The treatment of adult patients with a mental disability. Part 2: Assessment of competence.

Over recent years practitioners are increasingly being asked to attend to, or to provide treatment for, adult patients with some degree of mental illness, either in their homes or in the dental surgery. Because the issue of competence and the assessment of the patient is crucial to this aspect of dental practice this second paper is devoted to an overview of that assessment process; outlining the legal tests and standards to be employed.

The treatment of adult patients with a mental disability. Part 3: The use of restraint.

Over recent years practitioners are increasingly being asked to attend to, or to provide treatment for, adult patients with some degree of mental illness, either in their homes or in the dental surgery. This final paper in the series deals with the lawful delivery of care or treatment in the face of resistance, through the use of restraint.

Mental incapacity and restraint for treatment: present law and proposals for reform.

The House of Lords in F v West Berkshire Health Authority [1989] considered the lawfulness of providing care and treatment for a mentally incapacitated adult. They did not, however, directly consider the use of restraint to enable the provision of care in the face of resistance from the patient. The law has since had good cause to give consideration to this important issue. This paper establishes the present law in the context of using restraint to deliver care. Although the legal principles established have derived from what might be considered to be "hard cases", life-and-death cases, they apply to all aspects of routine medical, dental and nursing care. Further, the paper considers the recent government proposals and the effect those proposals may have on the routine care of such patients.

The treatment of adult patients with mental disability. Part 1: Consent and duty.

Over recent years practitioners are increasingly being asked to attend to, or to provide treatment for, adult patients with some degree of mental illness, either in their homes or in the dental surgery. Demographic changes, an ageing population with increasing incidence of dementia, and the philosophy of 'care in the community' for those with long-term mental health problems will ensure that such requests will continue. Such requests present the practitioner with a number of ethical and legal problems. This series of papers looks at the legal issues that arise by reference to case scenarios in this area of 'special needs' dentistry. This first paper deals with the issue of consent, and the legal duty of care that arises on the part of the dentist when attending a patient who is unable to consent to treatment.

Teaching and assessing ethics and law in the dental curriculum.

The General Dental Council's recommendations on dental education places a new emphasis on the importance of ethics and law in the dental curriculum, stating that students should have an awareness of moral and ethical responsibilities involved in the provision of care to individual patients and to populations. The duties of care to protect a patient's life and health at all times, to respect their autonomy to make informed choices about what happens to them, and to do this fairly and without prejudice, are widely accepted as the fundamental ethical principles governing all health care. The specifics of these duties of care are detailed in Maintaining Standards: guidance to dentists on professional and personal conduct, published by the GDC.

Oligonucleotide dendrimers: synthesis and use as polylabelled DNA probes.

Oligonucleotide dendrimers were synthesized using a novel phosphoramidite synthon, tris-2,2,2-[3-(4,4'-dimethoxytrityloxy) propyloxymethyl]ethyl- N , N -diisopropylaminocyanethoxy phosphoramidite. Label, incorporated using [gamma-32P]ATP and polynucleotide kinase, was increased in proportion to the number of 5'-ends. There was a similar increase in signal when these multiply labelled oligonucleotides were used as probes to oligonucleotide arrays. A dendrimeric oligonucleotide was used successfully as a primer in the PCR. The strand bearing the dendrimer was resistant to degradation by T7 Gene 6 exonuclease making it easy to convert the double-stranded product of the PCR to a multiply-labelled, single-stranded probe.

An improved method for the synthesis of mercurated dUTP. Enzymic synthesis of Hg-labelled DNA of high molecular weight suitable for use in an image based DNA sequencing strategy.

The development of high-resolution scanning-probe microscopes has reawakened interest in the possibility of sequencing large nucleic acid molecules by direct imaging. Such an approach would be facilitated by the availability of effective methods for increasing contrast by labelling specific nucleotides, and the utility of introducing mercury atoms into complete DNA molecules through the enzymic polymerisation of mercurated pyrimidine deoxynucleoside triphosphates has been re-investigated. A simplified and improved method for the synthesis of a heat- and thiol-stable, mercurated derivative of deoxyuridine triphosphate in high yield and the incorporation of this precursor into full-length copies of a single-stranded phage M13 template are described. The DNA product has been fully characterised and the quantitative and specific replacement of thymidylic acid residues by the mercurated analogue demonstrated.

Asymptomatic carotid artery stenosis and stroke in patients undergoing cardiopulmonary bypass.

PURPOSE: This study was undertaken to assess the natural history of carotid artery stenosis in patients undergoing cardiopulmonary bypass (CPB) at a Veterans Administration Medical Center. METHODS: Between January 1989 and August 1993, all patients undergoing CPB were offered preoperative carotid artery ultrasound screening as part of an investigative protocol. Patients were monitored in-hospital for the occurrence of perioperative neurologic deficit. RESULTS: A total of 582 patients underwent carotid artery ultrasound screening. Greater than 50% stenosis or occlusion of one or both internal carotid arteries was present in 130 patients (22%), with 80% or greater stenosis or occlusion of one or both arteries present in 70 patients (12%). In-hospital stroke or death occurred in 12 (2.1%) and 36 (6.2%) patients, respectively. Of the 12 strokes, five were global and seven were hemispheric in distribution. Of the five patients who had global events, none had evidence of carotid artery stenosis. However, of the seven patients who had hemispheric events, five had significant 50% or greater stenosis or occlusion of the internal carotid artery ipsilateral to the hemispheric stroke. Therefore the presence of carotid artery stenosis or occlusion was significantly associated with hemispheric stroke (no stenosis 0.34% vs stenosis 3.8%; p = 0.0072). Furthermore, the risk of hemispheric stroke in patients with unilateral 80% to 99% stenosis, bilateral 50% to 99% stenosis, or unilateral occlusion with contralateral 50% or greater stenosis was 5.3% (4 of 75). No strokes occurred in patients with unilateral 50% to 79% stenosis (n = 52). CONCLUSIONS: It is concluded that carotid atherosclerosis is a risk factor for hemispheric stroke in patients undergoing CPB.

Management of atopic eczema in the community.

Eczema tends to be over-shadowed by asthma. Professionals often regard it as a simple skin problem which will go away. But eczema can persist for many years, and be a considerable source of distress and difficulty for both the affected child and its parents. Ann Bridgman describes ways to lessen its impact, including the wet-wrap technique.

Mixed clinicopathologic behavior of a solitary mesothelioma.

A large solitary mesothelioma was found to exhibit malignant features microscopically, but benign characteristics grossly, including a surgically curative resection. The mixed behavior of this tumor supports the evolving understanding of mesotheliomas as progeny of multipotential subserosal cells with capabilities of differentiating into several tissue types with varying degrees of anaplasia.

Spontaneous regression of squamous cell lung carcinoma with adrenal metastasis.

A 61-year-old man was found to have squamous cell carcinoma of the left hilum with metastasis to the left adrenal gland documented by needle aspiration. About two years later, the primary tumor is not detectable, and the adrenal gland is of normal size on follow-up computerized tomography. To our knowledge, this is the first documented case of spontaneous regression of squamous cell carcinoma of the lung with adrenal metastasis.

Effects of vitreous from photocoagulated eyes on retinal microvascular cells in culture: a preliminary report.

Panretinal photocoagulation was carried out in mini pigs in an attempt to elucidate the mechanisms involved in laser therapy. The effect of the vitreous from these eyes on the proliferation of retinal microvascular endothelial cells was then studied. Vitreous removed 4 days after panretinal photocoagulation had no effect on the proliferation of bovine retinal microvascular endothelial cells in basal medium but inhibited proliferation in growth medium. Control vitreous was mitogenic for the microvascular cells in basal medium but this effect was not observed in growth medium.

Intravenous infusion of prostaglandin E1 (PGE1) in management of limb ischemia.

Twenty-three patients who had advanced arteriosclerotic disease of the lower extremities as manifested by rest pain, nonhealing ischemic ulcers, or impending gangrene and who were not candidates for direct arterial revascularization procedure underwent intravenous infusion of prostaglandin E1 (PGE1). Thirty-nine per cent of the patients showed subjective and/or objective improvement in the blood supply, and in 22 per cent (5 patients) amputation was avoided. Complications were minor and disappeared once the infusion was discontinued. PGE1 in prescribed dosages can be safely infused intravenously. Even though the results are not as encouraging as when PGE1 is given by the intra-arterial route, IV therapy improves the ischemic symptoms and avoids the necessity of amputation in some patients.