Acute arsenic poisoning: clinical, toxicological, histopathological, and forensic features

This report describes a suicide case by acute arsenic intoxication via intravenous injection. A 30-year-old woman injected arsenic As (V) (sodium arseniate disodique: Disodium Hydrogena Arsenik RP) in a successful suicide attempt. Three hours following administration, the woman developed severe digestive symptoms. She was admitted to a hospital and transferred to the intensive care unit within 12 h of the massive administration of arsenic. Despite therapeutic efforts, over the next 2 h she developed multiorgan failure and died. A postmortem examination was performed. Pulmonary edema and congestion of liver were apparent. As (V) and As (III) were determined by high performance liquid chromatography and inductively coupled plasma mass spectrometry after mineralization of samples by concentrated nitric acid. Toxicological analysis revealed high concentrations of arsenic in biological fluids as well as in organs. Histopathological examination showed a typical indication of myocarditis. These findings were in agreement with acute arsenic poisoning. The symptoms developed by this young woman (intoxication by intravenous administration) were comparable to oral intoxication. The clinical signs, survival time, and administration type are discussed in light of the literature on acute and chronic arsenic poisoning.     

Sexual offenders with serious mental illness: prevention, risk, and clinical concerns

Individuals with serious and persistent mental illness who have also engaged in illegal sexual behavior present a unique challenge for our legal and clinical systems. Frequently, these individuals may engage in problematic sexual behaviors which result in hospitalization rather than incarceration, and an overburdened and resource-deficient public community mental health system is ill-equipped to address the seriousness of these sexual behaviors. We have a rather limited understanding of how prevention programs, intervention strategies, and risk assessment would work with this population. Here we evaluate data from a sample of 245 inpatient psychiatric sexual offenders in a forensic mental health setting and compare these with what information has already been presented in some of the literature. Through an examination of seriously mentally ill sexual offenders and their clinical presentation, legal history, and risk management concerns, we illustrate a variety of tertiary prevention needs. Future directions in the area of prevention and risk management for seriously mentally ill sexual offenders are also discussed.     

The Federal Trade Commission, clinical integration, and the organization of physician practice

This article examines Federal Trade Commission (FTC) policy--in particular, the agency's controversial 1996 statements on clinical integration--toward joint negotiations for nonrisk contracts with health plans by physicians organized into independent practice associations (IPAs) and (with hospitals) into physician-hospital organizations (PHOs). The article concludes that the policy is consistent with anti-trust principles, consistent with current thinking on the use of organized processes to improve medical care quality, specific enough to provide guidance to physicians wanting to integrate clinically, and general enough to encourage ongoing innovations in physician organization. The FTC should consider stronger sanctions for IPAs and PHOs whose clinical integration is nothing more than a sham intended to provide cover for joint negotiations, should give the benefit of the doubt to organizations whose clinical integration appears to be reasonably consonant with the statements, and should clarify several ambiguities in the statements. Health plans should facilitate IPA and PHO efforts to improve care by rewarding quality and efficiency and by providing clinically integrated organizations with claims information on individual patients. Though creating clinically integrated organizations is difficult and expensive, physicians should recognize that clinical integration can help them both to gain some negotiating leverage with health plans and to improve the quality of care for their patients.     

Medicare, Medicaid, and CLIA programs; clinical laboratory requirements--extension of certain effective dates for clinical laboratory requirements under CLIA--CDC, HCFA. Final rule with comment period

This final rule extends certain effective dates for clinical laboratory requirements in regulations published on February 28, 1992, and subsequently revised December 6, 1994, that implemented provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA). This rule extends the phase-in date of the quality control requirements applicable to moderate and high complexity tests and extends the date by which an individual with a doctoral degree must possess board certification to qualify as a director of a laboratory that performs high complexity testing. These effective dates are extended to allow the Department additional time to issue revised quality control requirements and to ensure laboratory directors are able to complete certification requirements. These effective date extensions do not reduce the current requirements for quality test performance.     

Ruptured berry aneurysms: a clinical, pathological and forensic review

A retrospective autopsy survey of 583 cases of ruptured berry aneurysm over a period of 25 years with reference to incidence, circumstances and predisposing factors. Over half of the deaths occurred in the 50-80 year age group, the overall male/female ratio being 2:3, the aneurysms being predominately on the middle and anterior cerebral arteries. Most deaths occurred in the home environment without precipitating factors, one fifth being sudden and unexpected in nature. There was no connection between physical trauma and ruptured aneurysm and no instance of a criminal or civil charge. Autopsy and dissection of the cerebral vessels is vital to diagnosis, particularly when deaths are unexpected in nature.     

Lowering the age of consent: Legal,ethical, and clinical implications of adolescent-directed therapy

This article discusses a recently enacted Colorado law that aims to reduce the youth suicide rate by lowering the age of consent for psychotherapy from age 15 to age 12. The author discusses the challenges therapists face when young adolescents seek therapy without parental consent in cases involving interparental conflict. Suggestions for managing adolescent-directed therapy are offered.     

Schizophrenia in a high-security hospital: long-term forensic,clinical, administrative & social outcomes

Objective: To determine forensic, clinical, social and administrative outcomes of high-security patients. Method: Prospective year follow-up study of 169 patients with schizophrenia, 1992–1993. Results: By the end of the study, 46 (27.2%) patients were in high security, 43 (25.5%) in medium- or low-secure units, 35 (20.7%) in an open ward, 3 (1.8%) in prison and 40 (23.7%) in the community. Violence occurred in 75% of patients over the 10-year follow-up period, and this was serious in 25%. Continuous positive symptoms of psychosis were present in over one-third. One-third had self-harmed during this period but there was only one known suicide and 11 (6.5%) deaths in total. At the end of the study, there was only one person in voluntary employment, 18 (12.7%) living independently and 10 (7.1%) in a relationship. Models were developed to determine factors relevant to these major outcomes. Conclusions: This is the first study providing comprehensive outcome data over a 10-year period. Forensic services appear good at managing the risk to the community but poor at promoting better social outcomes. The levels of violence within inpatient units are high.     

Social justice,the raison d'etre of clinical legal education

Jindal Global Law Review -     

Investigational new drug, antibiotic, and biological product applications; clinical hold and termination--FDA. Final rule

The Food and Drug Administration (FDA) is issuing a final regulation that provides additional grounds for placing an investigation on "clinical hold" and for terminating an investigational new drug application (IND). Under this rule, FDA may require sponsors to cease distributing an experimental drug in an open, nonconcurrently controlled investigation if any of several specified conditions exist. This final rule is part of the Public Health Service's(PHS's) efforts to make promising drugs widely available to people with acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV)-related disease who lack satisfactory alternative therapies, while simultaneously ensuring that the adequate and well-controlled clinical trials essential to establishing a new drug's safety and effectiveness are expeditiously conducted.