[Autonomy and patient prisoners]. / Autonomía y pacientes reclusos.

The authors study a recent Spanish High Court decision declaring liability on the Administration's part for the death of an inmate in a prison hospital. We analyse the Court's decision using legal, ethical, medical and social perspectives. The conclusions are that: 1. the Administration has no legitimate right to force a prisoner to take medical treatment, except in circumstances in which there is a grave and definite risk to the patient's life, or when the patient lacks capacity or when there is the risk of harm to the health of third parties; 2. That in the case of health decision making that might affect a patient, the Court has mounted a frontal attack on the autonomy of patients in prison; 3. That from a medical point of view the decision is discriminatory since it does not apply the same standards of measurement to all chronic illnesses that might be found in the prison context; 4. That it is inapplicable in daily practice due to the fact that its strictness of application would seriously affect the already highly fragile ordered coexistence that exists in a prison.

Autonomía y pacientes reclusos / Autonomy and patient prisoners

Los autores estudian una reciente sentencia de la Sala 3ª del Tribunal Supremo en la que se declara la responsabilidad patrimonial de la Administración por la muerte de un paciente preso. Se analizan los argumentos de la Sala desde una perspectiva jurídica, ética, médica y social. Concluyen que: 1: la Administración no está legitimada para imponer tratamientos médicos a los reclusos, salvo que medie riesgo grave y cierto para su vida, incapacidad para decidir o riesgo para la salud de terceros; 2: que la sentencia supone un ataque frontal a la autonomía de los pacientes presos en la toma de decisiones sanitarias que les afecten; 3: que desde un punto de vista médico es discriminatoria, ya que no mide por el mismo rasero a todas las enfermedades crónicas que se pueden dar en prisión y 4: que resulta inasumible en la práctica diaria, porque su estricta aplicación alteraría considerablemente la ya de por sí frágil ordenada convivencia en un centro penitenciario

The authors study a recent Spanish High Court decision declaring liability on the Administration’s part for the death of an inmate in a prison hospital. We analyse the Court’s decision using legal, ethical, medical and social perspectives. The conclusions are that: 1. the Administration has no legitimate right to force a prisoner to take medical treatment, except in circumstances in which there is a grave and definite risk to the patient’s life, or when the patient lacks capacity or when there is the risk of harm to the health of third parties; 2. That in the case of health decision making that might affect a patient, the Court has mounted a frontal attack on the autonomy of patients in prison; 3. That from a medical point of view the decision is discriminatory since it does not apply the same standards of measurement to all chronic illnesses that might be found in the prison context; 4. That it is inapplicable in daily practice due to the fact that its strictness of application would seriously affect the already highly fragile ordered coexistence that exists in a prison

Utilization of banana agricultural waste: production of cellulases by soil fungi.

Banana a major cash crop of Maharashtra is cultivated over 46900 hectares generating large amount of agro waste after the harvest. Attempts were made to utilize these agro wastes for production of cellulases. Of the 127 fungi isolated from the soil of banana field, 12 fungi were found to utilize cellulose as source of carbon. Trichoderma lignorum showed appreciable cellulolytic activity. It produced Cl, Cx and beta glucosidase in Carboxymethyl Cellulose Peptone medium as well as on agro waste based medium containing leaves, stem and rhizome powders. T. lignorum (0. 45 U/ml) produced maximum enzymes on leaf based medium.

Herbal supplements and skin testing: the lack of effect of commonly used herbal supplements on histamine skin prick testing.

BACKGROUND: The use of herbal supplements is common, yet little is known about their pharmacologic properties. The purpose of this study was to assess the effects of 23 commonly used herbal supplements on histamine skin prick testing (SPT). METHODS: Fifteen healthy volunteers participated in a double-blind, placebo-controlled, single-dose, crossover study. Wheal and flare responses to SPT with histamine phosphate (1 mg/ml) were measured before and 4 h after administration of each of the 23 popular herbal supplements, fexofenadine (60 mg) and placebo. Wheal and flare areas were recorded with tracings performed 10 min after the prick test and measured with a PC-digitizer using stereometric software. RESULTS: Fexofenadine significantly suppressed the wheal (P < 0.001) and flare (P = 0.02) areas compared with placebo. None of the herbal supplements caused significant suppression of the wheal and flare areas compared with placebo (P > 0.10). CONCLUSION: When taken in single-doses, the popular herbal supplements tested did not significantly affect the histamine skin response. Therefore, it seems unnecessary for clinicians to ask patients to discontinue these herbal supplements prior to allergy skin testing.

Problemas médico-legales del consumo de drogas / No disponible

Los trastornos derivados del consumo de alcohol y drogas son causa de múltiples problemas en diferentes ámbitos del Derecho, siendo necesario para su resolución que Jueces y Tribunales dispongan de un informe pericial que valore el estado del paciente y que les permita conocer la situación real, para acorde con ello dictar una resolución motivada. Para la valoración psicopatológica proponemos atender a 2 criterios: uno médico basado en los síntomas y signos clínicos, la gravedad de cuadro y el momento de inicio del mismo en relación con los hechos de trascendencia jurídica, y otro médico legal, que relaciona los hechos con el estado del paciente partiendo de un análisis estructural de sus funciones cognitivas y volitivas y del estudio de la gravedad de la adicción. Dada la frecuencia con la que las conductas adictivas coexisten con otras patologías psiquiátricas, proponemos un estudio completo recurriendo a métodos prospectivos (seguimiento del paciente), retrospectivos (basado en autoinformes referidos a periodos de tiempo concretos) y objetivos (análisis y distintas pruebas de laboratorio) para el correcto diagnóstico diferencial entre los trastornos inducidos por drogas y otros trastornos psiquiátricos. Para la valoración pronostica, proponemos estudiar los elementos que pueden influir en el éxito o el fracaso de la asistencia médica o psicosocial del problema, atendiendo básicamente a: 1) los factores que motivan el consumo, 2) los motivos que motivan la solicitud de ayuda para abandonar el consumo, y 3) viabilidad del plan Terapéutico propuesto (AU)

The dysfunctions derived from the consumption of alcohol and drugs are the cause of multiple problems in different spheres of Law. To resolve them, judges and tribunals require an expert report assessing the condition of the patient enabling them to ascertain the real situation prior to reaching a decision. For the psychopathological evaluation we propose 2 criteria, one medical based on the clinical symptoms and signs, the seriousness of the case and the commencement of the same in relation to the facts of the legal case in question, and another legal- medical one which lists the facts with the medical condition of the patient on the basis of a structural analysis of his/her cognitive and volitive functions and a study of the seriousness of the addiction. Given the frequency with which addictive behaviours coexist with other psychiatric pathologies, we propose a complete study based on prospective methods (patient followups), retrospectives (based on self-reports referring to specific periods) and objectives (analysis and different laboratory tests) for the correct differential diagnosis between dysfunctions induced by drugs and other psychiatric dysfunctions. Lastly and for the evaluation for the prognosis, we propose to study the elements that can influence the success or the failure of the medical or psychosocial attention to the problem, basically: 1) the factors that motivate the consumption, 2) the reasons that motivate the request for assistance in giving up consumption, and 3) viability of the proposed therapeutic plan (AU)

Use of word processors to support written communication: an annotated bibliography.

When children with disabilities have difficulty with written communication, members of their educational teams, including occupational therapists and physical therapists, often recommend use of a word processor. This annotated bibliography summarizes a variety of articles that describe the use of word processing technology with school-aged children. The articles include research reports, descriptions of special features used with word processing programs, and guidelines for using word processing with students. Implications for occupational therapists and physical therapists working with students who have written communication problems are discussed.

Failure of pentavalent antimony in visceral leishmaniasis in India: report from the center of the Indian epidemic.

In India, 320 patients with visceral leishmaniasis (209 in the state of Bihar and 11 in the neighboring state of Uttar Pradesh) received identical pentavalent antimony (Sb) treatment. Sb induced long-term cure in 35% (95% confidence interval [CI], 28%-42%) of those in Bihar versus 86% (95% CI, 79%-93%) of those in Uttar Pradesh. In Bihar, the center of the Indian epidemic, traditional Sb treatment should be abandoned.

Short-course of oral miltefosine for treatment of visceral leishmaniasis.

A total of 54 Indian patients with visceral leishmaniasis were treated with oral miltefosine, 50 mg given twice daily, for 14 days (18 patients; group A), 21 days (18; group B), or 28 days (18; group C). Cure was achieved in 89% of group A, 100% of group B, and 100% of group C. Adverse reactions were self-limited and primarily mild. The 21-day miltefosine regimen combines high-level efficacy, convenient dosing, and a relatively short duration.

Utility of an HIV-1 RNA assay in the diagnosis of acute retroviral syndrome.

Highly active antiretroviral therapy (HAART) begun during primary infection with human immunodeficiency virus type 1 (HIV-1) can preserve immune function and may alter the long-term clinical course of HIV-1 infection. To diagnose primary HIV-1 infection (PHI) early, when screening serologies may yield negative or indeterminate results, the Department of Health and Human Services recommends the use of an HIV-1 RNA assay for at-risk patients suspected of having acute retroviral syndrome (ARS). Because of the RNA assay's 1.9% to 3.0% false-positive rate, results must be carefully interpreted and compared to HIV-1 viral load levels seen during proven HIV-1 seroconversion. We report the case of a sexually active woman with symptoms suggestive of ARS who had a false-positive HIV-1 RNA assay result. We discuss use and interpretation of the HIV-1 RNA assay in diagnosing PHI.

The General Practice computer system project: a doctor's desktop for Australia.

The Australian Department of Health and Family Services engaged the IBM consulting practice to develop a functional specification and technical architecture for a General Practice computer system (GPCS) in January, 1997. The project was completed in September, 1997. This paper describes the rationale for development of the specification, the process that was undertaken and provides an overview of the completed specification and architecture. The paper also explores a number of issues related to computing in general practice which were raised during the consultative process, and considers factors which were found to be important in obtaining adoption and use of computer technology on the doctor's desk.

Ear-piercing techniques as a cause of auricular chondritis.

OBJECTIVE: To investigate the different methods of ear and body piercing as possible sources of infection, and to provide a brief literature review of infections resulting from high ear piercing as well as bacterial coverage of common disinfectants used as preparation agents. METHODS: Two cases of auricular chondritis caused by Pseudomonas are presented. A survey of 14 businesses that pierce ears was conducted using a scheduled interview. Information regarding the type of piercing instrument, composition of earring, training of employees, anatomic placement of earrings, and preparation and aftercare of ears was obtained. RESULTS: One hundred percent of the interviews attempted were completed. The cosmetic shops and earring kiosks both used hand-powered earring "guns" to pierce ears, while the tattoo parlors used sterile needles and forceps. All of the businesses interviewed used earrings composed of either 14K or 24K gold, stainless steel, and other piercing-grade metals. None of the businesses used earrings made of nickel. The cosmetic shops and kiosks used a combination of videos, demonstrations, and direct supervision to train employees but did not have a specified training period. The tattoo parlors required their employees to complete an apprenticeship training program of varying time lengths. All of the businesses pierced the lobe and cartilaginous portions of the ear. The cosmetic shops and kiosks used benzalkonium chloride or isopropyl alcohol as ear preparation agents, while the tattoo parlors used only iodine-based solutions. At all of the businesses, minimal aftercare instructions were given and they typically dealt with maintaining ear-hole patency. CONCLUSION: The cosmetic shops and earring kiosks used piercing methods that predisposed to auricular chondritis, such as poor training of employees and use of benzalkonium chloride as a preparation agent. Emergency physicians need to be aware of the severity of these types of infections, which often require surgical management and intravenous antibiotics covering Pseudomonas.

Treatment of antimony-unresponsive Indian visceral leishmaniasis with ultra-short courses of amphotericin-B-lipid complex.

High cost is the principal drawback of treating visceral leishmaniasis (VL; kala-azar) with any of the new lipid formulations of amphotericin B. The aim of the present study was to see if the costs of treatment with such drugs could be reduced by using ultra-short courses. Amphotericin-B-lipid complex (ABLC) was given to 77 Indian patients with antimony-unresponsive VL, either as a single infusion of 5 mg/kg (Group A) or two infusions, each of 5 mg/kg, given 5 days apart (Group B) or on consecutive days (Group C). Other than the anticipated higher fever and chills, treatment was well-tolerated. On day 19 after first infusion, 72 patients were considered apparent cures: 24 (89%) of the 27 in Group A; all 24 (100%) in Group B; and 24 (92%) of the 26 patients in Group C. Six months after treatment, 19 (70%) of 27 in Group A, 19 (79%) of 24 in Group B, and 21 (81%) of 26 in Group C were healthy, relapse-free and considered definitive cures. These cure rates were not statistically different. All 18 treatment failures (five initial non-responders and 13 relapses) were cured after treatment with a 5-day course of ABLC at a higher dose (10-15 mg/kg.day). In a related analysis of hospital plus drug costs for treating antimony-unresponsive VL, short-course ABLC (1-5 days) was compared with conventional amphotericin B (0.75-1.0 mg/kg on alternate days over 30-34 days). This analysis, which included the cost of re-treatment, identified one short-course ABLC regimen with an overall estimated expense which was only modestly higher than that of amphotericin B. Together, the present results provide further support for the use of ABLC in the management of VL patients who fail antimony therapy.

Comment on Black's (1993) article, "comparing genuine and simulated suicide notes: a new perspective".

The recent article by Stephen T. Black (1993) comparing genuine suicide notes with simulated notes is examined here. This article corrected a sampling error made in the original study by E. S. Shneidman and N. Farberow (1957), but Black's design suffers from theoretical and methodological problems that render it uninterpretable: First, no theoretical background is elaborated, and no hypotheses are offered. Second, no constructs are operationalized, and no predictions are tested. In the present article, the operational design is critiqued, and then it is suggested that the study of suicide notes in this fashion should cease.

How we built our PPO.

To get control of soaring health care costs, Southern California Edison is doing its own negotiating with physicians and hospitals.

Combination therapy with ranitidine and pirenzepine for control of intragastric pH in the critically ill.

In a prospective study of pH control for stress ulcer prophylaxis, intermittent iv infusion of the anticholinergic drug pirenzepine maintained the intragastric pH above 4 in only one of 17 ICU patients, while similar administration of the H2-receptor antagonist ranitidine was successful in seven of 32 patients. This difference was not statistically significant. Of 15 patients in whom a maximum dose of 600 mg/day of ranitidine or 90 mg/day of pirenzepine failed to maintain pH, combination therapy was successful in 11, a significant (p less than .01) improvement. We conclude that neither ranitidine nor pirenzepine provides adequate control of pH for stress ulcer prophylaxis when used alone. If used together they are the most effective combination so far described for parenteral control of gastric pH in the critically ill. Regular monitoring of gastric pH is nevertheless essential to allow detection of therapeutic failures.