Individual cases: the risk,the challenge

Translating research findings in the area of risk assessment into daily practice can be problematic. The aim of this paper is to illustrate and compare how professionals from different backgrounds apply their knowledge and expertise to individual cases and clinical situations. Three case vignettes were formulated, depicting typical histories and dilemmas that might be encountered in the everyday practice of forensic psychiatry. For each case, commentaries were invited from three professionals in the field belonging to different disciplines. All respondents recognized that some degree of risk was present, an essential prerequisite to considering a plan of action as to how to reduce it. International and professional differences of emphasis and approach serve to illustrate the importance of a multidisciplinary input, perhaps especially in relation to the most seriously violent offences.     

Towards a new methodology for making sense of case material: an illustrative case involving attempted multiple murder

Functional analysis provides a method of understanding behaviour in terms of its consequences for the individual concerned. The suggestion is made here that the application of this method to past behaviour will be useful to both practitioners and researchers. It offers benefits in terms of organising case material, understanding the aetiology of the behaviour, planning interventions and predicting dangerousness. It should be noted, however, that this is not an exercise in developing causal models of specific offences. In this paper multiple sequential functional analysis methodology is described and the problems of applying it retrospectively to criminal behaviours discussed. The methodology is illustrated with the case of a man who formulated a plan to kill 20 people and was convicted of two counts of attempted murder.     

PHENAZOCINE WITH NITROUS OXIDE ANAESTHESIA

A blind trial was undertaken to compare phenazocine with pethidine.Both drugs were used to supplement nitrous oxide and oxygenanaesthesia in cases in which spontaneous respiration was possibleduring maintenance. Forty-six cases were given pethidine andforty-five cases phenazocine. There was no difference betweenthe two drugs in their ability to provide satisfactory anaesthesia,or in the degree of respiratory depression, or in the effectupon the blood pressure. Recovery of reflexes following anaesthesiawas more rapid in the phenazocine group but the results werenot statistically significant. The literature upon phenazocinewas discussed together with the results of the present trial.     

Advances in the psychological treatment of delinquent behaviour*

This paper offers an overview of behavioural and cognitive— behavioural approaches to working with young offenders. The literature is considered in terms of individualised programmes and residential and community programmes. Despite the range and numbers of these and other studies, until recently there was no clear picture of the effectiveness of treatment programmes with young offenders. The development of the statistical technique of meta-analysis, however, now allows the effective components of treatment programmes to be identified with some degree of confidence. A summary of the findings of the most recent meta-analyses is given. Finally, suggestions are offered both to identify and to overcome barriers to successful programme design and effectiveness.     

Vascular tissue adaptations in end-to-end autologous arterial grafts in rats: a morphometric analysis

Autologous vein grafts are employed extensively to bypass stenoses in the arterial circulation. More recently arterial segments have been used for such bypass surgery. In this study the adaptation of regenerating vascular tissues in experimental autologous artery grafts (4 mm long and 1 mm in diameter) in 20 adult male Wistar rats was analysed. At 1, 2, 4, 8 and 16 wk after insertion, 4 grafts per time interval were removed, processed for high resolution light microscopy and the thicknesses of the media and neointima, as well as the area fractions of smooth muscle cells, were analysed morphometrically. All grafts were reendothelialised by 2 wk. Neointimal hyperplasia (a subendothelial layer of smooth muscle cells) developed in all grafts and reached its maximal thickness (40.4±4.7 μm) at 2 wk. The area fraction of smooth muscle cells in the neointima of the artery grafts did not change significantly at any time from 2 to 16 wk. The media underlying the neointima of the artery grafts remained relatively constant throughout the 16 wk duration of the experiment. Whilst the total wall thickness of the grafts reduced significantly between 2 and 4 wk after insertion, at all times the grafts were thicker than the host artery.     

Phenytoin kinetics during pregnancy and the puerperium

Summary. During pregnancy changes in maternal physiology and plasma composition may alter drug binding and dose requirements. We have measured plasma unbound and total phenytoin, and saliva concentrations at intervals in 11 pregnant epileptics. Plasma albumin concentrations were also measured in pregnant and non-pregnant women. Saliva phenytoin correlated closely with the plasma unbound concentrations ( r = 0·98). The sa1iva:plasma (S:P) ratio, reflecting the free fraction, was variable during pregnancy but tended to increase to maximal values at delivery and return to non-pregnant values within 2–8 weeks thereafter. Plasma albumin concentrations correlated poorly with phenytoin binding. Binding in umbilical cord plasma appeared higher than that in maternal plasma and total fetal concentrations correlated closely with maternal plasma concentrations at delivery. No ill effects of phenytoin were detected in the newborn infant. During the third trimester phenytoin dose increments were necessary to maintain therapeutic concentrations. After delivery maternal saliva phenytoin concentrations rose, and dose reductions were necessary to avoid clinical symptoms of toxicity. It is therefore appropriate to monitor saliva phenytoin concentrations regularly both during pregnancy and the puerperium.     

REMISSION OF PSEUDO-SPONDYLITIS WITH TREATMENT OF WHIPPLE'S DISEASE

An HLA-B27 negative case of Whipple's Disease with ‘spondylitis’is reported in which antibiotic therapy gave sustained remissionof spondylitis as well as intestinal disease. KEY WORDS: Whipple's disease, Spondylitis, Antibiotic therapy