Sexual offenses and traumatic brain injury.

A sample of 476 male sexual offenders, seen at a university psychiatric hospital for forensic assessment, was examined for the incidence of traumatic head injuries. A total of 49.3% had sustained head injuries that led to unconsciousness and of these 22.5% sustained significant neurological insults. A major causative factor was motor vehicle accidents, but lifestyle variables including alcohol and drug abuse and history of violence also contributed. The brain-injured group was convicted for a wide range of sexual offenses and was comparable to the non-injured group in this respect, but tended more often to offend against adults than against children and to show somewhat more exhibiting and polymorphous sexual behavior. In spite of the serious legal implications for these men and the additional distress to their families, psychologists, psychiatrists, and the professional literature have been relatively silent on the subject which calls for more attention to sexual behavior as part of assessments and treatment planning.

A study of clerics who commit sexual offenses: are they different from other sex offenders?

OBJECTIVE: The goal of this study was to determine if cleric-sex offenders differed significantly from other sex offenders when compared to a control group and assessed with standard instruments that examine the major factors important in sexual offenses. METHOD: Twenty-four male clerics accused of sexual offenses were compared to 24 male sex offender controls, matched on offense type, age, education, and marital status. Both groups were compared to a general sample of sex offenders (n = 2125) matched only for offense type. The three groups were compared on sexual history and preference, substance abuse, mental illness and personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities, using reliable and valid measures. RESULTS: The clerics in this study formed a statistically significant highly educated, older, and predominantly single subgroup of sex offenders. The majority of cleric-sex offenders suffered from a sexual disorder (70.8%), predominantly homosexual pedophilia, as measured by phallometric testing, but did not differ from the control groups in this respect. The clerics were comparable to the other two groups in most respects, but tended to show less antisocial personality disorders and somewhat more endocrine disorders. The most noteworthy features differentiating the clerics from highly educated matched controls were that clerics had a longer delay before criminal charges were laid, or lacked criminal charges altogether, and they tended to use force more often in their offenses. CONCLUSIONS: In spite of differences in age, education, and occupation between cleric-sex offenders and sex offenders in general, the same procedures should be used in the assessment of this group as for the sex offender population in general. Hypotheses about reduced sexual outlet and increased sexual abuse of clerics in childhood were not supported. Assessment and treatment of cleric-sex offenders should focus especially on sexual deviance, substance abuse, and endocrine disorders.

Physicians who commit sexual offences: are they different from other sex offenders?

OBJECTIVE: To determine if physician sex offenders differ significantly from other sex offenders by using a control group and assessing both groups with reliable and valid instruments. METHOD: Nineteen male physician sex offenders were compared with 19 male sex offender control subjects, matched on offence type, age, education, and marital status. Both groups were compared with a general sample of sex offenders (n = 2125). The 3 groups were compared on sexual history and preference, substance abuse, mental illness, personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities. RESULTS: Physicians in this study were highly educated and older, forming a statistically significant subgroup of sex offenders. The majority of physician sex offenders suffered from a sexual disorder (68.4%), as did the other 2 groups. Physicians showed more neuropsychological impairment and endocrine abnormalities and less antisocial behaviour than did the general sample of sex offenders but did not differ from the matched control group. Physician offenders who sexually assaulted their patients did not differ from those who had nonpatient victims. CONCLUSIONS: Despite differences in age, education, and occupation between physician sex offenders and sex offenders in general, the same assessment procedures can be recommended for examining both groups. Although the sample size is small, results suggest that physicians who commit sexual offences should be scrutinized by phallometric assessment of sexual deviance and especially for neurological and endocrine abnormalities.

Temporal horn enlargement is present in schizophrenia and bipolar disorder.

BACKGROUND: Ventricular enlargement and temporal lobe volume deficits have been demonstrated in patients with affective disorder as well as those with schizophrenia. This study compares quantitative measures of temporal lobe, hemispheric, and ventricular volumes in a group of patients with chronic schizophrenia and bipolar disorder and seeks to determine if the groups can be differentiated on the basis of measured brain abnormalities. METHODS: A series of coronal magnetic resonance imaging sections were acquired and analyzed for each of 22 patients with chronic schizophrenia, 14 patients with bipolar disorder, and 15 community volunteers. Eleven regions of interest for each brain were defined, which included temporal lobe, superior temporal gyrus, hemisphere, lateral ventricle, third ventricle, and temporal horn measures. Tissue measures were obtained by tracing, and cerebrospinal fluid measures were obtained by fluid-tissue thresholding using specialized computer software. RESULTS: Both patient groups had significantly larger temporal horn volumes in comparison with the control group both before and after correction for intracranial volume. The two patient groups did not differ from each other or controls on any other tissue or fluid measure. CONCLUSIONS: This study confirms the findings of increased temporal horn volume in patients with schizophrenia and suggests that this structural abnormality does not differentiate the structural neuropathology of schizophrenia from that of bipolar disorder.

Deficits in gray matter volume are present in schizophrenia but not bipolar disorder.

Studies using magnetic resonance (MR) imaging have provided strong evidence that patients with schizophrenia as a group have structural brain abnormalities, including enlarged ventricles and sulci as well as smaller cortical gray matter volumes. This study was undertaken to investigate whether the brain abnormalities found in schizophrenia could be distinguished from those seen in bipolar disorder. The MR scans of 23 patients with schizophrenia were compared to those of 17 healthy community volunteers and 14 patients with bipolar disorder. Images were processed using computer-based image processing techniques to generate quantitative measures of cerebrospinal fluid (CSF), gray matter and white matter volumes. Compared to the community volunteers, the schizophrenia group had larger total CSF volumes while the bipolar group had larger ventricles. Smaller cortical gray matter volumes were found in the schizophrenia group, but not in the bipolar group. The schizophrenia group had regional deficits in gray matter volumes in comparison with both the community volunteers and the bipolar group. These findings suggest that the brain tissue abnormalities found in schizophrenia and bipolar disorder may be distinguishable using MR imaging.

Thermoelectric technique to precisely control hyperthermic exposures of human whole blood.

The need in military research to avoid exposing humans to harsh environments and reduce animal use requires the development of in vitro models for the study of hyperthermic injury. A thermoelectric module (TEM) system was employed to heat human whole blood (HWB) in a manner similar to that experienced by heat-stroked rats. This system precisely and accurately replicated mild, moderate, and extreme heat-stress exposures. Temperature changes could be monitored without the introduction of a test sample thermistor, which reduced contamination problems. HWB with hematocrits of 45 or 50% had similar heating curves, indicating that the system compensated for differences in sample character. The unit's size permitted its containment within a standard carbon dioxide incubator to further control sample environment. These results indicate that the TEM system can precisely control temperature change in this heat stress in vitro model employing HWB. Information obtained from such a model could contribute to military preparedness.

CT-guided aspiration of suspected pancreatic infection: bacteriology and clinical outcome.

We have performed CT-guided percutaneous needle aspiration in 104 patients with severe pancreatitis strongly suspected of harboring pancreatic infection on the basis of systemic toxicity and CT findings (Balthazar CT grade D or E). Of these 104 patients, 51 (49%) were documented with pancreatic infection. Gram stain was positive in 54 of 58 infected aspirates, and culture was positive in all 58. Klebsiella, Escherichia coli, and Staphylococcus aureus were the most frequent organisms. Eighty-six percent of infected processes contained only one organism. Overall, pancreatic infection was documented by GPA within the first 2 wk in approx one-half of patients. There were no complications. The overall rate of infection decreased from 60 (1980-1987) to 34% (1988-1995) (p = 0.011). This change was caused by a reduction in the rate of infected necrosis from 67 to 32% (p = 0.015). The overall mortality rate remained at 20%. The mortality of sterile pancreatitis was not different from infected pancreatitis (p = 0.14). We conclude that GPA is a safe, accurate method of diagnosis of pancreatic infection. The rate of pancreatic infection appears to be decreasing. The overall mortality of severe pancreatitis among patients suspected of harboring pancreatic infection has remained unchanged because of the high mortality associated with both infected necrosis and severe sterile necrosis.

Clinical features and natural history of central cavitary necrosis.

Central cavitary necrosis (CCN) is an unusual complication of acute pancreatitis in which the necrosis is confined almost entirely to the pancreatic parenchyma and there is little if any extrapancreatic necrosis. In our experience with 10 patients with CCN, clinical features suggested that the episodes of acute pancreatitis were initially severe, with high Ranson scores (mean, 4.2; range, 1-6), development of systemic complications, computed tomography (CT) grade of D or E by the Balthazar-Ranson scoring system, need for intensive care unit admission in 8 of 10 patients, and mean length of hospitalization of 56 days (range, 28-153 days). However, the incidence of infection was low (20%) and mortality was also low (10%). Factors that help explain a favorable prognosis were low APACHE-II scores at admission and at 48 h, absence of shock, paucity of extrapancreatic necrosis, and rapid resolution of clinical toxicity prior to the diagnosis of CCN by CT scan at a mean of 19.8 days (range, 9-63 days) after the onset of symptoms. Surgical debridement is indicated for complications such as secondary infection and ongoing pain. In the absence of complications, an attempt should be made to treat CCN medically.

Prognostic factors in sterile pancreatic necrosis.

Although the overall mortality in sterile pancreatic necrosis is low, patients who experience systemic complications may have a higher mortality. To study the impact of systemic complications and other factors on survival, possible prognostic factors were evaluated among 26 patients who experienced at least one systemic complication. Mortality was 38%. Factors that correlated with a fatal outcome were high Ranson's scores during the first 48 hours (P = 0.01), high APACHE-II scores at admission (P = 0.04) and at 48 hours (P = 0.03), shock (P < 0.001), renal insufficiency (P < 0.05), multiple systemic complications (P < 0.001), and high body mass index (P = 0.01). Most systemic complications occurred during the first 2 weeks of illness. Logistic regression analysis showed that shock was the best predictor of a fatal outcome. Patients with favorable prognostic factors survived whether treated medically or surgically, whereas those with unfavorable factors had a fatal outcome whether treated medically or surgically. It is concluded that patients with severe sterile necrosis have a high mortality rate and that shock and other prognostic factors identify which patients are most likely to have a fatal outcome.

Human coronary and peripheral arteries: on-line three-dimensional reconstruction from two-dimensional intravascular US scans. Work in progress.

To explore the feasibility of computer-based, on-line three-dimensional reconstruction, timed manual withdrawal (pullback) recordings were obtained with two-dimensional intravascular ultrasound (US) in 42 patients who underwent percutaneous revascularization. Three-dimensional processing was performed with commercial software that stacked serially obtained intravascular US scans and created a new set of data points in four steps: interpolation, segmentation, boundary encoding, and surface rendering. In all 42 patients, satisfactory on-line three-dimensional reconstruction was accomplished. In the first three patients, 70-90 seconds was required for three-dimensional processing, and display was limited to the sagittal format. In the next six patients, a sagittal display was rendered in 45-60 seconds, and on-line reconstruction in the cylindrical format was achieved within 30 additional seconds. In the last 33 patients, an unlimited number of sagittal views could be produced in 30-40 seconds, the extra time required for cylindrical display was shortened to 15-20 seconds, and a luminal cast display was added to the on-line menu.

In vivo assessment of vascular pathology resulting from laser irradiation. Analysis of 23 patients studied by directional atherectomy immediately after laser angioplasty.

BACKGROUND: The pathological consequences of cardiovascular laser irradiation have been studied extensively in vitro. Previous in vivo studies of laser-induced injury have included analyses of acute and/or chronic findings in experimental animals. Little information, however, is available regarding the acute effects of laser irradiation of human vascular tissues in vivo. METHODS AND RESULTS: To determine the acute pathology resulting from laser irradiation of human vascular tissue in vivo, specimens retrieved from 23 patients by directional atherectomy immediately after laser angioplasty (19 peripheral and four coronary) were examined by light microscopy. Of the 23 patients, three (13.0%) were treated with a metal-capped ("hot-tip") fiber coupled to a continuous-wave neodymium:yttrium-aluminum-garnet (Nd:YAG) laser using up to 18 W power and 18-305 seconds of cumulative exposure time; in all three patients (100%), thermal injury, including frank charring several cell layers thick, was seen along the luminal borders of the atherectomy specimen. In eight of the 23 patients (34.5%), laser angioplasty was performed using a 250-microseconds holmium:YAG laser at fluences up to 2,300 mJ/mm2, a repetition rate of 5 Hz, and 25-200 seconds of cumulative exposure; in seven of eight patients (85.5%), the atherectomy specimen showed signs of vacuolar injury consisting of central and satellite Alcian-blue-negative vacuoles. In two patients (25.0%), there was a "smudged" or "shredded" edge, whereas in one patient, frank signs of thermal injury were observed. Finally, in 12 of the 23 patients (52.2%), laser angioplasty was performed using a 120-nsec excimer laser at fluences up to 60 mJ/mm2, a repetition rate of 25 Hz, and a cumulative exposure time of 21-315 seconds. Pathological findings among these 12 patients were limited to nine patients (75%) in whom a weakly basophilic, smudged, and/or shredded appearance approximately one cell layer thick was observed along the luminal border of the atherectomy specimen and two patients (16.7%) with small foci of vacuolar injury. None of the atherectomy specimens retrieved after excimer laser angioplasty disclosed signs of thermal injury. CONCLUSIONS: These findings document that acute pathological alterations resulting from in vivo laser angioplasty are variable, depending on the laser source used, and are similar to that predicted by experimental studies performed previously in vitro. The prognostic implications of these varying pathological features remain to be clarified.

Three-dimensional reconstruction of human coronary and peripheral arteries from images recorded during two-dimensional intravascular ultrasound examination.

BACKGROUND: Intravascular ultrasound provides high-resolution images of vascular lumen, plaque, and subjacent structures in the vessel wall; current instrumentation, however, limits the operator to viewing a single, tomographic, two-dimensional image at any one time. Comparative analysis of serial two-dimensional images requires repeated review of the video playback recorded during the two-dimensional examination, followed by a "mind's eye" type of imagined reconstruction. METHODS AND RESULTS: Computer-based, automated three-dimensional reconstruction was used to generate a tangible format with which to assess and compare a "stacked" series of two-dimensional images. Three-dimensional representations were prepared from sequential images obtained during intravascular ultrasound examination in 52 patients, 50 of whom were studied before and/or after percutaneous revascularization. Conventional two-dimensional ultrasound images were acquired by means of a systematic, timed pullback of the ultrasound catheter through the respective vascular segments. Images were then assembled in automated fashion to create a three-dimensional depiction of the vessel lumen and wall. Computer-enhanced three-dimensional reconstructions were generated in both sagittal and cylindrical formats. The sagittal format resulted in a longitudinal profile similar to that obtained during angiographic examination; in contrast to angiography, however, the sagittal reconstruction offered 360 degrees of limitless orthogonal views of the plaque and arterial wall as well as the vascular lumen. The cylindrical format yielded a composite view of a given vascular segment, and a hemisected version of the cylindrical reconstruction enabled en face inspection of the reconstructed luminal surface. Sagittal reconstructions facilitated analysis of dissections and plaque fractures resulting from percutaneous revascularization, and the hemisected cylindrical reconstructions enhanced analysis of endovascular prostheses. CONCLUSIONS: This preliminary experience demonstrates that computer-based three-dimensional reconstruction may further augment the use of intravascular ultrasound in assessing vascular pathology and guiding interventional therapy.

Combination balloon-ultrasound imaging catheter for percutaneous transluminal angioplasty. Validation of imaging, analysis of recoil, and identification of plaque fracture.

BACKGROUND: We investigated the hypothesis that an ultrasound transducer positioned within an angioplasty balloon could be used to perform quantitative assessment of arterial dimensions before and after percutaneous transluminal angioplasty (PTA) and to identify certain mechanical alterations consequent to PTA, including vascular wall recoil and the initiation of plaque fractures. METHODS AND RESULTS: A combination balloon-ultrasound imaging catheter (BUIC) that houses a 20-MHz ultrasound transducer within and halfway between the proximal and distal ends of an angioplasty balloon was used to perform PTA in 10 patients with peripheral vascular disease. Each PTA site was also evaluated before and after PTA by standard (nonballoon) intravascular ultrasound (IVUS) technique. In eight patients in whom satisfactory images were recorded with the BUIC before PTA, luminal cross-sectional area (XSA) of stenotic sites (0.10 +/- 0.01 cm2) did not differ significantly from measurements of XSA by IVUS (0.09 +/- 0.01 cm2, p = NS). Likewise, minimum luminal diameter (Dmin) measured by BUIC (0.34 +/- 0.02 cm) was similar to that measured by IVUS (0.33 +/- 0.01 cm, p = NS). In nine patients in whom satisfactory images were recorded with the BUIC after PTA, XSA measured by BUIC (0.29 +/- 0.03 cm2) did not differ significantly from XSA measured by IVUS (0.30 +/- 0.03 cm2, p = NS). Dmin measured by BUIC after PTA (0.57 +/- 0.02 cm) was also similar to Dmin measured by IVUS (0.57 +/- 0.03 cm, p = NS). After PTA, XSA and Dmin measured immediately after deflation were significantly less than balloon XSA and diameter at full inflation, indicating significant elastic recoil of the dilated site. For the nine patients in whom post-PTA images were satisfactory for quantitative analysis, including four patients in whom recoil was 39%, 46%, 50%, and 61%, percent recoil measured 28.6 +/- 7.2%. Finally, plaque fractures were identified on-line in six of 10 patients (60%); in each case, initiation of plaque fracture was observed at inflation pressures of 2 atm or less. CONCLUSIONS: The results of this preliminary human investigation indicate that an ultrasound transducer positioned within an angioplasty balloon can be used to perform quantitative and qualitative analyses of lumen-plaque-wall alterations immediately preceding, during, and immediately after PTA in patients with peripheral vascular disease.

Percutaneous intravascular US as adjunct to catheter-based interventions: preliminary experience in patients with peripheral vascular disease.

Catheter-based ultrasound (US) transducers may be introduced into the vascular system to record high-resolution images of the vessel wall and lumen. The potential advantages and existing liabilities of percutaneous intravascular US as an adjunct to transluminal vascular recanalization were investigated. A 6.6-F braided, polyethylene catheter enclosing a rotary drive shaft with a single-element, 20-MHz transducer at the distal tip was used in 17 patients undergoing percutaneous transluminal (balloon) angioplasty (PTA) alone (10 patients), PTA with implantation of an endovascular stent (two patients), atherectomy alone (two patients), or laser angioplasty with PTA and/or atherectomy (three patients). The arteries treated and examined included the common iliac in five patients, the external iliac in two, the superficial femoral in nine, and a vein graft-arterial anastomosis in one. In 14 cases PTA was employed as sole or adjunctive therapy; plaque cracks were clearly delineated with intravascular US in all 14 (100%) and dissections were observed in 11 (78%). Plaque-arterial wall disruption was less prominent in the arteries treated with mechanical atherectomy. The results of laser angioplasty reflected the adjunctive modality employed. After stent implantation, serial intravascular US documented effacement of PTA-induced plaque cracks and/or dissections. Intravascular US also aided in the quantitative assessment of luminal cross-sectional areas after the procedures (19.0-51.8 mm2). The observations recorded in this preliminary group of 17 patients illustrate the potential utility of intravascular US as an adjunct to conventional angiography in patients undergoing percutaneous revascularization.

Marital relations in incest offenders.

The study compared 92 incest perpetrators to 40 (noncriminal) married males on two marital inventories, the Clarke Martial Relations Questionnaire (CMRQ), and the Sexual Behavior and Marital Satisfaction Questionnaire (SBMSQ). Results showed that marital disharmony, in the form of mistrustfullness, lack of mutual friends and time together, emotional instability (in both partners), but not sexual relations, were predominant factors in incest perpetrators' profiles. A discriminant function analysis correctly classified 91.3% of incest offenders, but only 30.0% of controls, into their a priori group. Incest perpetrators reported less mutual give-and-take in disagreements with their spouses, a trend to confide less in their wives, and being more lonely in their marriage. Incest offenders reported they knew their spouses less well prior to marriage, despite the lack of any between-group differences in length of marriage or number of prior marriages. No differences emerged with respect to the range of sexual behaviors experienced or the degree of satisfaction with them. There were no group differences in the frequency of coitus nor in sexual dysfunction. In general, the lack of a satisfying emotional relationship between the incest offenders and their wives appeared as the most prominent factor in their marital relationships. The prominent aspects of their marital disharmony and sexual relations identified in the study reflect, in part, the inherent treatment goals needed for the incest perpetrator.

Delayed common bile duct obstruction in acute pancreatitis.

Common bile duct obstruction during acute pancreatitis usually occurs in the early symptomatic phase of the illness, involves only the distal portion of the common bile duct, and subsides with clinical improvement. We present two cases of persistent common bile duct obstruction that developed 2-3 months after complete clinical subsidence of the initial episode of severe acute pancreatitis and involved a long segment of the common bile duct. After surgical decompression, there was no recurrence of common bile duct obstruction or pancreatitis.

Serum pituitary and steroid hormone levels in the adult male: one value is as good as the mean of three.

The result of the hormone concentration of one blood sample was used to determine the accuracy of predicting not only the hormone concentrations of a second and third sample drawn 15 minutes apart, but also the mean value of the three samples. Three blood specimens from 73 men involved in two previously reported studies (A and B) were assayed individually for luteinizing hormone, follicle-stimulating hormone, prolactin, testosterone, androstenedione, dehydroepiandrosterone sulfate, estradiol, and cortisol. The predictive correlation of one single hormone value, when compared with the mean of three values, was 0.90 or greater, except for prolactin in study A (0.86) and testosterone in study B (0.86). Since the hormone level obtained for one sample has such a high predictive value for the hormone levels of the other two samples, drawing more than one sample is redundant.