Patient Capacity in Mental Health Care: Legal Overview

The discriminatory effects of categorizing psychiatric patients into competent and incompetent, have urged lawyers, philosophers and health care professionals to seek a functional approach to capacity assessment. Dutch and English law have produced some guidelines concerning this issue. So far, most legal systems under investigation have concentrated on alternatives for informed consent by the patient in case of mental incapacity, notably substitute decision-making, intervention of a judge and advance directives. It is hard to judge the way in which the law may further adapt to a more functional assessment of capacity, because the nature of law shows that legal reforms usually take place only when new methods have been accepted by the field. This is not yet the case today.     

The importance of inspection in clinical cardiology: Frank's sign

The Frank''s sign (FS) is a diagonal earlobe crease running from the tragus to the edge of the auricle. In this case, we describe a 71 years‐old male patient with FS who presented to the emergency department complaining of epigastric pain. A non‐ST elevation myocardial infarction was diagnosed.     

The relationship between Rarebit perimetry and OCT‐derived retinal nerve fibre layer thickness in glaucoma

Purpose: To examine the association between measures of neuroretinal matrix integrity as determined with Rarebit perimetry and optical coherence tomography (OCT)‐derived retinal nerve fibre layer thickness. Methods: One randomly selected eye of 30 White primary open‐angle glaucoma patients (age: 60.9 ± 11.7 years; MD: ?3.2 ± 5.1 dB) and 16 healthy White individuals (age: 33.2 ± 6.4 years; MD: ?0.8 ± 0.8 dB) were included in the study. Participants underwent Rarebit perimetry testing (central field, software version 4) and an OCT fast retinal nerve fibre layer (RNFL) scan. Correlation was investigated between hemifield Rarebit scores and the corresponding RNFL values, as well as between global Rarebit scores and the respective RNFL measures. Results: Statistically significant correlations of average hit rate (HR) < 90 and mean hit rate (MHR) were detected with Max–Min and average thickness (Pearson’s r ranging from 0.393 to 0.474). Number HR < 90 showed a moderate correlation only with Max–Min (r = ?0.396, P = 0.030). Regarding the association between hemifield hit rates and the corresponding OCT thickness parameters, only inferior maximum correlated moderately with HR superior (r = 0.385, P = 0.035). A tendency was detected for the relationship of superior maximum with HR inferior (r = 0.345, P = 0.062). For the control group, no significant correlation was found for any of the global or hemifield indices and the corresponding thickness values. Conclusion: Although Rarebit perimetry is based on a physiological principle distinctly different from conventional perimetry, it provides global indicators of neuroretinal matrix integrity that correlate with some OCT‐derived RNFL thickness measures.     

Fetal stroke and cerebrovascular disease: Advances in understanding from lenticulostriate and venous imaging,alloimmune thrombocytopaenia and monochorionic twins

Fetal stroke is an important cause of cerebral palsy but is difficult to diagnose unless imaging is undertaken in pregnancies at risk because of known maternal or fetal disorders. Fetal ultrasound or magnetic resonance imaging may show haemorrhage or ischaemic lesions including multicystic encephalomalacia and focal porencephaly. Serial imaging has shown the development of malformations including schizencephaly and polymicrogyra after ischaemic and haemorrhagic stroke. Recognised causes of haemorrhagic fetal stroke include alloimmune and autoimmune thrombocytopaenia, maternal and fetal clotting disorders and trauma but these are relatively rare. It is likely that a significant proportion of periventricular and intraventricular haemorrhages are of venous origin. Recent evidence highlights the importance of arterial endothelial dysfunction, rather than thrombocytopaenia, in the intraparenchymal haemorrhage of alloimmune thrombocytopaenia. In the context of placental anastomoses, monochorionic diamniotic twins are at risk of twin twin transfusion syndrome (TTTS), or partial forms including Twin Oligohydramnios Polyhydramnios Sequence (TOPS), differences in estimated weight (selective Intrauterine growth Retardation; sIUGR), or in fetal haemoglobin (Twin Anaemia Polycythaemia Sequence; TAPS). There is a very wide range of ischaemic and haemorrhagic injury in a focal as well as a global distribution. Acute twin twin transfusion may account for intraventricular haemorrhage in recipients and periventricular leukomalacia in donors but there are additional risk factors for focal embolism and cerebrovascular disease. The recipient has circulatory overload, with effects on systemic and pulmonary circulations which probably lead to systemic and pulmonary hypertension and even right ventricular outflow tract obstruction as well as the polycythaemia which is a risk factor for thrombosis and vasculopathy. The donor is hypovolaemic and has a reticulocytosis in response to the anaemia while maternal hypertension and diabetes may influence stroke risk. Understanding of the mechanisms, including the role of vasculopathy, in well studied conditions such as alloimmune thrombocytopaenia and monochorionic diamniotic twinning may lead to reduction of the burden of antenatally sustained cerebral palsy.     

Role of visfatin, insulin-like growth factor-I and insulin in fetal growth

OBJECTIVE: IGF-I and insulin are the main regulators of intrauterine and postnatal growth. Adipose tissue secreted cytokines are implicated in intrauterine growth. The relevant function of the adipocytokine visfatin is unknown. MATERIALS AND METHODS: Serum visfatin, IGF-I and insulin levels were measured by enzyme immunoassays in 40 singleton full-term fetuses and neonates on postnatal days 1(N1) and 4 (N4). RESULTS: No significant correlations exist between visfatin and IGF-I or insulin. N1 and N4 visfatin positively correlated with customized (adjusted) birth weight centiles (r=0.511, P=0.021, and r=0.597, P=0.005, respectively). Fetal and N1 IGF-I positively correlated with customized centiles (r=0.608, P<0.001 and r=0.485, P=0.006, respectively). Fetal insulin positively correlated with customized centiles (r=0.654, P=0.021). CONCLUSIONS: Potential implication of visfatin in fetal growth is probably not mediated by IGF-I or insulin. Although a more active role cannot be excluded, visfatin may simply represent a marker of fat accumulation.     

Sexual dysfunctions: classifications and definitions

Sexual classification systems are based on precise and understandable definitions of sexual dysfunctions and are needed for investigative research, determination of diagnostic standards, and delineation of treatment strategies. The four major categories of sexual dysfunctions include disorders of sexual desire/interest, arousal, orgasm, and sexual pain. The purpose of this article is to review the major features, differences, and similarities of the six classification systems widely used in sexual medicine, including the International Classification of Diseases, the Diagnostic and Statistical Manual of Mental Disorders, the National Institute of Health Consensus Conference on Impotence, the American Foundation for Urologic Diseases, International Consensus Conference on Women's Sexual Dysfunction, and the First and Second International Consultations on Sexual Dysfunctions.     

Cavotricuspid isthmus ablation guided by force‐time integral – A randomized study

BackgroundForce‐time integral (FTI) is an ablation marker of lesion quality and transmurality. A target FTI of 400 gram‐seconds (gs) has been shown to improve durability of pulmonary vein isolation, following atrial fibrillation ablation. However, relevant targets for cavotricuspid isthmus (CTI) ablation are lacking.HypothesisWe sought to investigate whether CTI ablation with 600 gs FTI lesions is associated with reduced rate of transisthmus conduction recovery compared to 400 gs lesions.MethodsFifty patients with CTI‐dependent flutter were randomized to ablation using 400 gs (FTI400 group, n = 26) or 600 gs FTI lesions (FTI600 group, n = 24). The study endpoint was spontaneous or adenosine‐mediated recovery of transisthmus conduction, after a 20‐min waiting period.ResultsThe study endpoint occurred in five patients (19.2%) in group FTI400 and in four patients (16.7%) in group FTI600, p = .81. First‐pass CTI block was similar in both groups (50% in FTI400 vs. 54.2% in FTI600, p = .77). There were no differences in the total number of lesions, total ablation time, procedure time and fluoroscopy duration between the two groups. There were no major complications in any group. In the total population, patients not achieving first‐pass CTI block had significantly higher rate of acute CTI conduction recovery, compared to those with first‐pass block (29.2% vs. 7.7% respectively, p = .048).ConclusionsCTI ablation using 600 gs FTI lesions is not associated with reduced spontaneous or adenosine‐mediated recurrence of transisthmus conduction, compared to 400 gs lesions.