The impact of the amended Ontario Mental Health Act (Bill 7) on patients discharging themselves from hospital against medical advice (AMA): a preliminary study

Bill 7, the most recent amendment to the Ontario Mental Health Act was introduced in December 1986. It has resulted in some major changes to the practice of psychiatry, especially in provincial hospitals. We compared patients who had discharged themselves against medical advice (AMA) during the six months before the Bill was enacted, with those who discharged themselves AMA in the 12 months following. Significantly more patients discharged themselves AMA in the post- than the pre-Bill period. The majority of these were potentially treatable, acutely ill individuals with schizophrenia or affective disorder. We argue that Bill 7 has largely failed in its objective to improve the overall "quality of care" to psychiatric patients, at least in the short term.     

Der Wert der Duplexsonographie nach der orthotopen Lebertransplantation Erfahrungen an 44 Patienten

Zusammenfassung In einer prospektiven Untersuchung wurde an 44 Patienten (33 Männer, 11 Frauen) riach einer elektiven orthotopen Lebertransplantation die Duplexsonographie 196ma1 angewendet. Ziel der Untersuchung war es festzustellen, inwieweit and in welchem zeitlichen Zusammenhang sich die Parameter pulsatiler FluBindex (PFI) und Dämpfungsindex (DI) bei Komplikationen wie Abstoung und Cholangitis verändern. Der Duplex-Doppler-Ultraschall wurde im Mittel 5mal pro Patient durchgeführt. Die letzte Sonographie erfolgte am Entlassungstag. Bei den Messungen fiber der Leberarterie, der Pfortader und den Lebervenen wurden jeweils der PFI und der DI bestimmt. Die Ergebnisse der Indexuntersuchungen wurden mit dem klinischen Verlauf (Abstoung, Cholangitis) sowie mit den Resultaten von 88 Biopsiepräparaten der Lebertransplantate in Beziehung gesetzt. Bezüglich einer histologisch gesicherten AbstoBung ergab der PFI (über der Leberarterie gemessen) eine Sensitivität von 69,4 % and eine Spezifitdt von 72,2 %, der DI (über den Lebervenen gemessen) eine Sensitivität von 89,4% und eine Spezifitdt von 89,1 %. Wenn auch die einfach und beliebig oft anwendbare Untersuchungstechnik die bioptische Sicherung einer Rejektion nicht ersetzen kann, so ist sie in hohem Mae in der Lage, Indikationen zur Biopsie frühzeitig stellen zu lassen und ein Ansprechen auf eine Therapie kurzfristig und mit holier Genauigkeit anzuzeigen.

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Duplex sonography after orthotopic liver transplantation: findings in 44 patients

In a prospective study, 44 patients (11 women, 33 men) who had received orthotopic liver transplants underwent a total of 196 consecutive duplex Doppler ultrasound examinations. The aim of the study was to evaluate the correlation between the pulsatile flow index (PFI) and the damping index (DI) as far as complications as rejection or cholangitis were concerned. The patients were examined five times each on average. The PFI and DI were measured in the hepatic artery, the portal vein and the hepatic veins. The findings were compared with the clinical course (cholangitis, rejection) and the histomorphological diagnosis as determined in biopsy specimens. In biopsy-proven rejection episodes, the sensitivity of the PFI in the hepatic artery was 69.4%, the specificity 72.2%. The sensitivity of the DI in the hepatic vein was 89.4%, the specificity 89.1 %. Combining the two, specificity was more than 90%. PFI and DI in the portal vein bore no apparent relation to clinical course or histomorphological diagnosis. We found duplex Doppler ultrasound extremely beneficial in determining the timing and indication for liver biopsy. In addition, this simple examination, which can be performed as often as desired, accurately shows the transplanted liver's response to measures taken to counter rejection.

     

Characterization and prediction of IVF cycles generating “slow-cleaving” embryos

Purpose To characterize and predict cycles generating slowcleaving embryos in in vitro fertilization, 86 cycles were retrospectively divided into two groups (slow, n=41, and fast, n=45 according to whether the number of blastomeres per embryo on day 3 was or > than the mean of the distribution, respectively.Results Cycles generating slowcleaving embryos were treated with luteinizing hormonereleasing hormone agonist before ovarian stimulation for a shorter period (12.1±0.5 versus 15.6±1.1 days; P0.01) and had higher immaturity grade of oocyte-corona-cumulus complexes which resulted in embryos (1.6±0.1 vs 1.3±0.1; P0.05) when compared to cycles producing fastcleaving embryos. Both variables entered in a logistic regression model applied in order to predict the probability of a cycle generating slowcleaving embryos (goodness-of-fit chisquare=180.0, degrees of freedom (df)=80, P=0.4786. This model predicted correctly 86.7% (13 of 15) of cycles generating slowcleaving embryos and 83.3% (10 of 12) of cycles producing fastcleaving embryos when the estimated probability of a cycle producing slowcleaving embryos was 0.7 or 0.3, respectively.Conclusion Shorter treatment with hormone-releasing hormone agonist before ovarian stimulation and higher immaturity grade of oocyte-corona-cumulus complexes which result in embryos are predictive characteristics of in vitro fertilization cycles generating slow-cleaving embryos.     

Psoas muscular abscess in children

Symptoms of psoas muscular abscess in children are nonspecific and differential diagnosis is made among diseases included in childreńs acute hip pain syndrome, imaging tests being necessary for diagnostic confirmation. During the first semester of 1995, 48,550 children were examined in Pronto Socorro do Instituto da Crian?a do Hospital das Clínicas da Faculdade de Medicina da Universidade de S?o Paulo, four of them diagnosed as having psoas muscular abscess (2 females and 2 males, ages varying from 1 to 12 years). All of them had nonspecific clinical features and diagnosis was confirmed by abdominal ultrasound and/or computerized tomography. Staphylococcus aureus was isolated as the etiologic agent in 3 children, findings similar to the ones in literature.     

How do normal subjects learn a simple adaptative task: How and why do paranoid schizophrenic patients fail?

Summary The authors studied the behavior of normal subjects and paranoid schizophrenic patients in a simple problem-solving situation. The schizophrenics were divided into two sample groups, one of individuals under treatment and the other of individuals not under treatment.The learning process involved in this problem-solving situation is very similar to an instrumental conditioning, and can be understood by means of the following assumptions: (1) the subjects use decision functions in reacting to the stimuli, although they may be not fully aware of this; (2) learning is the result of successive transformations of these decisions in the course of time; (3) the changes have specific probabilities and are related to (a) those responses which are made to the latest stimuli, and (b) a differential probability for decision functions which were effective, or only interrupted painful reinforcement, or were completely ineffective.In schizophrenics further factors of importance were (1) an inertia factor and (2) the rigidly continued use of unsuccessful or only partially successful decision criteria.The authors used a systems theory based on Galois field theory and a calculus of operators specifying three groups of subjects. A computer program based on these hypotheses was tested in a simulation experiment.The statistical evaluation of the results showed a congruence between the theoretical approach and the experimental data.This work was carried out with financial support from the Institute de Alta Cultura, Lisbon, between 1970 and 1974     

Anesthetic experience with cardiac transplantation.

The anesthetic management of 17 patients undergoing cardiac transplantation is described. Recipients had severe biventricular failure and pulmonary hypertension. Careful administration of diazepam and morphine was the preferred induction method, and pancuronium was the favored relaxant for both intubation and maintenance. Sterile technique was used in placing endotracheal tubes. Relatively small doses of morphine and diazepam, combined with 50 percent nitrous oxide, were satisfactory for the maintenance of anesthesia. Postperfusion problems were few but included poor tolerance of hypovolemia and an exaggerated hypotensive response to protamine. Isoproterenol was required to support ventricular performance, but no other cardiac stimulants were needed. Postoperative courses were uneventful. There were no operative deaths and no recall of awareness during the operation with the described method of "light" anesthesia.     

Noradrenaline transport by rat heart sympathetic nerves: A re-examination of the role of sodium ions

Summary The effect of sodium ion on ³H-(–)-noradrenaline (0.0875 to 0.5 M) transport by rat heart atrial hemi-appendages incubated in vitro has been studied, and the following observations made: a) When sodium was omitted (choline and lithium substitution) there was no evidence for active noradrenaline transport, and only a component that did not show saturation kinetics up to 1 M noradrenaline, remained. b) Omission of sodium or addition of 4×10^–5 M desipramine inhibited noradrenaline transport to exactly the same extent, and their effects were not additive. Alprenolol did not reduce this sodium-independent transport, but tropolone lowered it somewhat. c) No evidence for corticosterone-sensitive noradrenaline transport (uptake-2) was found in this preparation at the low amine concentrations used. d) In control medium, the kinetic parameters of transport were: K _m: 0.59 ± 0.063 M and V _max: 2.44 ± 0.43 (pmoles/mg protein/min). With 26 mM sodium and the rest substituted by choline, K _m:2.26 ± 0.70 M (P0.001) and V _max: 2.74 ± 0.43 (pmoles/mg protein/min) (not significant). Also with 26 mM sodium, but with sucrose substitution, K _m: 0.76 ± 0.13 M (N.S.) and V _max: 1.06 ± 0.13 (pmol/mg/min) (P<0.05). Such results indicate that sodium only modifies the affinity of the transport system for noradrenaline, without changing V _max, and that changes in the latter are only a consequence of a reduction of the ionic strength. e) When noradrenaline transport was studied at different concentrations of external sodium, at constant ionic strength and with precautions to minimize the noradrenaline-releasing effect of low sodium, it was found that the data could be best represented by two hyperbolas placed in series. This suggests that the noradrenaline carrier has two sites for sodium, that do not interact with each other. When the same experiments were repeated in the absence of chloride, it was found that the noradrenaline transport system had lost virtually all its affinity for sodium. f) The effect of prolonged tissue incubation in the absence of sodium was found to produce a relatively small inactivation of noradrenaline transport. Such phenomenon was enhanced by raising the calcium concentration to 2 mM.     

The effect of growth hormone on the growth failure of chronic renal failure

To investigate the effects of growth hormone (GH) on the reversal of growth failure in uremia, recombinant human GH (rhGH) was administered to rats with chronic renal failure (CRF). The dosage of rhGH was 3 IU/day (i.p.) for 13 days after the induction of CRF by 5/6 nephrectomy. Animals were classified into four groups: untreated nephrectomized rats (NX,n=40), GH-treated nephrectomized rats (NX+GH,n=18), sham-operated rats fed ad libitum (SHAMAL,n=27), and sham-operated rats pair-fed with 10 NX rats (SHAMPF,n=10). NX and NX+GH rats developed a similar and moderate degree of CRF, serum urea nitrogen being (mean±SEM) 49±3 and 54±4 mg/dl, respectively, compared with 16±4 and 19±0 mg/dl in SHAMAL and SHAMPF groups. Weight (56.0±3.3 g) and length (3.5±0.1 cm) gains of NX rats were lower than those of SHAMAL rats (94.2±4.0 g,P<-0.0001 and 4.1±0.2 cm,P<-0.01). Growth of the SHAMPF group and the matched NX rats was not significantly different. Weight (56.2±5.0 g) and length (3.4±0.2 cm) gains of NX+GH and NX rats were similar, the beneficial effect of GH therapy on growth being observed in only those animals with more severe degrees of uremia. This growth-promoting action resulted from greater food efficiency and not from stimulated food intake. The hypercholesterolemia seen in NX rats, 81±2 mg/dl versus 55±3 mg/dl in SHAMAL (P0.0001), was not increased in the NX+GH group, 87±3 mg/dl. There was a positive and significant correlation between serum cholesterol and serum urea nitrogen values in NX and NX+GH animals. This study suggests that growth impairment of mild CRF is mainly due to malnutrition and is refractory to GH administration. GH therapy improves the growth rate of animals with advanced CRF without aggravating their lipid abnormalities.     

An assessment of fructose-1,6-bisphosphate as an antimicrobial and anti-inflammatory agent in sepsis.

Tissue lesion mechanisms provoked by sepsis include the infectious process, inflammation, and cellular energy deficit. We chose to test fructose-1,6-bisphosphate (FBP) because of its possible anti-inflammatory and antimicrobial actions. Wistar rats were used and divided into three experimental groups: a control group (n=10), in which a capsule was introduced into the peritoneum of the animals; a septic group (n=10), in which a capsule containing non-sterile fecal matter was introduced together with Escherichia coli (1.5 x 10(9)CFU); and a septic group treated with FBP 500 mg/kg (n=10). The blood cell tests revealed that levels of leukocytes increased significantly in the septic group when compared to both the septic group treated with FBP and the control group. The blood cultures were 100% positive in both the septic group and the septic group treated with bisphosphorylated sugar. The antibiogram only revealed an inhibitory halo in the case of the antibiotic ampicillin, there was no such indication for FBP. The anti-inflammatory power of FBP remained at 60% for 5 h in the rats that received the carrageenan injection. What is more, the sugar reduced the levels of ionic calcium in relation to the control group. This data proves the validity of using FBP in the treatment of sepsis, possibly due to its anti-inflammatory rather than antimicrobial action.