Marfan syndrome. A contribution to forensic medicine cases

A 19-year-old school boy suffered from fluctuating uncharacteristic chest pain in the last 20 h before his death. He died unexpectedly within a few minutes of a hemopericardium, which resulted from an aneurysmal rupture of the ascending aorta. The patient's past history as well as the autopsy and ultrastructural findings led to the diagnosis of Marfan's syndrome with alterations of the cardiovascular skeletal system but no ophthalmological involvement ("oligosymptomatic" form of Marfan's syndrome). Appraisal of the cause of death is made more difficult by the fact that medical treatment was undertaken on the same day, whereby subtotal liver crushing was established that had resulted from attempts at resuscitation.     

Legislative and educational alternatives to a judicial remedy for the transfer trauma dilemma

Transfer trauma is alleged to be an increase in morbidity and mortality in institutionally relocated chronically ill elderly. Efforts by the legal profession to persuade courts that transfer trauma should be a legally recognized phenomenon invoking judicial protections against transfer (the "transfer trauma argument") have been unproductive. In O'Bannon v. Town Court Nursing Center, Inc., the United States Supreme Court denied standing to elderly persons claiming a property interest in remaining in alleged substandard facilities. The Court rejected the argument that the possibility of transfer trauma constituted a deprivation of life or liberty that would have required due process protections of notice and hearing. Despite the Court's preclusion of transfer trauma litigation in a constitutional context and the general unwillingness of lower courts to recognize the phenomenon, attorneys continue to burden the judicial system with frivolous transfer trauma arguments. The unfruitful pursuit of a judicial remedy for the ethical and social problems that arise with relocation of the elderly continues, in part, because of a misguided belief that this distressing social phenomenon is best remedied by the courts. Judicial unwillingness to recognize the transfer trauma argument, however, does not preclude legislative consideration of the humanitarian issues concerning the institutional relocation of elderly persons. This Article examines gerontological research in order to understand the judicial rejection of the transfer trauma argument and argues in support of legislative and educational solutions for the ethical and social problems attending transfer.     

The "empty heart" sign

Approximately 15% of victims of instantly lethal central nervous system trauma have an empty or nearly empty heart at autopsy. This article defines and discusses the "empty heart" sign.     

Development assistance: Ruined hopes and great expectations in Africa

This paper highlights the difficulties and complexities of development assistance projects through an analysis of 2 Urban Functions in Rural Development projects conducted by the US Agency for International Development (AID) in Upper Volta and northern Cameroon in 1977-82. The general objectives of the Upper Volta project were to carry out urban function studies, develop a plan for strengthening the contributions of urban centers to rural development, develop a list of investment priorities for facilities and services, and increase the capacities of the Ministry in planning processes and methods. The 2-year project was hindered by a 1-year delay in initiating assistance due to difficulties in locating a contractor. In addition, the contractor and other team members felt there was little justification for studies of spatial organization in a country with so much evident need; rather, they focused on a small rural works program and establishment of effective local government, producing an inconsistency between team activities and the original project agreement. A request by the team to extend the project 1 year beyond its official completion date to compensate for early delays was rejected by USAID. Nonetheless, there was agreement that the project had a small positive impact in Upper Volta. Key lessons from Upper Volta were transferred to the Cameroon project. Although this project was judged to have achieved its objective of preparing a regional plan and of identifying programs for facilities, services, and small-scale enterprises, it was beset by problems of inexperience and technical underqualification of team members, poor communication, inconsistency of USAID guidelines, and methodological confusion. It is suggested that a central challenge for such programs is to create a body of qualified Americans who can work with their local counterparts in meeting the challenges of development. A measure of the success or failure of these projects should be the degree to which learning contributes to improved performance.     

Competence to consent to treatment as a psycholegal construct

The issue of whether civilly committed patients should be extended the right to accept or refuse treatment has generated much controversy and litigation during the past 15 years. In general, the current rule is that in nonemergency situations, individuals who are competent to give informed consent to treatment should be extended the right to refuse it. Obviously, the manner in which this rule is implemented partly depends on how competence to consent to treatment is defined and measured. Most researchers have implicitly assumed that an understanding of treatment information is the sole criterion of competence. It is argued that such a definition may be incomplete and is in need of reexamination. Following a review and analysis of the relevant legal and psychological literature, a comprehensive construct of competency to consent to treatment is proposed and future directions for research are discussed.