On the Criminal Culpability of Successful and Unsuccessful Psychopaths

The psychological literature now differentiates between two types of psychopath: successful (with little or no criminal record) and unsuccessful (with a criminal record). Recent research indicates that earlier findings of reduced autonomic activity, reduced prefrontal grey matter, and compromised executive activity may only be true of unsuccessful psychopaths. In contrast, successful psychopaths actually show autonomic and executive function that exceeds that of normals, while having no difference in prefrontal volume from normals. We argue that many successful psychopaths are legally responsible for their actions, as they have the executive capacity to choose not to harm (and thus are legally rational). However, many unsuccessful psychopaths have a lack of executive function that should at least partially excuse them from criminal culpability. Although a successful psychopath's increased executive function may occur in conflict with, rather than in consonance with their increased autonomic activity—producing a cognitive style characterized by selfdeception and articulate-sounding, but unsound reasoning—they may be capable of recognizing and correcting their lack of autonomic data, and thus can be held responsible.     

Surgical education at Weill Bugando Medical Centre: supplementing surgical training and investing in local health care providers

Global surgery initiatives increasingly are focused on strengthening education and local health care systems to build surgical capacity. The goal of this education project was to support local health care providers in augmenting the surgical curriculum at a new medical school, thus promoting long-term local goals and involvement. Working with local surgeons, residents, and medical and assistant medical officer students, we identified the most common surgical conditions presenting to Weill Bugando Medical Centre in Mwanza, Tanzania, and the areas of greatest need in surgical education. We developed an 8-week teaching schedule for undergraduate students and an electronic database of clinical surgery topics. In addition, we started teaching basic surgical skills in the operating theatre, bridging to an official and recurring workshop through a supporting international surgery organization. The medical and assistant medical officer students reported increased satisfaction with their clinical surgery rotations and mastery of key educational subjects. The initiation of an Essential Surgical Skills workshop through the Canadian Network for International Surgery showed students had improved comfort with basic surgical techniques. Short-term surgical missions may appear to fill a void in the shortage of health care in the developing world. However, we conclude that global health resources are more appropriately used through projects giving ownership to local providers and promoting education as a foundation of development. This results in better coordination among local and visiting providers and greater impact on education and long-term growth of health care capacity.Les initiatives internationales en ce qui concerne la chirurgie sont de plus en plus axées sur le renforcement des programmes de formation et des systèmes de soins de santé locaux pour consolider les capacités dans ce domaine. L’objectif de ce projet éducatif était d’aider les professionnels de la santé locaux à enrichir le programme de chirurgie d’une nouvelle faculté de médecine et de favoriser ainsi l’atteinte des objectifs et une meilleure participation à long terme à l’échelle locale. En travaillant avec des chirurgiens, des résidents, des étudiants en médecine et de futurs aides-médecins locaux, nous avons recensé les chirurgies les plus fréquentes au Centre médical Weill Bugando à Mwanza à la Tanzanie, et les domaines de la chirurgie où les besoins de formation sont les plus grands. Nous avons mis sur pied un calendrier d’enseignement échelonné sur 8 semaines pour les étudiants et une base de données électronique sur les différents types de chirurgie clinique. Nous avons également commencé à enseigner les techniques chirurgicales de base au bloc opératoire, en parallèle avec un atelier officiel récurrent, grâce au soutien d’une association internationale de chirurgie. Les étudiants en médecine et les futurs aides-médecins se sont dits plus satisfaits de leur stage de chirurgie clinique et de leur maîtrise des principaux enjeux didactiques. Le lancement d’un atelier sur les compétences chirurgicales de base, rendu possible grâce au Réseau canadien pour la chirurgie internationale, a montré que les étudiants se sentent plus à l’aise avec les techniques chirurgicales de base. Les missions chirurgicales de courte durée peuvent sembler combler une lacune dans les pays en développement où les soins de santé sont insuffisants. Toutefois, nous concluons que les ressources en santé internationale sont utilisées de manière plus appropriée dans le cadre de projets qui responsabilisent les fournisseurs de soins locaux et favorisent leur formation comme base du développement. Cela donne lieu à une meilleure coordination entre les professionnels locaux et les coopérants et exerce un impact plus grand sur la formation et la croissance des capacités en matière de soins de santé à long terme.International volunteerism has a long-standing history among surgeons, particularly those with academic affiliations and relationships with departments of global health. With growing recognition of World Health Organization (WHO) projections that surgical diseases will represent a substantial global health burden by 2030,¹ and with current data showing that 90% of deaths from injuries occur in developing countries,² this interest in surgical volunteerism has increased steadily in recent years.³Many attempts to ameliorate the disparities in worldwide surgical care have been focused on short-term medical missions. However, these missions arguably undermine the local health care systems and disrupt relationships among physicians and their patients.⁴ This mode of service delivery is unsustainable, perpetuating a cycle of externally imposed and often uncoordinated “solutions” that fail to offer systematic education and infrastructural development based on local goals.In an effort to develop a sustainable global surgery relationship that will provide long-term support and engender self-reliance among local surgeons, Weill Cornell Medical College has established a relationship with the newly founded Weill Bugando University College of Health Sciences (Weill BUCHS) in Mwanza, Tanzania. Working with both Weill BUCHS and the existing Bugando Medical Centre (BMC), the project involves assisting with improving and organizing the existing surgical curriculum for undergraduate medical students, emphasizing scheduled bedside teaching, and providing training in basic surgical procedures and surgical subspecialty techniques for residents and attending surgeons in neurosurgery. It also includes the addition of the Canadian Network for International Surgery (CNIS) Essential Surgical Skills (ESS) workshop for all final-year medical students, which aims to improve student skills on a defined set of basic surgical procedures.Unlike other missions or surgical electives in which Western surgeons travel for brief periods of time to developing countries with the purpose of performing large volumes of surgical cases, the emphasis of involvement with Weill BUCHS is to assist in the training and education of physicians to create independent and sustainable medical care. Weill Cornell has worked with Weill BUCHS surgeons to provide instruction on didactic topics and basic surgical skills and to schedule recurring visits by Weill Cornell surgical faculty and residents for teaching purposes.This development of Weill BUCHS grew from recognition that Tanzania suffers from a dearth of physicians, with only 0.1 physicians per 10 000 population — one of the lowest physician:patient ratios in the world.⁵ In addition, the health work force in Tanzania is unevenly distributed, with only one-third of doctors practising in the rural areas where three-quarters of the population resides.     

Pharmaceutical Industry Gifts to Physicians: Patient Beliefs and Trust in Physicians and the Health Care System

BACKGROUND  

Pharmaceutical industry gifts to physicians are common and influence physician behavior. Little is known about patient beliefs about the prevalence of these gifts and how these beliefs may influence trust in physicians and the health care system.     

A Randomized Trial of Dietary Sodium Restriction in CKD

There is a paucity of quality evidence regarding the effects of sodium restriction in patients with CKD, particularly in patients with pre-end stage CKD, where controlling modifiable risk factors may be especially important for delaying CKD progression and cardiovascular events. We conducted a double-blind placebo-controlled randomized crossover trial assessing the effects of high versus low sodium intake on ambulatory BP, 24-hour protein and albumin excretion, fluid status (body composition monitor), renin and aldosterone levels, and arterial stiffness (pulse wave velocity and augmentation index) in 20 adult patients with hypertensive stage 3–4 CKD as phase 1 of the LowSALT CKD study. Overall, salt restriction resulted in statistically significant and clinically important reductions in BP (mean reduction of systolic/diastolic BP, 10/4 mm Hg; 95% confidence interval, 5 to 15 /1 to 6 mm Hg), extracellular fluid volume, albuminuria, and proteinuria in patients with moderate-to-severe CKD. The magnitude of change was more pronounced than the magnitude reported in patients without CKD, suggesting that patients with CKD are particularly salt sensitive. Although studies with longer intervention times and larger sample sizes are needed to confirm these benefits, this study indicates that sodium restriction should be emphasized in the management of patients with CKD as a means to reduce cardiovascular risk and risk for CKD progression.Cardiovascular disease (CVD) is the leading cause of premature mortality in the CKD population.^1,2 CVD risk increases with only mild kidney impairment (estimated GFR [eGFR] <60 ml/min per 1.73 m²) and further escalates as CKD progresses,³ making early intervention to reduce CVD risk of utmost importance.⁴Dietary sodium intake shows great promise as a modifiable risk factor for reducing the risks of cardiovascular disease and CKD progression.^5,6 Extensive research has demonstrated the effect of sodium intake on fluid overload and hypertension,^7,8 which are predictors of cardiac and vascular remodeling.⁹ Trials in sodium restriction recently showed significant reductions in proteinuria and albuminuria,^7,10,11 which are strong predictors of CKD progression and CVD events.¹² In addition, excessive sodium intake is thought to have direct toxic effects on blood vessels through mediating factors such as oxidative stress, inflammation, endothelial cell dysfunction, and vascular stiffness.^13–15The available evidence detailing the effects of sodium restriction in CKD patients is of poor quality, lacks randomization,^16–18 a control group,¹⁷ or blinding,^10,11 or does not use gold-standard measurement techniques (e.g., using clinic instead of ambulatory BP).^10,11 Furthermore, several studies failed to either evaluate or adjust for the influence of key confounding factors, such as potassium intake or body weight,^{10,11,19–22} thereby making it difficult to assess whether the observed results can be solely attributed to dietary sodium.The aim of this double-blind placebo-controlled randomized crossover study was to evaluate the effects of dietary sodium intake on BP, proteinuria, extracellular fluid volume, and arterial stiffness as markers of risks of cardiovascular and CKD progression. We hypothesized that a low sodium intake would decrease 24-hour BP, fluid volume, and 24-hour urinary protein and albumin compared with high sodium intake in patients with moderate-to-severe CKD.     

Longitudinal study of levodopa in Parkinson's disease: Effects of the advanced disease phase

Thirty‐four patients have been studied from the time of initiation of pharmacological treatment in a long‐term prospective study of levodopa effects and disease progression in Parkinson's disease. Objective motor scoring of the response to levodopa in defined off states was performed every 3 years. The mean time from the initiation of levodopa treatment to the most recent measurements was 18.2 years. Of 8 patients who are still alive, only 3 had none of the features of the advanced disease phase (dementia, hallucinations, frequent falling). Off‐phase motor function worsened at a yearly rate of 1.9% of the maximum disability score, although the plots of the serial scores showed that the magnitude of the levodopa response is well preserved. There was little difference in the rate of progression between patients with tremor‐dominant and non‐tremor‐dominant motor subtypes. Those who developed dementia had more rapid deterioration of motor scores, with significantly worse off‐phase (P = .008) and on‐phase (P = .03) motor function. A graph of serial scores of patients who have died, aligned for time of death, showed an upward curving trend of motor disability in the last 5 years of the disease course. Its advanced phase may reveal that Parkinson's disease has an exponential pattern of progression. © 2013 Movement Disorder Society     

Ten years of enhancing neuro-imaging genetics through meta-analysis: An overview from the ENIGMA Genetics Working Group

Here we review the motivation for creating the enhancing neuroimaging genetics through meta-analysis (ENIGMA) Consortium and the genetic analyses undertaken by the consortium so far. We discuss the methodological challenges, findings, and future directions of the genetics working group. A major goal of the working group is tackling the reproducibility crisis affecting “candidate gene” and genome-wide association analyses in neuroimaging. To address this, we developed harmonized analytic methods, and support their use in coordinated analyses across sites worldwide, which also makes it possible to understand heterogeneity in results across sites. These efforts have resulted in the identification of hundreds of common genomic loci robustly associated with brain structure. We have found both pleiotropic and specific genetic effects associated with brain structures, as well as genetic correlations with psychiatric and neurological diseases.