E-mail and the psychiatrist-patient relationship

E-mail correspondence between psychiatrists and patients raises numerous legal concerns with respect to the ethics of the doctor-patient relationship. Case law has shown that a doctor-patient relationship may be established in the absence of face-to-face contact. Despite this, a surprisingly high number of physicians respond to unsolicited e-mails, some even going so far as to suggest diagnoses or to offer advice. Courts may decide that a doctor-patient relationship exists where a psychiatrist has corresponded with a patient by e-mail. Psychiatrists may be faced with difficult ethics-related decisions regarding unsolicited e-mails from members of the public as well as e-mail from current patients and third parties, such as family members of patients. This article addresses relevant law and ethics guidelines and seeks to assist psychiatrists in making sound, ethical decisions about the professional use of e-mail.     

Cardiovascular autonomic control in myotonic dystrophy type 1: a correlative study with clinical and genetic data

The autonomic nervous system has been evaluated in myotonic dystrophy with contradictory results and its relationship with heart disturbances remains unclear. Twenty-three patients with myotonic dystrophy type 1 were investigated by a battery of six cardiovascular autonomic tests and power spectral analysis of heart rate variability. Although 15 patients (65%) revealed abnormal or borderline results in some tests, only one patient had a definite autonomic damage, as indicated by two or more abnormal tests. As a group, myotonic dystrophy type 1 patients showed a significant reduction of heart rate variability during deep breathing (P < 0.0001). The exclusive involvement of parasympathetic tests suggests that a mild vagal dysfunction occurs in some myotonic dystrophy type 1 patients. The results indicate that such autonomic abnormalities are not: (1) part of a peripheral neuropathy; (2) related to cytosine-thymine-guanine repeat size or breathing pattern. Power spectral analysis showed a reduction of supine low-frequency band, which is, but not exclusively, a marker of sympathetic activity. It was inversely correlated to disease duration (P < 0.04), suggesting a progression as the disease advances. A low-frequency power, recorded after standing, was significantly associated (P < 0.02) with presence of heart involvement. Our findings suggest that a mixed, especially parasympathetic, autonomic dysfunction may occur in myotonic dystrophy type 1, although it is not a major finding. It could play a role in the occurrence of cardiac abnormalities, or increase the risk of sudden cardiovascular events.     

Open-angle glaucoma: variations in the intraocular pressure after visual field examination

PURPOSE: To evaluate intraocular pressure (IOP) variations after automated visual field examination in patients with primary open-angle glaucoma and in healthy subjects. PATIENTS AND METHODS: Intraocular pressure was measured in 49 patients (94 eyes) with primary open-angle glaucoma and in 13 healthy subjects (26 eyes) before and immediately after automated visual field examination. All patients had stable IOP and were using local medication to treat glaucoma. The visual field test was performed with a Humphrey 630 VF analyzer and the Central 30-2 full-threshold program. RESULTS: Mean IOP increased significantly in glaucomatous patients immediately after automated visual field examination (P < 0.01), and returned to pretest values after 1 hour (P = 0.2). Mean IOP variation was 2.38 (range, -6-11) mm Hg. In 42 (44.68%) glaucomatous eyes, IOP increased more than 2 mm Hg, with a mean increase of 5.5 mm Hg. Elderly glaucoma patients showed a significantly higher IOP rise than younger patients. No significant IOP variation was detected in healthy subjects. CONCLUSION: Intraocular pressure varied significantly and tended to increase immediately after automated visual field examination in patients with primary open-angle glaucoma. Age seemed to contribute to these IOP changes, but other factors could be involved.     

Fetal malformations diagnosed using ultrasonography during tri-test. A retrospective study of 1633 fetuses

BACKGROUND: To find out which fetal malformations are diagnosed during the tri-test. METHODS: A total of 1633 pregnant women were enrolled in the study and underwent biochemical screening for Down s syndrome and DTN at the Outpatient Clinic for Prenatal Diagnosis of Santo Bambino Hospital in Catania between January 1997 and December 1998. Scans were performed using a TA route in all cases and mainly during the 16th week. RESULTS: 21 abnormal fetuses were diagnosed, equal to 1 out of 77 fetuses (3 cases of isolated DTN; 1 case of cyst in the posterior cranial fossa associated with complex heart malformation; 6 cases of cyst of the choroid plexus; 2 cases of bone dysplasia; 2 cases of cardiopathy; 4 cases of non-immunological fetal hydrops; 1 case of hygroma). In 8 out of 21 abnormal fetuses the tri-test was positive for DNT and SD or atypical. One case of trisomy 18 and 1 case of mosaicism were diagnosed. CONCLUSIONS: A fetal abnormality was diagnosed in one out of 77 fetuses. This finding, although it underestimates the real frequency of these anomalies (retrospective study, selected sample, non optimal period for the diagnosis of fetal malformations, non-systematic study of 4 chambers), once again underlines the importance of a careful morphological evaluation in eyery scan carried out. In our study some malformations were not diagnosed previously because this was the first scan (1 case of anencephaly), or because the abnormality was presumably not present in earlier tests (bone dysplasia at early stage of pregnancy) or because the earlier test was inadequate (2 DTN tested after the 12th week). In some cases it is also possible to diagnose images, such as transient hygromas which indicate a group of patients with a risk of chromosome pathology. Since they are transient, these lesions are only found if the test is performed at a period of pregnancy before the optimal moment for the tri-test. In personal experience the execution of biochemical screening for Down s syndrome and DTN should always be associated with a scan not only to date the pregnancy, but also because it is not infrequent to diagnose malformations.     

Challenges of Childhood TB/HIV Management in Malawi

The diagnosis and management of childhood tuberculosis (TB) are major challenges in countries such as Malawi with high incidence of TB and human immunodeficiency virus (HIV) infection. Diagnosis of TB in children often relies only on clinical features but clinical overlap with the presentation of HIV and other HIV-related lung disease is common. The tuberculin skin test (TST), the standard marker of M. tuberculosis infection in immune competent children, has poor sensitivity in HIV-infected children and is not usually available in Malawi. HIV test should be routine in children with suspected TB as it improves clinical management. HIV-infected children are at increased risk of developing active disease following TB exposure which justifies the use of isoniazid preventive therapy (IPT) once active disease has been excluded but this is difficult to implement and appropriate duration of IPT is unknown. HIV-infected children with active TB experience higher mortality and relapse rates on standard TB treatment compared to HIV-uninfected children, highlighting the need for further research to define optimal treatment regimens. HIV-infected children should also receive appropriate supportive care including cotrimoxazole prophylaxis and anti-retroviral treatment (ART) if indicated. There are concerns about concurrent use of some anti-TB drugs such as rifampicin with some ARTs.     

Variations in the resting oxygen consumption of small babies

Over 200 measurements of the resting rate of oxygen consumption using an open-circuit method were made on 15 small babies nursed in their usual clinical setting during the first month of life. There were striking and persistent variations between babies that could not be explained by postnatal age, relationship to feed, sleep, or time of day. It was not possible from clinical examination to predict which babies had the higher or lower metabolic rates, except that babies who were light-for-dates generally had higher values. Because of these variations the appropriate thermal temperature for small babies cannot be predicted from average values adjusted for body weight and postnatal age alone.     

Randomized, Evaluator-Blind, Split-Face Comparison Study of Single Cross-linked versus Double Cross-linked Hyaluronic Acid in the Treatment of Glabellar Lines

BACKGROUND At present, various hyaluronic acids are being used to rejuvenate facial skin. There is no comparative study of single cross-linked hyaluronic acid (SCHA) versus double cross-linked hyaluronic acid (DCHA). The objective of our study is to compare the effectiveness and complications of SCHA versus DCHA in the treatment of glabellar lines.
METHODS Ten female patients were enrolled in this randomized, evaluator-blind study. One side (left vs. right) of each patient's glabellar lines was treated with SCHA and the other side was treated with DCHA. Two independent blinded observers reviewed the clinical photographs at 3, 6, 9, and 12 months after the treatment and assessed for degree of improvement as well as complications.
RESULTS The two products were equally effective in producing an optimal cosmetic result, although at 6, 9, and 12 months posttreatment, a higher proportion of patients showed over 50% improvement with DCHA than with SCHA. At 12 months posttreatment, DCHA was considered superior in 70% of patients, whereas SCHA was superior in 10% of patients.
CONCLUSIONS Both SCHA and DCHA are equally effective in producing an optimal cosmetic result. DCHA provides a more durable esthetic improvement when compared to SCHA in the treatment of glabellar lines.