Decentralization of forensic services

Decentralization of mental health services to persons in contact with the criminal justice system is essential in the application of community mental health concepts. This is feasible considering the levels of "dangerousness" of such persons, costs of the typical isolated central facility, and implications of the Supreme Court decision Jackson v. Indiana (406 U.S. 715, 1972). In Tennessee, reform began with legal review of unit records, pretrial screening in mental health centers, revision of state law, liaison with the Tennessee Board of Pardons and Paroles, and use of consultant staff. The results are positive wherever decentralization of services has been maintained.     

Health care worker opinions on use of isolation precautions in long-term care facilities

To address controversies surrounding contact isolation precautions in skilled nursing facilities (SNF), we surveyed 356 nurses and nurses' aides from 7 SNFs on their opinions regarding benefits and harms of contact isolation precautions. Whereas a majority of health care workers believed that contact isolation reduces transmission of antibiotic-resistant organisms, they were also concerned about potentially harmful consequences to the SNF residents including depression and isolation.     

The Development of a Decision Tool for the Empiric Treatment of Suspected Urinary Tract Infection in Frail Older Adults: A Delphi Consensus Procedure

Objectives

Nonspecific signs and symptoms combined with positive urinalysis results frequently trigger antibiotic therapy in frail older adults. However, there is limited evidence about which signs and symptoms indicate urinary tract infection (UTI) in this population. We aimed to find consensus among an international expert panel on which signs and symptoms, commonly attributed to UTI, should and should not lead to antibiotic prescribing in frail older adults, and to integrate these findings into a decision tool for the empiric treatment of suspected UTI in this population.

Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia

BACKGROUND: In children undergoing a unilateral inguinal herniotomy, the contralateral groin is often explored on the basis of a high incidence of patency of the processus vaginalis. The patency rate is highest in infants but there are no data on the subsequent risk of contralateral hernia development purely in this population. This was a study of the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infancy (aged less than 1 year). METHODS: All infants who underwent a unilateral inguinal herniotomy between January 1986 and December 1991 were studied retrospectively. RESULTS: One hundred and eighty-one infants (165 boys and 16 girls) were studied. Median gestational age was 37 (range 25-42) weeks and median age at operation was 87 (range 1-365) days. The herniotomy was right sided in 82.9 per cent of infants. Follow-up ranged from 5 to 10 years. A contralateral hernia/hydrocele developed in 14 infants (7.7 per cent). None of the hernias was incarcerated. Median time from operation to occurrence of the contralateral hernia was 18 (2-67) months. Gestational age, sex and the side of the hernia did not influence the incidence of contralateral hernia development. CONCLUSION: The low incidence of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.     

Continuous enteral feeding impairs gallbladder emptying in infants

OBJECTIVE: The objective was to test the hypothesis that continuous enteral feeding impairs gallbladder emptying in infants.Study design: A prospective crossover study was performed in 15 infants: (1) bolus enteral feeds were given in phase A, (2) a continuous milk feed was given for 3 days in phase B, and (3) bolus feeds were resumed in phase C. The gallbladder was studied with ultrasonography in phase A, on days 1 and 3 of phase B, and at the start and on days 2 and 4 of phase C. RESULTS: Baseline volume was 116.1 mm(3) (range, 48.1 to 374.8 mm(3)) in phase A and 293.3 mm(3) (range, 109.4 to 1134.9 mm(3)) (P <.001) after 3 days of phase B; it returned to the phase A value after 4 days of phase C. The contraction index was 65.2% (range, 40.6% to 78.2%) in phase A and 1.7% (range, 0% to 8.4%) (P <.001) after 3 days of phase B. It returned to its phase A value immediately after bolus enteral feeds were resumed in phase C. CONCLUSIONS: Continuous enteral feeding leads to an enlarged, noncontractile gallbladder in infants. Emptying is observed immediately after bolus feeds are resumed, and volume returns to baseline after 4 days. The mode of feeding has important bearings on the motility of the extrahepatic biliary tree.     

Relationships among morphine metabolism,pain and side effects during long-term treatment: an update

The two metabolites of morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), have been studied intensively in animals and humans during the past 30 years in order to elucidate their precise action and possible contribution to the desired effects and side effects seen after morphine administration. M3G and M6G are formed by morphine glucuronidation, mainly in the liver, and are excreted by the kidneys. The metabolites are found in the cerebrospinal fluid after single as well as multiple doses of morphine. M6G binds to opioid receptors, and animal studies have demonstrated that M6G may be a more potent analgesic than morphine. Results from human studies regarding the analgesic effect of M6G are not unanimous. The potency ratio between systemic M6G and morphine in humans has not been settled, but is probably lower than previously assumed. Hitherto, only a few studies have found evidence for a contributory effect of M6G to the overall effects observed after morphine administration. Several studies have demonstrated that administration of M6G is accompanied by fewer and a milder degree of opioid-like side effects than observed after morphine administration, but most of the studies have used lower doses of M6G than of morphine. M3G displays very low affinity for opioid receptors and has no analgesic activity. Animal studies have shown that M3G may antagonize the analgesic effect of morphine and M6G, but no human studies have demonstrated this. M3G has also been connected to certain neurotoxic symptoms, such as hyperalgesia, allodynia and myoclonus, which have been observed after administration of M3G or high doses of morphine in animals. The symptoms have been reported sporadically in humans treated primarily with high doses of morphine, but the role of M3G in eliciting the symptoms is not fully elucidated.