Confabulation in children with autism.

Some children with high-functioning autistic spectrum conditions (ASC) have been noted clinically to produce accounts and responses akin to confabulations in neurological patients. Neurological confabulation is typically associated with abnormalities of the frontal lobes and related structures, and some forms have been linked to poor performance on source monitoring and executive function tasks. ASC has also been linked to atypical development of the frontal lobes, and impaired performance on source monitoring and executive tasks. But confabulation in autism has not to our knowledge previously been examined experimentally. So we investigated whether patterns of confabulation in autism might share similarities with neurologically-based confabulation. Tests of confabulation elicitation, source monitoring (reality monitoring, plus temporal and task context memory) and executive function were administered to four adolescents with ASC who had previously been noted to confabulate spontaneously in everyday life. Scores were compared to a typically developing (TD) and an ASC control group. One confabulating participant was significantly impaired at reality monitoring, and one was significantly worse at a task context test, relative to both the ASC and TD controls. Three of the confabulators showed impairment on measures of executive function (Brixton test; Cognitive Estimates test; Hayling Test B errors) relative to both control groups. Three were significantly poorer than the TD controls on two others (Hayling A and B times), but the ASC control group was also significantly slower at this test than the TD controls. Compared to TD controls, two of the four confabulating participants produced an abnormal number of confabulations during a confabulation elicitation questionnaire, where the ASC controls and TD controls did not differ from each other. These results raise the possibility that in at least some cases, confabulation in autism may be less related to social factors than it is to impaired source memory or poor executive function.

Cardiac arrest due to a missed diagnosis of Boerhaave's syndrome.

A 91-year-old presented with a rare cause of cardiac arrest. He was initially admitted with severe back pain following vomiting and diagnosed with probable aspiration pneumonia. On day 3 of admission, he was discovered in cardiac arrest and cardiopulmonary resuscitation was started. On intubation, a left-sided pneumothorax and subcutaneous emphysema were noted. Needle decompression showed gastric fluid leaking from the cannula. The patient regained a cardiac output, and a subsequent CT scan confirmed a large pneumomediastinum with air tracking to the neck and chest, and bilateral pneumothoraces. A diagnosis of Boerhaave's syndrome was made. The patient was transferred to the intensive care unit but did not survive. This case demonstrates the importance of looking for and treating the rarer reversible causes of cardiac arrest, and of maintaining a high index of suspicion for Boerhaave's syndrome. Despite its rarity, Boerhaave's syndrome is often misdiagnosed on initial presentation, leading to delayed treatment and poor outcomes.

Elective surgical referral guidelines--background educational material or essential shared decision making tool? A survey of GPs' in England.

BACKGROUND: To investigate general practitioners' (GPs') attitudes to guidelines for elective surgical referral in England. To understand their use of guidelines, and attitudes to shared decision making in the referral decision. METHODS: A questionnaire was developed which investigated attitudes to and use of guidelines. It was given to a stratified random sample 30% (n = 310) drawn from GP lists of 10 English health districts (primary care trusts (PCTs)). GPs were invited to respond online, by telephone, fax or post. Data were analysed using descriptive statistics and backwards stepwise logistic regression. RESULTS: Responses were representative of GPs in England, but (despite up to 6 contacts per non-responder) the overall response rate was 41.6% (n = 129; with the range across PCTs of 25-61%). Most responding GPs indicated support for referral guidelines but 18% reported that they had never used them. Less than three per cent reported use for most or all referral decisions. The odds of using guidelines decreased with increasing age, with a ten year increase in age associated with halving odds of use (OR = 0.53, 95%CI = 0.29-0.90). Over 50% of GPs wanted good access to electronic guidelines with expert information and advice on guideline availability. Almost all (>89%) GPs agreed with sharing referral decisions with patients. Female doctors (OR = 5.2, 95%CI: 1.02-26.3) were more likely to agree with this than male GPs as were those working in larger compared to small or single handed practices (OR = 5.3, 95%CI: 1.4-19.9). CONCLUSIONS: This group of responding GPs was supportive of guidelines but used them in different ways. Referral guidelines should have an educational component for background reading; include key messages for internalisation and application; and incorporate mechanisms to facilitate accessibility and appropriate shared decision making with patients.