to identify the typical characteristics of such a patient and to give some practical guidance to the physician "in the field'. A number of examples of the management of dangerous or even violent patients is presented. The objective of this contribution is to increase awareness of this issue, even among non-psychiatric medical personnel. Part I deals with epidemiology, etiology and prediction of dangerousness.     

Short-term immobilization after eccentric exercise. Part II: creatine kinase and myoglobin

PURPOSE: Although creatine kinase (CK) is commonly used as a marker of muscle damage, there is large variability in the response to exercise. We previously found short-term immobilization blunted the rise in plasma CK after eccentric exercise, suggesting subsequent movement of damaged muscle may contribute to variability. We hypothesized that immobilization decreases lymphatic transport of CK from damaged muscle, blunting the CK response. In this study, we compared changes in plasma CK and myoglobin (Mb), as Mb is released from damaged muscle directly into the bloodstream whereas CK is released first into the lymph. METHODS: Twenty-five college-age males were matched according to force loss after 50 maximal eccentric contractions of the elbow flexors and placed into an immobilization (IMM, N = 12) or control (CON, N = 13) group. IMM had their arm immobilized at 90 degrees and secured in a sling for 4 d (treatment). Venipuncture was performed during baseline, treatment, and for 5 d after treatment (recovery) to assess plasma CK activity and Mb. Urine specific gravity (USG) and muscle activity (ACT) were assessed. RESULTS: Immobilization significantly blunted increases in CK activity (IMM: 955 +/- 316 IU.L-1 vs CON: 2884 +/- 1083 IU.L-1; P < 0.05) but not increases in Mb (IMM: 712 +/- 278 ng.mL-1 vs CON: 891 +/- 253 ng.mL-1; P > 0.05). There were no differences in USG between groups over time (P > 0.05) and no group differences in ACT (P > 0.05). CONCLUSIONS: Short-term immobilization after eccentric exercise blunted the CK response but not the Mb response, suggesting lymphatic transport of CK may be responsible. Because hydration status and muscular activity after exercise were not different between groups, the blunted CK response was likely due to inactivation of CK activity before entering circulation.     

Detecting the dangerous, violent or criminal patient: an analysis of referrals to maximum security psychiatric care

Britain's high security hospitals provide care for mentally disordered patients who have dangerous, violent or criminal propensities. The State Hospital, Carstairs, takes referrals from the population of Scotland and Northern Ireland. This retrospective case-control study describes the sociodemographic and clinical characteristics of referrals (n=149) to the State Hospital during a 12-month period, and delineates differences between admitted (n=57) and rejected (n=92) patients. The referrals had an average age of 31.1 years, and were mostly male (86.6%), single (64.4%) and unemployed (90.6%). Admitted patients were more likely to have a criminal history, to be psychotic, to have a family history of mental disorder and to be viewed by the assessor as having psychotic beliefs which contributed to the behaviour or alleged offence leading to the referral. Rejected patients were more likely to have been remanded to prison or assessed by specialist registrars. Patients admitted to high security psychiatric care are more likely to show dangerous behaviour secondary to psychosis. These findings are in keeping with the requirements of mental health legislation and the admissions policy.     

The Chiari II malformation: Part IV. The hindbrain deformity

Summary Computed tomography successfully delineates the multiple components of the Chiari II malformation at the craniocervical junction, the hindbrain, and the cervical spinal cord. These include wide foramen magnum and upper cervical spinal canal; incomplete fusions of the posterior arches of C1 and lower cervical vertebrae; cascading protrusions of vermis, fourth ventricle, medulla, and cervical cord into the spinal canal; cervicomedullary kinking; anterior displacement and sequential sagittal compression of each protrusion by the protrusions posterior to it; compression of all protrusions by the posterior lip of foramen magnum and the posterior arch of C1; and associated cervical hydromyelia, cervical diastematomyelia, and cervical arachnoid cysts.Presented in part at the CT '82, International Computer Tomography Symposium, Seefeld/Tirol, Austria, 28–30 January 1982; and presented in nearly complete form at the 10th Annual Meeting of the International Society for Paediatric Neurosurgery, Philadelphia, Pennsylvania, USA, 12–15 September 1982     

Surgical treatment for early osteoarthritis. Part II: allografts and concurrent procedures

Young patients with early osteoarthritis (OA) represent a challenging population due to a combination of high functional demands and limited treatment options. Conservative measures such as injection and physical therapy can provide short-term pain relief but are only palliative in nature. Joint replacement, a successful procedure in the older population, is controversial in younger patients, who are less satisfied and experience higher failure rates. Therefore, while traditionally not indicated for the treatment of OA, cartilage repair has become a focus of increased interest due to its potential to provide pain relief and alter the progression of degenerative disease, with the hope of delaying or obviating the need for joint replacement. The field of cartilage repair is seeing the rapid development of new technologies that promise greater ease of application, less demanding rehabilitation and better outcomes. Concurrent procedures such as meniscal transplantation and osteotomy, however, remain of crucial importance to provide a normalized biomechanical environment for these new technologies. LEVEL OF EVIDENCE: Systematic review, Level II.     

CT of pancreatic neoplasms Part II: The unusual tumors

The pancreas gives rise to a remarkable variety of neoplasms other than ductal adenocarcinoma. Although no individual type of tumor in this category is prevalent enough to qualify as common, most types are currently encountered with a frequency far greater than that in decades of the recent past. This change is largely the result of the expanded use of contemporary abdominal imaging. The unusual tumors of the pancreas vary greatly in their biologic behavior and, accordingly, in their clinical consequences and therapeutic requirements. Accurate diagnosis, therefore, can be of considerable clinical relevance. Not only is it worthwhile to distinguish one type of unusual pancreatic tumors from another, it is perhaps of even greater consequence to distinguish the unusual tumors from ordinary pancreatic adenocarcinomas. The goals of this discussion are to expand radiologic awareness of these uncommon but interesting pancreatic neoplasms and to increase familiarity with their diagnostically salient features.     

Short-term immobilization after eccentric exercise. Part I: contractile properties

PURPOSE: The purpose of this study was to examine the compound muscle action potential (M-wave) and evoked contractile properties of immobilized muscle after high-force eccentric exercise. We believed that changes in these variables would contribute to the enhanced recovery of maximal voluntary force observed after short-term immobilization of damaged muscle. We hypothesized that immobilization after eccentric exercise would result in an enhanced M-wave and a change in contractile properties toward characteristics of faster muscle fibers. METHODS: Twenty-five college-age males were matched according to force loss after 50 maximal eccentric contractions of the elbow flexors and placed into an immobilization (IMM, N = 12) or control (CON, N = 13) group. IMM had their arm immobilized at 90 degrees and secured in a sling during a 4-d treatment. Maximal isometric torque (MVC) was assessed at baseline and for 8 d after treatment. M-wave and evoked contractile properties of the muscle (twitch torque [TT], maximal rate of torque development [MRTD], time to peak torque [TPT], and one-half relaxation time [HRT]) were assessed at baseline and for the first 5 d after treatment. RESULTS: Immediately postexercise, MVC was reduced 43% and 42% in IMM and CON, respectively. Recovery of MVC was significantly greater in IMM during recovery (P < 0.05), 95% of baseline MVC compared with 83% in CON. M-wave was reduced 32%, and all contractile properties were altered immediately postexercise. M-wave, MRTD, TPT, and HRT were not significantly different between groups during recovery (P > 0.05). TT demonstrated enhanced recovery in IMM (P < 0.05). CONCLUSIONS: Short-term immobilization after eccentric exercise resulted in enhanced recovery of maximal voluntary force. However, enhanced force recovery cannot be explained by muscle activation and evoked contractile properties of the muscle.     

Trends in radiology: Part II

The major force driving radiology today is the need to contain costs and find new sources of revenue. How is the field of radiology reacting to these forces? The remaining data from the 1989 AHRA Trends Survey reported in this article includes results on competition, marketing, new programs, operations, staffing, and equipment purchase and maintenance. Comparisons from the 1985 and the 1987 Trends Surveys are also included.     

Pancreas. Part II: Tumors

Adenocarcinoma is the most common malignant pancreatic tumor, affecting the head in 60-70% of cases. By the time of diagnosis, approximately 80% of tumors are unresectable. Helical CT is very effective in detection and staging of adenocarcinoma, with a sensitivity of 76-92% for detection and an accuracy of 80-90% for staging, but it has limitations in the detection of small cancers (< or =2 cm). Multidetector CT (MDCT) has brought substantial improvements with its inherent 3D imaging capability. Mangafodipir-enhanced MRI is a problem-solving tool in the depiction of small cancers following an equivocal CT imaging result. Gadolinium-enhanced 3D gradient-echo MRI is helpful in the assessment of vascular invasion of cancer and in determining the etiology of cystic lesions. Serous cystadenoma is benign, has a lobulated contour and contains innumerable small cysts of 0.1-2 cm in diameter. Mucinous cystic neoplasms are unilocular or multilocular (fewer than six cysts), and the cyst diameter exceeds 2 cm. The presence of solid nodular components should alert the radiologist to suspect cystadenocarcinoma. Neuroendocrine tumors are mostly hypervascular. Diagnosis of insulinoma is a challenge: they are <2 cm in 90% of cases and mostly hypervascular at CT or MRI. A combination of contrast-enhanced MDCT, MRI, endosonography, and/or somatostatin receptor scintigraphy is used to detect these small tumors. This review summarizes the imaging features of the most common pancreatic tumors and discusses the limitations of CT, MRI and endosonography.     

The Meckel cave: computed tomographic study. Part I: Normal anatomy; Part II: Pathology

A semi-empirical model was used to identify specific pulse sequences that cause most lesions to appear distinctly brighter than normal tissues in magnetic resonance (MR) images of the head. Clinical trials confirm the utility of these sequences for patient screening. As a result, a strategy for effective and efficient MR imaging of the head is proposed. The previously described gray-scale model has been modified to account for the effect of image noise. By means of computer simulation, 13,800 different hypothetical cerebral lesions were imaged with a variety of pulse sequences. A number of conclusions resulted. First, two sequences are expected to be sufficient to visualize most intracranial lesions, a "diagonal" SE sequence (e.g., SE 2500/80) and an IR sequence with a short inversion time (e.g., IR 1800/200). These sequences are orthogonal, i.e., lesions missed by one are likely to be detected by the other. Second, signal averaging the screening sequences is expected to be more effective than optimized sequences when lesion tissue parameters differ little from brain. Finally, the effectiveness of unaveraged screening sequences suggests that improved signal-to-noise ratio (SNR) is not necessary for the detection of most large lesions. Therefore, the increased SNR achievable through signal averaging or increased field strength might best be utilized to improve spatial resolution so that smaller lesions can be detected.     

The mechanical properties of guidewires. Part II: Kinking resistance

The tolerated acute angle in kinking constitutes a good relative measure for kinking resistance. It is quite a constant parameter for steel wires (about 30°) and for titanium wires (about 80°). The force required to bend a wire to a specific angle depends only on the stiffness of the wire. This means that kinking resistance is also a function of stiffness.     

The pathophysiology of primary blast injury and its implications for treatment. Part II: The auditory structures and abdomen.

The authors have previously considered the mechanisms by which primary blast injury affects the respiratory and cardiovascular systems and what deductions may be made about management of the resulting injuries. This article considers the somatic effects of primary blast on abdominal and auditory structures. These injuries are usually of less immediate concern but require accurate management in order to avoid late mortality and morbidity and to return the casualty to full function. Recognition of likely injury patterns is vital to the instigation of correct management. The tympanic membrane, for instance, is easily damaged by blast and such an injury may be complicated by ossicular disruption, perilymph fistula or forceful distribution of squamous epithelium around air filled spaces with potential to form cholesteatoma. Abdominal organs can be severely disrupted by primary blast. The treatment of such injuries is not dissimilar to that of any other cause of abdominal trauma. The most challenging aspect is the identification of intestinal intramural haemorrhage and discrimination between those lesions destined for perforation or for spontaneous recovery. In this article the range and mechanism of injury are described for each system, drawing on experience from other modes of injury closely related to blast, followed by suggestions for their management established from literature reviews and experimental work undertaken by the authors during periods of full time research.