高原部队医疗机构加强信息化条件下远程救治的几点思考等

信息编号11326901至11326950间共50条。
☉ 11326901:高原部队医疗机构加强信息化条件下远程救治的几点思考
关键词高原；部队医院；远程医疗远程医疗是远程通讯技术、计算机和现代化医学三者紧密结合的产物，它是利用通讯技术远距离传输所有医疗、教育、信息和管理的服务方式，在现代战争的卫勤保障中起着不可缺少的重要作用，在地理条件特殊的青藏高原尤显重要，作者对此谈几点看法。 1 远程救治是高原部队平时卫勤保障的现实需要西藏高原空气稀薄，气候恶劣，部队官兵生活、工作在这样的特殊自然环境中...查看详细 (3596字节)

☉ 11326902:婴幼儿颌面部真性血管瘤的临床分型与治疗
关键词真性血管瘤；平阳霉素；婴幼儿自Mukkiken和Gkowacki(1982)[1]依据血管瘤内皮细胞的生物学特性将传统的血管瘤重新划分为真性血管瘤和血管畸形两大类以来，推动了对血管瘤的进一步研究。本文通过笔者近年来(1995～2003年)对婴幼儿颌面部真性血管瘤89例的诊治经验，认为真性血管瘤在临床上尚有多种表现形式，应进一步分型，并采用适当的治疗方法，方可获得更为满意的治疗效果。 1 婴幼儿颌面部真性血管瘤的分型真性血管瘤与血管畸形不同...查看详细 (5832字节)
☉ 11326903:神经组织工程细胞外基质材料研究进展
关键词神经组织工程；细胞外基质材料组织工程学是一门以细胞生物学、分子生物学、生物材料学和临床医学等学科为基础的多学科交叉学科，目的是要运用工程学和生命科学的原理和方法，研究和开发、修复、维持或改善病损组织功能的生物替代物的一门学科。方法是体外分离、培养细胞，将一定量的细胞种植到具有一定结构的三维支架上，然后将此细胞支架复合物植入体内或体外继续培养，通过细胞间的相互粘附，增殖和分化，分泌细胞外基质...查看详细 (15996字节)

☉ 11326904:中药治疗影响乳腺雌激素受体的研究进展
关键词中药；雌激素受体；研究进展近年来，随着分子生物学的发展及雌激素在临床上的广泛应用，对雌激素受体(ER)的研究亦日趋活跃。同时，中药在疾病治疗中的地位越来越受到重视，越来越多的学者致力于中药对ER的影响研究。本文拟对ER的结构、作用机理以及在乳腺疾病治疗中的意义作一简单回顾，对不同种类的中药复方和中西药结合疗法及针药疗法对乳腺增生症病人ER的影响进行归纳总结，力图阐明中药的药理机制，以指导临床应用...查看详细 (11339字节)
☉ 11326905:肝性脑病患者灌肠疗法的临床应用进展
关键词肝性脑病；灌肠术；临床护理；综述肝性脑病是内科的危急重症之一，目前认为肝性脑病由于严重肝功能衰竭时，来自肠道的毒性代谢产物未被肝脏解毒和清除，经侧枝循环进入体循环，透过血脑屏障引起中枢神经系统功能紊乱。而灌肠术可清除肠中粪便，排除毒素以及灌入药物，通过肠粘膜吸收，达到治疗目的。目前，国内学者通过广泛研究，总结一系列灌肠术治疗肝性脑病的临床措施，现综述如下。 1 灌肠药液的选择 1.1 中药制剂取大黄、乌梅等加减处方[1...查看详细 (6249字节)

☉ 11326906:丹参对缺血再灌注时细胞凋亡的调节作用
关键词缺血再灌注；凋亡；丹参；中药在肝、肾、脑等器官缺血再灌注损伤(Ischimia reperfusion injury，IRI)造成的细胞死亡形式中，凋亡也是一种常见而重要的形式[1，2，3，4]。组织细胞一旦坏死，目前人们尚无办法干预。但细胞凋亡是受一系列程序控制的过程，人们有可能通过干预死亡程序加以挽救。丹参经现代先进实验技术证实，对IRI时细胞过度凋亡有抑制作用。本文就此方面的内容予以综述...查看详细 (6768字节)
☉ 11326907:前列地尔的药理研究进展
摘要综述了近年来前列地尔(前列腺素E1，PGE1)在扩张血管、抑制血小板聚集、细胞保护等方面的作用，以及其在脑血管疾病、循环系统、呼吸系统、肢体血管疾病等多方面药理活性的研究近况，为进一步研究前列地尔提供参考。关键词前列地尔；药理作用；研究进展前列地尔属于天然前列腺素(PG)类物质。20世纪60年代初确定前列地尔的化学结构为具有一个五碳环和2条侧链的二十碳脂肪酸的基本骨架。内源性前列地尔在体内分布广...查看详细 (10345字节)
☉ 11326908:浅谈检验医学实习教学工作的环节管理
关键词检验医学；实习教学；管理检验医学实习教学工作是军队综合性医院教学工作的重要组成部分。笔者结合十余年医学教学管理体会，通过对检验医学实习教学工作进行了具体分析，总结出检验医学实习教学工作应该重视的五个环节管理问题，与同行探讨。 1 计划管理当前，随着军队和地方医学院校检验系的扩招和社会对检验系本科生以及本科生以上学位人员需求量的增大，使检验医学实习教学工作具有了“要求高、难度大、任务重、范围广”等特点...查看详细 (2459字节)

☉ 11326909:卫生员教材在教学中遇到的主要问题与改进建议
关键词卫生员教材；修订；建议中国人民解放军卫生员教材(以下简称：卫生员教材)是全军部队卫生员培训的基本依据。随着军事斗争准备的深入和现代医学模式的发展趋势，结合卫生专业兵实行分期服役制度的实际，现行的教学内容已不适合或不能满足培养的需求。虽然近几年总后勤部卫生部组织相关人员进行过几次修订，但笔者认为改革力度还不大，还未脱离传统的教学模式和框架。现以2005年10月第4版的卫生员教材为蓝本，结合笔者的教学实践体会...查看详细 (5146字节)
☉ 11326910:中心静脉置管化疗的应用体会
关键词静脉置管；化学治疗；护理化疗是目前治疗癌症的主要方法之一，与外科手术、放疗等治疗方法结合，能使多种癌症得到缓解，延长病人生存期。但抗癌药物在杀伤或抑制癌细胞的同时，也对机体正常细胞有严重的损伤，如化疗中的胃肠道反应，化疗药漏出血管引起组织坏死等，有部分化疗病人往往因化疗疗程长，毒副作用大而不能坚持按疗程化疗。我科从2004年以来采用ARROW国际公司的中心静脉导管，锁骨下静脉、颈内静脉纯肝素留置导管可留置6个月(180)天...查看详细 (2724字节)
☉ 11326911:智能化病案质量审查管理系统在我院病案质量管理中的应用
关键词病案质量；软件系统智能化病案质量审查管理系统是我院自行研发的一种用于在电子计算机上进行病案质量终末控制的软件系统。该系统是医院智能化管理系统的子系统之一。它充分运用了计算机技术，并利用数据库管理模式保存和分析处理病案审查结果。从而便于医院管理部门准确、及时地掌握病案质量情况，同时采取实时通报，可以有效地解决质量缺陷，全面提高医疗文书质量。在病案质量管理智能化办公的问题上，缩短了病案管理周期...查看详细 (5712字节)
☉ 11326912:驻军医院护理安全隐患与防范对策
关键词护理安全；护患纠纷防范《医疗事故处理条例》以及“举证倒置”政策的颁布实施以来，护理工作已被纳入法制轨道。护理行为的法律风险愈加突出，各种影响护理安全的因素越来越多。为进一步规范护理行为，提高护理质量，有效规避护理风险，确保护理安全，现结合工作体会就护理安全管理存在的隐患及风险防范探讨如下。 1 护理工作中常见的安全隐患 11 安全意识和法律意识不强我院地处西南边疆...查看详细 (8214字节)

☉ 11326913:银屑病合并糖尿病13例临床分析
关键词银屑病；合并症银屑病是常见的难治性皮肤病之一，作者统计分析了90例银屑病患者，结果显示有13例合并糖尿病，现报道并作简要分析。 1 临床资料 1.1 一般资料收集2003.01.01～2006.02.28在我院住院治疗的银屑病患者90例，均符合银屑病的诊断。男80例，女10例；平均年龄37.6±20.5岁(9～83岁)。发病年龄：最小8岁，最大65岁...查看详细 (2713字节)
☉ 11326914:硬脂酸代替二甲苯透明在石蜡切片中的应用
关键词石蜡切片；透明；硬脂酸；二甲苯石蜡切片的制作中要经过一个浸蜡透明的过程，传统使用的透明剂是二甲苯。我科从1993年至今使用硬脂酸代替二甲苯，经过多年实践取得了良好的效果，现报道如下。 1 材料和方法 1.1 材料硬脂酸：天津市化学试剂三厂生产，又名十八烷酸，分子式为CH3(CH2)16COOH，分子量284.48，本品为白色结晶粉末，不溶于水，易溶于乙醇、苯、氯仿、乙醚、石蜡溶液中...查看详细 (3429字节)
☉ 11326915:疣体包埋术治疗顽固性扁平疣33例
关键词扁平疣；治疗；疗效扁平疣是临床上常见而又难以治愈的皮肤病之一，为人类乳头瘤病毒感染所致，多发于青少年。目前临床治疗方法很多，但均存在疗效不确切，症状反复迁延不愈等不足。自2003年1月至2006年10月，笔者采用自体扁平疣包埋治疗顽固性扁平疣33例，取得了较好的疗效，现总结报道如下。 1 临床资料 1.1 一般资料患者共33例，男性12例，女性21例...查看详细 (1804字节)
☉ 11326916:小儿气管支气管异物67例临床分析
关键词小儿气管支气管异物；麻醉；外科手术气管支气管异物是耳鼻喉科急危症之一，大多发生于5岁以下的小儿，常危及小儿健康甚至生命。诊断依靠详细的病史，全面的肺部检查，结合X线表现综合分析。全麻手术安全，成功率高。1997年7月至2006年9月，我院共收治气管支气管异物患儿67例，报告如下。 1 资料与方法 1.1 一般资料本组患者67例，男39例，女28例；年龄8个月～7岁...查看详细 (4940字节)

☉ 11326917:穴位注射治疗枕大神经痛疗效观察
摘要目的探讨风池穴注射当归液在治疗枕大神经痛中的治疗效果。方法用10%葡萄糖液1mk加5%当归注射液1mk注射于双侧风池穴。结果有效率100%。治愈率94.7%。结论使用穴位注射当归液加葡萄液疗效确切，简便，可供针灸医务工作者应用参考。关键词枕大神经痛；穴位注射；治疗枕大神经痛是我科常见病。笔者自2003年以来应用穴位注射治疗该病38例，均取得满意疗效，现报告如下...查看详细 (1465字节)
☉ 11326918:乙肝“两对半”少见模式分析
关键词乙肝；免疫学检测；少见模式 HBV感染后血清标志物的模式表现呈多样化。本科血清免疫室2004年共检测到42例少见模式，占阳性总例数的06%(42/6744)。其中HBsAg(-)、抗HBs(-)、HBeAg(+)、抗HBe(-)、抗HBc(+)者33例，HBsAg(+)、抗HBs(-)、HBeAg(+)、抗HBe(+)、抗HBc(+)者9例。更换不同厂家试剂检得相同结果。HBVDNAPCR检测42例均呈阳性...查看详细 (2480字节)
☉ 11326919:22q11 Deletion Syndrome and Forensic Research: Can We Go There?
Dr. Harris is Assistant Professor, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA. Abstract Chromosome 22q11 deletion syndrome (22q11DS) encompasses velocardiofacial syndrome (VCFS), DiGeorge syndrome (DGS), and conotruncal anomaly face syndrome (CTAFS). The disorder may represent the interface between genetics and brain-behavior relationships. As there is a strong relationship between the genetic syndrome and schizophrenia, individuals with the disorder are likely to be disproportionately represented in the criminal justice system. The purpose of this article is to review the 22q11DS in the context of forensic research. The existing literature regarding the syndrome and its relationship to schizophrenia is reviewed. A study design is presented to determine the prevalence of the syndrome in correctional facilities compared with expected community prevalence rates. Finally, a brief history of genetic research in correctional facilities is reviewed as a potential model to determine the feasibility of research involving 22q11DS. 22q11 deletion syndrome (22q11DS) involves microdeletions on the long arm of chromosome 22 in area 11. These usually occur de novo, although 10 to 25 percent may be inherited in an autosomal dominant pattern.1–3 A wide variety of clinical findings have been described in affected individuals, including cardiac defects, palate anomalies, typical facial features, learning difficulties (LDs), mental retardation (MR), athymia, and characteristic physiognomy. The structures primarily affected are derivatives of the embryonic third and fourth pharyngeal arches and pouches. This suggests that haploinsufficiency (reduced gene dose) of two to three millibases3–5 is important in pharyngeal arch and pouch development. Gene searches have been successful in identifying more than 30 genes in the deleted segment.4 Conservatively, the prevalence of 22q11DS is estimated to be 1 in 3,0006 to 1 in 4,0003,7–9 live births. However, the syndrome is likely to be underdiagnosed for several reasons. First, there is incomplete penetrance and therefore a great variation in phenotype.1–6 Second, fluorescent in situ hybridization (FISH) of chromosomal preparations is needed, as conventional methods of chromosomal analysis do not demonstrate the microdeletion. Third, until recently, the syndrome was not widely described in the peer-reviewed literature. To date, most clinical studies have focused on children who attend clinics for craniofacial or congenital heart disorders.9,10 Later-onset illnesses associated with 22q11 deletions have also been described. Thrombocytopenia,3,11,12 hypocalcemia,3,13 hypothyroidism,10,14 and various neurological complications10,15 have been associated with 22q11DS. In addition to the highly variable phenotypic expression and later-onset illnesses, there is a high prevalence of serious mental illness in adult patients with 22q11DS. 22q11DS and Mental Illness In a review of clinical case reports on adults with 22q11DS by Cohen et al.,1 37 percent of 126 individuals suffered from a mental illness. More than one psychiatric disorder was present in 12 (27%) of the individuals. Seventy-three percent (n = 33) had evidence of a psychotic illness such as schizophrenia, schizoaffective disorder, or a paranoid disorder. Mood disorders, such as depression or bipolar disorder without psychosis, were present in 11 percent of the individuals. Another 16 percent of individuals had another psychiatric disorder or an unspecified behavioral problem. In children and young adults, the 22q11DS has also been associated with high rates of a neuropsychiatric disorder (56% of n = 32), attention deficit hyperactivity disorder (44%), autistic spectrum disorders (31%), and mental retardation, with test profiles suggestive of nonverbal learning disorders.16 While the psychiatric dysfunction among those with 22q11 DS is as varied as the phenotypic presentation, several common temperamental features have been described in studies of children and adolescents with velocardiofacial syndrome (VCFS), including poor social interaction skills, high levels of anxiety, enduring fearfulness of painful situations, behavioral excitation, exaggerated response to threatening stimuli, impulsivity, and irritability.17–20 These features often precede the onset of psychosis in children in whom schizophrenia later develops.17,20 However, individuals with a less severe phenotype of 22q11 DS are often undiagnosed until the later onset of behavioral manifestations becomes prominent.15,20 Recently, a specific psychiatric entity found in children with 22q11DS has been described. Multiplex developmental disorder (MDD) has been described as a combination of several psychiatric problems that have a pervasive impact on the development of the basic skills during the first years of life. The failure to achieve developmental milestones subsequently affects social, emotional, and cognitive development.21 The strong association between 22q11DS and schizophrenia (22q11DS-Sz) has been well described.2,5,10,11,15,17–19,22–24 Approximately 25 to 30 percent of adults with 22q11DS have schizophrenia. This suggests that schizophrenia in this population is at least 25 times more prevalent than in the general community and doubles the risk for the development of the illness in a first-degree relative of an individual with schizophrenia.17,19,25 22q11DS has been found in one to two percent of those with schizophrenia.10,18 Studies have suggested that 22q11DS-Sz may be a distinct genetic subtype of schizophrenia.10,22,24 Studies disagree as to whether the schizophrenic phenotype of 22q11DS is distinguishable from other forms of schizophrenia.25,26 One study22 suggested that those with 22q11DS-Sz had a later age of onset and fewer negative symptoms. However, a larger study found no significant differences in the severity of core positive or negative symptoms between the 22q11DS-Sz and comparison group.26 Further, no differences were found in the severity of anxiety-depression scores. The difference in core symptoms between schizophrenia and 22q11DS-Sz is currently debatable. However, there is agreement that excitement factor scores from the Positive and Negative Syndrome Scale are significantly higher among those with 22q11DS-Sz.22–24 Those with 22q11DS-Sz were shown to have poor impulse control, uncooperative behavior, and hostility that differed significantly from those with non-22q11DS schizophrenia.26 Neuroanatomic Correlates and 22q11DS-Sz The results of neuroimaging among individuals with 22q11DS-Sz are qualitatively and quantitatively similar to the findings in people with schizophrenia.17,22 In a qualitative magnetic resonance imaging (MRI) study of 11 adults with 22q11DS-Sz, a high prevalence of white matter foci, concavum vergae/cavum septum pellucidum, sulcal and ventricular enlargement, and cerebellar atrophy were found. While no specific anatomic correlates to the deep white matter bright foci have been identified, it is a recognized nonspecific abnormality among those with schizophrenia.27 Although there is some neuroanatomic correlation between adults with 22q11DS-Sz and those with schizophrenia, there is little correlation between the behavioral phenotype and the degree of deletion from chromosome 22. Individuals with similar genetic deletions and shared etiology for schizophrenia may have substantial variability in measures of brain tissue and cerebral spinal fluid (CSF) volume. This is a direct result of the heterogeneity in the expression of the genetic abnormality.22 In children and adolescents with 22q11DS in whom schizophrenia does not develop, consistent neuropsychological characteristics and behavioral phenotypes have emerged that are independent of the degree of chromosome deletion. These children and adolescents routinely display higher verbal than non-verbal IQ scores, and deficits in the areas of attention, story memory, visuospatial memory, arithmetic, and performance relative to other areas of achievement and psychosocial function.28 It is believed that the behavioral phenotypes observed in children and adolescents with 22q11DS are reflective of nonverbal learning disabilities, concomitant language deficits, and social-emotional delay. Neuropsychological functioning in adults with 22q11DS is also impaired compared with that in age- and gender-matched control subjects. In adults with a deletion in chromosome 22, there is significant impairment in visual-perceptual ability, problem solving, planning, and abstract social thinking. It has been suggested that the haploinsufficiency of a neurodevelopmental gene(s) mapping to 22q11 underlies the cognitive and behavioral effects observed in individuals with the deletion syndrome.29 Regardless of the etiology, it is noted that similar neuropsychological functioning has been described in adults with non-22q11DS schizophrenia.28 Schizophrenia and Correctional Settings It is clear that the absolute number of adults in the American correctional setting continues to increase. The point prevalence at midyear 2002 was 2.1 million adults incarcerated in federal, state (prisons), or county (jails) correctional facilities. Between 1995 and the end of 2002, the incarcerated population grew an average of 3.6 percent annually, with the largest increase among those held in federal facilities (5.8%).30–32 Despite the overall increase of the number of adults incarcerated, there continues to be disproportionate representation by those with schizophrenia.33–35 It is well accepted that the background community rate of schizophrenia is often reported as 0.5 to 1.5 percent.36 It has also been well documented that correctional facilities are collection and containment centers for those with mental illness. The numerous reasons for this phenomenon have been discussed extensively and include deinstitutionalization policies from the 1950s, mandatory incarceration for drug crimes, decreases in funding for outpatient treatment programs including outreach, and society's belief that police are the most appropriate resource to deal with an individual showing aberrant behavior. It is difficult to determine with precision the prevalence of schizophrenia among incarcerated adults. Methodological and diagnostic differences make it difficult to compare results across studies. However, it has been estimated that the current and lifetime prevalences of schizophrenia among male jail detainees are three and four percent, respectively.31 Among 1,272 women in the Cook County jail system, the prevalence of schizophrenia was found to be almost 2.5 percent.33,35 Among incarcerated individuals, it is possible that 22q11DS-Sz is more common than expected. In part, this would be due to the increased prevalence of individuals with schizophrenia who are incarcerated. However, it is possible that the prevalence of 22q11DS-Sz is disproportionately higher, even when considering the prevalence of individuals incarcerated who have schizophrenia. The behavioral manifestations of temper outbursts, coupled with the presence of schizophrenia, make it possible that correctional institutions have a greater prevalence of 22q11DS-Sz than expected, based on community epidemiology. 22q11DS-Sz in Correctional Facilities Correctional facilities may well represent collection and containment centers for those with 22q11DS-Sz. Visual-spatial recognition, impairment in social learning, and delayed emotional maturation may predispose individuals with 22q11DS-Sz to impulsive behavior outbursts. Further, it is reasonable to hypothesize that behavioral dyscontrol, in the context of hostility and uncooperative behavior,26 could be causally associated to the events leading to incarceration. Methodologically, it is relatively easy to design a prevalence study to identify individuals with 22q11DS-Sz who are incarcerated and to determine if the prevalence is higher than expected, on the basis of community epidemiology. If it is assumed that the prevalence of 22q11DS-Sz is approximately the same as that in the community (the null hypothesis),37 the expected prevalence of 22q11DS-Sz in any given correctional institution per year can be calculated based on several assumptions: 15 percent of those incarcerated have schizophrenia, 1 in 4,000 live births results in an individual with 22q11DS, and 25 percent of those with 22q11DS have schizophrenia. In addition, it is relatively easy to develop a screening protocol to identify individuals with suspected 22q11DS-Sz.19,38 According to recommendations by Bassett and Chow,19 individuals with schizophrenia with two or more of the following phenotypes are at an increased risk for 22q11DS: (1) hypernasal speech or a history of velopharyngeal incompetence; (2) characteristic facial features such as long narrow face, narrow palpebral fissures, flat cheeks, prominent nose, small ears, and small mouth; (3) learning difficulties, a history of special education, or mild/borderline mental retardation; (4) congenital heart defect; (5) another significant congenital abnormality such as polydactyl, kyphosis or scoliosis, and renal anomaly; (6) a history of hypocalcemia and/or hypoparathyroidism; or (7) a history of athymia or severe immune deficiency in infancy. A prevalence study of incarcerated adults with 22q11DS-Sz would therefore first involve identification of individuals with schizophrenia. Next, a subgroup of those with schizophrenia who met the criteria from the relatively simple screening test by Bassett and Chow19 would be identified. Blood from the subgroup would then be subjected to FISH with a fluorescently labeled probe from the 22q11.2 region to identify unequivocally the chromosomes that do not fluoresce (i.e., those with submicroscopic deletions). Genetic Research in Correctional Facilities Despite the relatively simple study design that could be employed to determine the prevalence of 22q11DS-Sz in correctional facilities, recent history illustrates the difficulties, limitations, and potential misuses of such forensic research. In 1968, a landmark letter was published in The Lancet that described chromosomal analysis on Danish men reported to be criminally insane.39 Results of chromosomal analysis of 155 men who had committed arson revealed that two individuals (1.3%) had the abnormal karyotype of 47, XYY. The community prevalence of 47, XYY was well established at 1 in 1,000 live male births, or 0.02 to 0.05 percent. As a result of the Danish work, it was suggested that the risk for an abnormal karyotype increased if the individual had committed arson. The belief of disproportionate incarceration was perpetuated when Waltzer et al.40 published work that described over-representation of 47, XYY in correctional settings. In psychiatric and penal settings, the published work suggested a three- to fourfold over-representation. In special security settings that were described as mental-penal (in essence, psychiatric facilities within a correctional setting), there was a 20-fold over-representation of 47, XYY men compared with background community rates. Both landmark studies were subject to ascertainment bias. Most of the information was obtained from populations selected precisely because they demonstrated a particular personality or physical characteristic. Further, the early prevalence studies on XYY were case studies, not cohort studies. By design, the study started with individuals who were incarcerated, and the researchers then looked for those with abnormal chromosomes. A stronger study design would have found individuals with abnormal chromosomes and then would have looked for criminal history. Controlled studies concerning XYY did not occur. However, researchers continued to find cross-sectional support for the belief that men with XYY genotype were over-represented in the institutions for mentally retarded individuals, mentally ill individuals, people found criminally insane, and aggressive offenders.39,41 Despite these findings, the XYY syndrome defense has not been successful in the five major U.S. cases that have attempted to use it. In the first case, People v. Farley (1969, unpublished), the jury rejected the defendant's claim that the XYY syndrome precluded him from forming the necessary intent to commit murder. The XYY syndrome was found to not meet the state's requirements for insanity and thus was not presented as evidence in the next two cases. In the fourth case, People v. Yukl (1975),42 an appeals court found that that the "presently available medical evidence is unable to establish a reasonably certain causal connection between the XYY defect and criminal conduct" (Ref. 43, p 250). 22q11DS-Sz Research in Correctional Facilities The principle rationale for research on the 22q11DS-Sz in correctional facilities is identification of those who have significant health-related problems3,11–15 and those who would benefit from aggressive treatment of the schizophrenia. Specifically, it has been hypothesized that the genetic basis for the schizophrenia in 22q11DS has important treatment implications. Incarcerated individuals with 22q11DS-Sz may well benefit from psychopharmacologic interventions that specifically target hostility, impulse dyscontrol, and uncooperative behavior. In addition, a prevalence study would assist in confirming or refuting the suspicion that the prevalence among those incarcerated is higher than in the surrounding community. Bassett and Chow19 set forth historical and physical features that should increase the index of suspicion for 22q11DS. Some individuals, such as those who have a cleft lip and/or have undergone palate repair for velopharyngeal insufficiency or repair of a congenital heart defect may be immediately evident with medical screening. Others, such as those with unusual facies, may be harder to discern. However, the combination of specific physical attributes and behavioral indicators or prenatal developmental history increases the likelihood of the presence of 22q11DS. Thus, it would be necessary only to conduct chromosomal analyses on those individuals with a high likelihood of the presence of the deletion syndrome. A prevalence study of 22q11DS-Sz in correctional facilities would not require a control group. In addition, it is unlikely that the low IQ present for many individuals with the deletion syndrome is severe enough to affect the autonomy necessary to provide informed consent for participation in research studies. However, as with the XYY studies, such a genetic study among incarcerated individuals raises three major ethical concerns. First, it is unclear how the individual would directly benefit. It is easily argued that symptomatic schizophrenia would be recognized and treated, without the knowledge of an underlying genetic abnormality. Case law suggests that the presence of the deletion syndrome is insufficient to prove mental incompetence regarding criminal behavior. Further, it is unlikely that courts would even accept such evidence as a mitigating circumstance, as the prosecution would only need to allude to all the noncriminal members of society who also possess the deletion syndrome. Another ethical concern regarding a prevalence study of 22q11DS-Sz among those incarcerated involves the issue of how society would benefit from such research. Clearly, there is no method to screen and identify individuals at risk for the deletion syndrome or for antisocial behavior among those with the deletion syndrome. Nor is it a factor for intervention after the commission of a crime. The simple knowledge of who has the deletion syndrome among those incarcerated is insufficient to benefit society. Finally, the ethical principle of justice in the application of the findings must be addressed when considering such research. It is entirely unclear how the finding of the deletion syndrome applied to a unique individual would provide justice to their idiosyncratic circumstances. Nor would there be justice available to victims of the alleged crimes, based on the genetic knowledge. In summary, it is highly possible that 22q11DS-Sz has a higher prevalence among those incarcerated than in the surrounding community. However, the application of the findings of previous genetic studies among those incarcerated, coupled with the ethical dilemmas raised by such a proposal, make it unlikely that a definitive project would be undertaken. Footnotes This paper was presented at the 35th Annual Meeting of the American Academy of Psychiatry and the Law, Scottsdale, AZ, October 21–24, 2004. References Cohen E, Chow EW, Weksberg R, et al: Phenotype of adults with the 22q11 deletion syndrome: a review. Am J Med Genet 86:359–65, 1999 Murphy KC: Schizophrenia and velo-cardio-facial syndrome. Lancet 359:426–30, 2002 Vogels A, Fryns JP: The velocardiofacial syndrome: a review. Genet Counsel 13:105–13, 2002 Yamagishi H: The 22q11.2 deletion syndrome. Keio J Med 51:77–88, 2002 Sugama S, Namihira T, Matsuoka R, et al: Psychiatric inpatients and chromosome deletions within 22q11.2. J Neurol Neurosurg Psychiatry 67:803–6, 1999 Emanuel BS, McDonald-McGinn D, Saitta SC, et al: The 22q11.2 deletion syndrome. Adv Pediatr 48:39–73, 2001 Devriendt K, Fryns JP, Mortier G, et al: The annual incidence of DiGeorge/velocardiofacial syndrome. J Med Genet 35:789–90, 1998 Murphy KC, Jones RG, Griffiths E, et al: Chromosome 22q11 deletions: an under-recognized cause of idiopathic learning disability. Br J Psychiatry 172:180–3, 1998 Eliez S, Blasey CM, Schmitt EJ, et al: Velocardiofacial syndrome: are structural changes in the temporal and mesial temporal regions related to schizophrenia? Am J Psychiatry 158:447–53, 2001 Bassett AS, Hodgkinson K, Chow EWC, et al: 22q11 deletion syndrome in adults with schizophrenia. Am J Genet 81:328–37, 1998 Lazier K, Chow EW, Abdel Malik P, et al: Low platelet count in a 22q11 deletion syndrome subtype of schizophrenia. Schizophr Res 50:177–80, 2001 Carlson C, Papolos D, Pandita RK, et al: Molecular analysis of velo-cardio-facial syndrome patients with psychiatric disorders. Am J Hum Genet 60:851–9, 1997 Cuneo BF, Driscoll DA, Gidding SS, et al: Evolution of the latent hypoparathyroidism in familial 22q11 deletion syndrome. Am J Med Genet 69:50–5, 1997 Ryan A, Goodship JA, Wilson DI: Replies to letters regarding clinical features of chromosome 22q11 deletion. J Med Genet 35:347, 1998 Vataja R, Elomaa E: Midline brain anomalies and schizophrenia in people with CATCH 22 syndrome. Br J Psychiatry 172:518–20, 1998 Niklasson L, Rasmussen P, Oskardottir S, et al: Neuropsychiatric disorders in the 22q11 deletion syndrome. Genet Med 3:79–84, 2003 Chow EW, Mikulis DJ, Zipursky RB, et al: Qualitative MRI findings in adults with 22q11 deletion syndrome and schizophrenia. Biol Psychiatry 46:1436–42, 1999 Hodgkinson KA, Murphy J, O'Neill S, et al: Genetic counseling for schizophrenia in the era of molecular genetics. Can J Psychiatry 46:123–30, 2001 Bassett AS, Chow EWC: 22q11 deletion syndrome: a genetic subtype of schizophrenia. Biol Psychiatry 46:882–91, 1999 Golding-Kushner KJ, Weller G, Shprintzen RJ: Velo-cardio-facial syndrome: language and psychological profiles. J Craniofac Genet Dev Biol 5:259–266, 1985 Prinzie P, Swillen A, Vogels A, et al: Personality profiles of youngsters with velo-cardio-facial syndrome. Genet Counsel 13:265–80, 2002 Chow EWC, Zipursky RB, Mikulis DJ, et al: Structural brain abnormalities in patients with schizophrenia and 22q11 deletion syndrome. Biol Psychiatry 51:208–15, 2002 Murphy KC, Jones LA, Owen HJ: High rates of schizophrenia in adults with velo-cardio-facial syndrome. Arch Gen Psychiatry 56:940–5, 1999 Bassett AS, Chow EWC, Abdel Malik P, et al: The schizophrenia phenotype in 22q11 deletion syndrome. Am J Psychiatry 160:1580–6, 2003 Eliez S, Schmitt EJ, White CD, et al: Children and adolescents with velocardiofacial syndrome: a volume MRI study. Am J Psychiatry 157:409–15, 2000 Kates WR, Burnette CP, Jabs EW, et al: Regional cortical white matter reductions in velocardiofacial syndrome: a volumetric MRI analysis. Biol Psychiatry 49:677–84, 2001 Lee SI, Jung HY, Kim SH, et al: Midline brain anomalies in a young schizophrenic patient with 22q11 deletion syndrome. Schizophr Res 60:323–5, 2003 Woodin M, Wang PP, Aleman D, et al: Neuropsychological profile of children and adolescents with the 22q11.2 microdeletion. Genet Med 3:34–9, 2001 Henry JC, van Amelsvoort R, Mooris RG, et al: An investigation into the neuropsychological profile in adults with velo-cardio-facial syndrome (VCFS). Neuropsychologia 40:471–8, 2002 Bureau of Justice Statistics: Corrections Statistics. http://www.ojp.usdoc.gov/bjs/correct.htm (accessed February 16, 2004) Bureau of Justice Statistics: Corrections Statistics. http://www.ojp.usdoc.gov/bjs/jails.htm (accessed February 16, 2004) Bureau of Justice Statistics: Corrections Statistics. http://www.ojp.usdoc.gov/bjs/prisons.htm (accessed February 16, 2004) Abram KM, Teplin LA, McClelland GM: Comorbidity of severe psychiatric disorders and substance use disorders among women in jail. Am J Psychiatry 160:1007–10, 2003 Teplin LA: Psychiatric and substance abuse disorders among male urban jail detainees. Am J Public Health 84:290–93, 1994 Teplin L, Abram KM, McClelland GM: Prevalence of psychiatric disorders among incarcerated women: I. Pretrial jail detainees. Arch Gen Psychiatry 53:505–12, 1996 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (ed 4, text revision). Washington, DC: American Psychiatric Association, 2000, p 308 Wassertheil-Smoller S: Mostly about statistics, in Biostatistics and Epidemiology: a Primer for Health Professionals (ed 2). Edited by Wassertheil-Smoller S. New York: Springer-Verlag, 1990, pp 55–6 Arinami T, Ohtsuki T, Takase K, et al: Screening for 22q11 deletions in a schizophrenia population. Schizophr Res 52:167–70, 2001 Neilsen J, Tsuboi T, Sturup G, et al: XYY chromosomal constitution in criminal psychopaths. Lancet 7:(7567):576, 1968 Waitzer S, Gerald PS, Shah SA: The XYY genotype. Annu Rev Med 29:568–70, 1978 Hoffman BF: Two new cases of XYY chromosome complement and a review of the literature. J Can Psychiatric Assoc 22:447–55, 1977 People v. Yukl, 372 N.Y.S.2d 313 (N.Y. Sup. Ct. 1975) Denno DW: Legal implications of genetics and crime research, in Genetics of Criminal and Antisocial Behavior. Ciba Foundation Symposium 194. New York: John Wiley & Sons, 1996, p 250...查看详细 (27016字节)
☉ 11326920:Mental Incapacity Defenses at the War Crimes Tribunal: Questions and Controversy
Dr. Sparr is Associate Professor of Psychiatry, School of Medicine, Oregon Health and Science University, Portland, OR. Abstract Following a report from the Secretary General in May 1993, the United Nations Security Council adopted Resolution 827 and its Statute establishing an International War Crimes Tribunal for the Former Yugoslavia (ICTY) located in The Hague, The Netherlands. Although such action has been discussed in the past, this is the first time the international community has established a tribunal to indict and try individuals for war crimes. The crimes had been previously "created" by multilateral international treaties. The ICTY Rules of Procedure and Evidence allowed for "any special defense, including that of diminished or lack of mental responsibility." Precise legal parameters of the defense were not specified. In 1998, a defendant at the ICTY "Celebici" Trial named Esad Landzo raised the defense of diminished mental responsibility. The Celebici Trial Chamber thus became the first legal body to consider reduced mental capacity as it applies to international criminal law. This article is an examination of the application of the affirmative defense of diminished responsibility at the ICTY and relates the process to the need for further definition of mental incapacity defenses at the newly established International Criminal Court (ICC). At the ICC preparatory commission, drafting material elements of crimes was emphasized, with less consideration given to mental elements. That diminished capacity and diminished-responsibility defenses have often confused scholars and practitioners alike is explored in this article with suggestions for further directions. In 1993, the International War Crimes Tribunal was established by the United Nations (UN) Security Council in response to the international community's demand for urgent action against widespread violations of international humanitarian law in the former Yugoslavia. The purposes of the Tribunal were threefold: to do justice, to contribute to the restoration and maintenance of peace, and to deter further crimes.1 The use of the defense of reduced mental capacity found its first concrete application in November 1998, in the Tribunal's Celebici Judgment, in which the Trial Chamber dealt with "diminished responsibility," a concept seemingly borrowed from the criminal law of England and Wales.2 The Celebici Indictment against three Bosnian Muslims and one Bosnian Croat alleged that in 1992 Bosnian Muslim and Croat forces took control of villages with predominantly Bosnian Serb populations in and around the Konjic municipality in central Bosnia-Herzegovina. Captured Serbs were held in a prison camp in the village of Celebici, where they were allegedly killed, tortured, sexually assaulted, and subjected to cruel and inhuman treatment. The accused, a young camp guard (Esad Landzo), the camp commander (Zdravko Mucic), the camp deputy commander and later commander (Hazim Delic), and the coordinator of Bosnian-Croat forces in the area and later a commander in the Bosnian Army (Zejnil Delalic), were charged with offenses under the international humanitarian law constituting grave breaches of the Geneva Conventions and violations of laws or customs of war pursuant to Articles 2 and 3 of the International Criminal Tribunal for the former Yugoslavia (ICTY).3 Mr. Landzo and Mr. Delic were charged for the most part with individual criminal responsibility pursuant to Article 71 of the ICTY Statute as direct participants in certain of the alleged crimes, including acts of murder, torture, and rape.4 Mr. Landzo was specifically charged with beating several detainees to death with wooden planks, baseball bats, chains, and other items and with torturing prisoners by inflicting burns and suffocation.5 At an early stage in the trial, in response to the charges brought against him, Mr. Landzo raised the special defense of "diminished, or lack of, mental responsibility," as specified in the ICTY rules of procedure and evidence.6 He later made a submission requesting clarification from the Trial Chamber as to the precise legal parameters of the defense. The Trial Chamber determined that a party offering a special defense of diminished or lack of mental responsibility "carries the burden of proving this defense on the balance of probabilities" but reserved a decision on a definition of the defense until final judgment.7 The Celebici Trial Chamber thus became the first and, at this writing, the only organ to infuse the ICTY's "diminished, or lack of, mental responsibility" formulation with practical content. Mr. Landzo raised the defense in the form of a "diminished responsibility" plea. Because Rule 67(A)(ii)(b)6 does not identify the elements of the defense, the Chamber established a two-part test: at the time of the alleged acts, the accused must have been suffering from an "abnormality of the mind" that "substantially impaired" his ability to control his actions.7,8 Another aspect of the analysis of this or most other criminal offenses relates to the necessary mental element (or mens rea) of the crime. Often, this centers on the question of criminal intent. At the Celebici Trial, the defense sought to rely on a circumscribed concept of intent, and, in particular, to establish that the defendant acted recklessly without specific intent to cause death by his actions. The defense argued that the mens rea element of the offense of "willful killing" as specified in the ICTY Statute required a showing by the prosecution that the accused must have had a specific intent to commit murder. Although different legal systems use different forms of classification of mental elements in the crime of murder, the ICTY Trial Chamber held that some form of intention was clearly required for a murder conviction, but was silent about the exact nature, or even the existence, of requisite mental elements.7 Because the interface between psychiatry and the law is often controversial, particularly regarding various forms of excuse from responsibility for criminal behavior, ICTY precedents in this area will undergo careful scrutiny.9 In particular, due to the diversity of practical content in the defense as defined by various municipal legal systems, the Celebici Trial raised questions about restraints on an international court's norm-creating authority under "general principles of law."10,11 This article is an examination of the application of mental abnormalities in the use of the affirmative defense of diminished responsibility at ICTY and how it may pertain to evolving international criminal law. I contrast this with three alternative concepts of reduced mental capacity, including diminished capacity or a "failure-of-proof" defense that was developed in the United States and was introduced by the defense at the Celebici Trial. I will show that even though the Celebici Trial Chamber expected to employ a single diminished responsibility concept, four variations were pursued and discarded without resolution about which one to use. As a result, the international legal community was figuratively left in the lurch, having received little practical guidance for the newly established International Criminal Court (ICC) where mental incapacity defenses have yet to be well defined.12 Background Following a report from the Secretary General in May 1993, the UN Security Council adopted Resolution 8271 and its Statute establishing an International War Crimes Tribunal for the former Yugoslavia (ICTY) to be located in The Hague, The Netherlands. The Statute defined the Tribunal's authority to prosecute particular crimes and set forth basic guiding principles. It authorized the Tribunal to indict and try four different categories of crimes: grave breaches of the 1949 Geneva Conventions; violations of the laws or customs of war; crimes against humanity; and genocide. The Security Council did not create the list. Each one was based on long-standing customary international law or international treaty.13 The Tribunal's Statute does not address defenses in general, but paragraph 58 of the Report of the Secretary General, which embodies the intent of the drafters, directs that "The International Tribunal itself will have to decide on various personal defenses that may relieve a person of individual criminal responsibility, such as minimum age or mental incapacity, drawing upon general principles of law recognized by all nations."14 Non-inclusive examples were given; therefore, it was interpreted that if a defense was available under general principles of law, it should be available under the Statute.15 Legal Concepts Criminal Intent Criminal law constitutes a description of harms that society seeks to prohibit by threat of criminal punishment. At the same time, the criminal law includes an elaborate body of qualifications to these prohibitions and threats based on absence of fault. A common usage is to express these qualifications to liability in terms of the mens rea requirement. This usage is the thought behind the classic maxim, actus non facit reum, nisi mens sit rea, or in Blackstone's translation, "an unwarrantable act without a vicious will is no crime at all" (Ref. 16, p 203). One way in which the mens rea requirement may be rationalized is through a common-sense view of justice that blame and punishment are inappropriate and unjust in the absence of choice.17 So viewed, a great variety of defenses to criminal liability may be characterized as presenting mens rea defenses—involuntary acts, duress, legal insanity, accident, or mistake, for example. This all-encompassing usage may be referred to as mens rea in its general sense. There is, however, a narrower use of mens rea, which may be referred to as mens rea in its special sense, that refers only to the mental state required by the definition of the offense that produces or threatens harm. Not all possible mental states are relevant to the law's purposes. Whether a defendant acted regretfully, arrogantly, eagerly, or hopefully may be relevant for a judge contemplating a sentence, but the mental states relevant to defining criminal conduct and differentiating degrees of culpability in legal systems are more limited. Indeed, mental state is something of a misnomer. The concern of criminal law is with the level of intentionality with which the defendant acted—in other words, with what the defendant intended, knew, or should have known.16 Every crime involves the uniting of act (actus reus) and criminal intent (mens rea). In the 20th century, in most U.S. jurisdictions, the idea of mens rea and the law has evolved from its earlier sense of guilty mind into a number of narrow and technically defined mental states.18 American law has employed an abundance of mens rea terms, such as general and specific intent, malice, willfulness, wantonness, recklessness, scienter, premeditation, criminal negligence, and the like, exhibiting what Justice Jackson, in a famous Supreme Court opinion, called, "the variety, disparity and confusion of definitions of the requisite elusive mental element" (Ref. 19, p 252). In the last century, mens rea terms have burgeoned in common law countries such as the United States and England. In civil law systems, such as those of most European countries, the mens rea concept is more limited, usually involving a combination of either awareness and desire or knowledge and intent. Process of Proof Rules allocating the burden of proof deal with two distinct problems. The first concerns allocating the burden of coming forward with enough evidence to put a certain fact into issue, commonly referred to as the burden of production. The second problem concerns allocating the burden of convincing the trier-of-fact, commonly called the burden of persuasion. With respect to most elements of most crimes, the prosecution bears both burdens. That is, the prosecution must introduce enough evidence not only to put the facts at issue but also to persuade the trier-of-fact beyond a reasonable doubt. In some instances, state law may require the defense to bear both burdens, but if it does, a due process proviso is that the defendant may never bear the burden of persuasion for an element of the crime. The state must always disprove defenses that negative an element of the crime beyond a reasonable doubt. An intermediate position is also possible: the law may allocate the burden of production to the defense, but allocate the burden of persuasion to the prosecution. For example, the state may provide that a defendant seeking acquittal on grounds of duress must introduce some evidence of duress, but once this is done, the prosecution must prove the absence of duress beyond a reasonable doubt. When the defendant bears the burden of production that does not negative an element of the crime, it is commonly referred to as an affirmative defense. In some states, when an issue is designated an affirmative defense, the defendant must bear the burdens of both production and persuasion, but it is common practice to treat burdens of production and persuasion as separate issues. Thus, the defendant may bear the burden of persuasion on some affirmative defenses, but with respect to others, he may only bear the burden of production.16 Under the American Law Institute Model Penal Code, the defendant generally bears only the burden of production, and once an affirmative defense is raised, the prosecution must disprove it beyond a reasonable doubt.20 Examples of affirmative defenses are self-defense, duress, or mental incapacity. Concepts of Justification and Excuse There are three distinct defenses that can be invoked to bar conviction for an alleged crime. The first asserts that the prosecution has failed to establish one or more required elements of the offense. The defendant may deny, for example, that he was anywhere near the scene of the crime, or he may concede the fatal shot but deny that he acted intentionally. These are simply efforts to refute (or raise a reasonable doubt about) whatever the prosecution must prove (failure-of-proof defense). The defendant may attempt to put forth evidence to disprove either the mental elements and/or material elements of the crime. In the former, the defendant essentially states, "I did not commit the crime charged because I did not possess the requisite mens rea." Of course, the prosecution always retains the burden of proving its own case and of disproving any rebuttal efforts beyond a reasonable doubt.21 The other two sorts of defenses are justifications and excuses, which do not seek to refute the required elements of the prosecution's case but rather suggest further considerations that negate culpability even when all elements of the offense are clearly present. Thus, both self-defense and insanity claims suggest reasons to bar conviction even when it has been clearly proved that a defendant killed intentionally. It is customary, moreover, to distinguish sharply between these two groups of defenses (justifications and excuses). Self-defense, for example, is traditionally considered a justification, while insanity is considered an excuse. In one defense, the defendant accepts responsibility but denies bad behavior; in the other, the defendant admits that the behavior was bad but does not accept full responsibility.22 The Celebici Trial Willful Killing and Murder at Celebici The Celebici indictment alleged that each of the accused was responsible for the killing of several detainees in the Celebici Detention Camp by either personal participation or exercise of superior authority over those directly involved. The indictment was formulated in such a way as to classify these acts as both "willful killing," punishable under Article II of the Statute of the International Tribunal, and "murder," punishable under Article III of the Statute. The Trial Chamber found that there was no qualitative difference between "willful killing" and "murder" and noted that "willful killing" was incorporated directly from the Four Geneva Conventions—in particular, Articles 50, 51, 130, and 147—which set out those acts that constitute "grave breaches" of the Conventions.7 Celebici defense lawyers, however, contended that there was a contradiction between the definition of "willful" in Article 85 of Additional Protocol I to the Geneva Convention and Article 32 of the Fourth Geneva Convention. Specifically, in the Additional Protocol it is noted that "most of the acts listed in this article can only be committed with intent."23 The defense, in a motion to dismiss, relied on the final sentence of the Commentary to Article 85 contending that it "strongly suggests that murder requires intent."24 The nature of this "intent" requirement listed in the protocol was left unexplained, however. The defense took the position that "intent" meant specific intent and that the "reckless" acts of the Celebici defendants may not meet requirements for a specific-intent crime. The prosecution disagreed and asserted that the defense wrongly sought to equate the concept of recklessness with simple negligence. The word "willful," they pointed out, should be interpreted to incorporate reckless acts as well as a specific desire to kill, therefore just excluding negligence, which by definition is inadvertent. In support of this argument, the Prosecution relied on the Commentary to Article 85 of Additional Protocol I, which defines "willfully" in the following terms: [T]he accused must have acted consciously and with intent, i.e., with his mind on the act and its consequences, and willing them ('criminal intent' or 'malice aforethought'); this encompasses concepts of 'wrongful intent' or 'recklessness,' viz, the attitude of an agent who, without being certain of a particular result, accepts the possibility of it happening; on the other hand, ordinary negligence or lack of foresight is not covered, i.e., when a man acts without having his mind on the act or its consequences [Ref. 25, ? 3474]. The Trial Chamber agreed, noting that the Commentary to Additional Protocol I, Article 11 incorporates the concept of "recklessness" into that of "willfulness," while just excluding mere negligence from its scope. In addition, in relation to Article 85 of the Additional Protocol, the Commentary sought to distinguish ordinary negligence from conscious-risk creation or recklessness and regarded only the latter as encompassed by the term "willful."5 The Trial Chamber also found that the ordinary meaning of the English term "murder" is also understood as something more than manslaughter, and thus no "difference of consequence" flows from the use of "willful killing" in place of "murder."7 Finally, the Trial Chamber stated that there was no doubt that the necessary intent, meaning mens rea, required to establish the crimes of willful killing and murder, as recognized by the Geneva Conventions, is present when intention is demonstrated on the part of the accused to kill or inflict serious injury in reckless disregard of human life. "It is in this light that the evidence relating to each of the alleged acts of killing is assessed... " (Ref. 7, ? 439, pp 160–1). Thus, the Trial Chamber failed to begin to create a hierarchy of international capital crimes with corresponding required mental elements, thereby eschewing a task of daunting complexity. They found, instead, that there is no definitional difference between willful killing and murder, both of which simply require intent to inflict serious harm and for practical purposes may be encompassed by mental elements of gravity greater than negligence. The Special Defense of Diminished Mental Responsibility In Sub-rule 67(A)(ii)(b) of the rules of procedure and evidence of the International Tribunal, it states that "the Defense shall notify the Prosecutor of its intent to offer: any special defense, including that of diminished or lack of mental responsibility...."6 The plea of diminished responsibility is distinguished from the plea of lack of mental responsibility (or insanity). In particular, it was apparent that the special defense provided for in Sub-rule 67 was interpreted to have its closest analogy in the English Homicide Act, clearly articulated in Section 2 (1) which only permits a diminished-responsibility defense when an accused who kills another "was suffering from such abnormality of mind (whether arising from a condition of arrested or retarded development of mind or any inherent causes, or induced by disease or injury) as substantially impaired his mental responsibility for his acts or omissions in doing or being party to the killing."26 The English interpretation had gained currency with the Trial Chamber because of the specific term "diminished responsibility" in the rule, as opposed to, for example, the American term "diminished capacity." In England, the first attempt to define the phrase "abnormality of the mind" within the meaning of Section 2, was in R. v. Byrne, in which Lord Chief Justice Parker, delivering the judgment of the court, stated as follows, "...[I]t means a state of mind so different from that of ordinary human beings that the reasonable man would term it abnormal" (Ref. 27, p 396). This cryptic definition avoided fastening a condition to any particular mental abnormality. As the Celebici Trial preparation progressed, the defense lawyers for Esad Landzo, after some debate, recommended a variation of the insanity defense to their client, and, as a result, pursuant to the rules of procedure and evidence, Mr. Landzo advanced the plea of diminished responsibility for all charges brought against him. He at first argued that he suffered from diminished responsibility due to circumstances that had precipitated the psychiatric condition post-traumatic stress disorder (PTSD). The plea of diminished responsibility was based on the premise that despite recognizing the wrongful nature of his actions, Mr. Landzo, on account of his abnormality of mind, was unable to be in complete control of his actions. A defense lawyer described Mr. Landzo as "a good kid driven to beastly acts by the war."28 While the concept of diminished responsibility was not defined in the Statute, it was the Trial Chamber's position that such a defense had been articulated in the laws of various national legal systems and that it was, therefore, permissible to resort to such systems in defining the diminished-responsibility concept expressed in the rules. Because of initial concerns about Mr. Landzo's emotional state during his early incarceration, he was examined by three court-appointed European psychiatrists to assess his fitness to stand trial. After he was determined to be fit, the same psychiatrists were then asked by the defense to comment about the existence of diminished or lack of mental responsibility. The decision to pursue a diminished-responsibility plea was initially proposed by one defense attorney over the objections of another, and the attorney who favored the strategy prevailed with the defendant.28 When initial evaluations pointed toward PTSD, it was decided to advance that diagnosis as a basis for a diminished-responsibility defense. Subsequent evaluations, however, were heavily weighted toward Mr. Landzo's abnormal personality dynamics and putative "personality disorder" which ultimately became the basis for his defense. At trial, five psychiatrists—two retained by the defense, one by the prosecution, and two originally appointed by the court and called by the defense—testified about Mr. Landzo's mental state at the time of the acts in question.7 With the exception of the prosecution's expert, all testified that Mr. Landzo suffered from mental disorder(s) at the time of the acts, but there was wide disagreement about specific diagnoses. In both their reports to the court and their testimony at trial, psychiatrists generally eschewed DSM-IV and ICD-9 diagnostic criteria, instead citing Mr. Landzo's personality characteristics variably described as narcissistic, antisocial, schizoid, compliant, borderline, inadequate, immature, impulsive, unstable, and deprived. The particular permutations of Mr. Landzo's personality-disorder defense were quite complex and are beyond the scope of this article. A companion article is in preparation that will focus on the use of personality disorder-based mental-incapacity defenses in international legal systems as exemplified by the Celebici Trial.29 Because, as mentioned previously, Sub-rule 67(A)(ii)(b)6 does not identify the parameters of the defense, the Trial Chamber established a two-part test for the "diminished-responsibility" component, with language borrowed from Section 2(1) of the Homicide Act. At the time of the alleged acts, the accused must have been suffering from an "abnormality of mind" which "substantially impaired" the ability of the accused to control his or her actions. It was also established that diminished responsibility is an affirmative defense and that the accused must bear both the burden of production and persuasion. On the facts, the Chamber accepted that Mr. Landzo suffered from an "abnormality of mind" at the time of his acts, but rejected his claim, not because an affirmative defense was raised but because he failed to satisfy the second prong (e.g., Mr. Landzo's "mental condition" did not prevent him from controlling his behavior). Mr. Landzo was found guilty on 17 counts of war crimes, and sentenced to 15 years' imprisonment. In pronouncing sentence, the Chamber cited Mr. Landzo's "mental condition" as a mitigating factor.7 Discussion The fact that Sub-rule 67 does not spell out the parameters of the special defense became an issue of contention at trial. The defense claimed that it was required to use a legal test of diminished responsibility without understanding the interpretation of the rule. Unfortunately, the Celebici Camp judgment provided little guidance on this crucial question. The concept of reduced mental capacity caused enormous confusion at trial, resulting in repetitive attempts at clarification.30 By not accepting the diminished-responsibility contention of defense, and therefore not demonstrating how their particular reduced-mental-capacity interpretation was applicable to future ICTY judgments, the Chamber in effect remained silent and left the matter in doubt. A key question is whether diminished responsibility is better considered as an affirmative defense or a sentencing mitigation factor. This is an important issue that can have significant substantive and procedural consequences. And, as any informed observer would acknowledge, diminished responsibility and its American counterpart, diminished capacity, have been exceptionally confusing and troublesome to courts and scholars alike. One reason is that there are several versions of the defense, each with a fundamentally different conceptual basis.31 Over time, municipal legal systems have established one or more of the following as possible consequences of a finding of reduced mental capacity: (1) the "diminished-responsibility" doctrine created by Section 2 of the English Homicide Act of 195726; (2) the mens rea variant; (3) the partial responsibility variant; and (4) the use of a mental disorder to reduce sentences. Diminished Responsibility The diminished-responsibility defense is a creation of Scottish common law in the 19th century. Scottish courts have used the term to refer to situations in which a person is found to merit a lesser punishment because of a mental disorder.32 Subsequently, England enacted it in statutory form at a time when capital punishment was still used in premeditated murder cases. Under the English statute, a defendant charged with first-degree murder could introduce evidence showing that he was mentally disturbed at the time of the offense.33 If the jury agreed, it could find him guilty of manslaughter if it also concluded that this abnormality of mind substantially impaired his responsibility for his acts, even though the prosecution had proved all the elements of murder. The jury was permitted to enter a more lenient verdict because it would avoid the imposition of a death sentence on a mentally disturbed, but not insane, offender. Thus, the purpose of the English rule of diminished responsibility was to alleviate the inflexibility of the mandatory death sentence. In essence, the British doctrine is a form of punishment mitigation by reducing the grade of the offense in homicide cases.31 In the course of the Celebici Trial, the Tribunal Chamber essentially adopted the definitional features of the English model in an effort to recognize the relationship between partial mental incapacity and criminal charges. A question, however, arises as to whether the English sense of proportionality in this matter is transferable to international criminal law, which has never tried to distinguish between murder and manslaughter.34 As a general principle, do categories of international crimes exist in a fundamental hierarchy? For a structure incorporating the English variant to function, a system of lesser included offenses would either have to be found within one or more of the core crimes, or the core crimes themselves would have to be arranged in a vertical hierarchical structure based on gravity. In either case, it would necessitate close examination of the elements of international crimes to determine a proper hierarchy. An impediment to the foreseeable realization of such an undertaking is the fact that the task of identifying the mental elements of international crimes is far from complete. In sum, it can be said that reception of the English variant would entail considerable doctrinal and practical complexities. Regardless, it could still be viewed as suitable for international prosecution if indeed it is necessary to advance the system's objectives. In this regard, however, seemingly crucial factors are the absence in the international system of minimum mandatory sentences and the apparent availability of the partial-responsibility variant due to the flexible sentencing discretion afforded to international courts.9,35 As a result, the English variant's rationale—the avoidance of mandatory sentencing—is not relevant, and simple mitigation of punishment could satisfy the fundamental fairness concerns associated with the mental-incapacity defense, unless it is determined that the English principle of dictated correlation between the crime and its punishment should take priority. If these conclusions are valid, it would be beneficial for the ICTY to consider abandoning the English variant, particularly since the notion of lesser crimes has not received universal acceptance in the ICTY itself.11,36 This could be accomplished either by plenary amendment of Sub-rule 67(A)(ii)(b), or by judicial decision, in which the ICTY would make the phrase "diminished responsibility" applicable only to mitigation of punishment, not reduction of the level of criminal responsibility. Mens Rea Variant The second use of mental-abnormality evidence is referred to as the mens rea variant and is the only mental variant explicitly adopted in U.S. jurisdictions.21 In this view, which is usually termed diminished capacity, evidence of mental abnormality is admitted to negate the required state of mind or mental element of the offense charged. As mentioned earlier, diminished capacity is called a "failure-of-proof" defense because it is used to show that the prosecution has not proved its case. This view recognizes that because the defendant must possess a certain state of mind to be convicted of certain crimes, any evidence showing the absence of that state of mind is admissible. Celebici defense lawyers' efforts to introduce U.S. mens rea definitional concepts into ICTY proceedings failed because the Trial Chamber hesitated to enter territory where others have lost their way. Indeed, the most far-reaching mens rea defenses grew out of a series of provocative landmark California cases in the 1950s and 1960s, but the defense eventually lost national credibility after the Dan White murder trial in 1981 (and the "Twinkie defense").37 In a short period, diminished capacity went from being only known to lawyers to being notorious, and deeply troubling to the public.38 In 1984, Professor Stephen Morse aptly coined the phrase "undiminished confusion" to highlight the fact that definitions of mens rea mental elements had become increasingly arcane and difficult to understand.39 He argued for the use of a "properly defined" and actually formed mens rea rather than whether the defendant possessed the "capacity" to form it. California eventually abolished the diminished-capacity defense, which it had previously nurtured. The new statute declared that, while evidence of a mental disorder could not be introduced to negate a defendant's "capacity" to form a required mental state, such evidence was still admissible on the question of whether the accused had actually formed the required specific intent. This has been referred to as "diminished actuality" in California, to emphasize its distinction from the now forbidden diminished-capacity plea.37 In practice, the distinction between the capacity to form mens rea and actually forming mens rea has mostly become a semantic one. Similar problems surfaced when the ICC Preparatory Commission, meeting in 2000, discussed draft recommendations for mental elements of crimes, and it became clear that national practices and theories differed substantially.40 When concepts such as recklessness or negligence were advanced, there was a widespread disposition to avoid including culpability based on either one. Most conceded that, at best, the occasions for recklessness or negligence liability would be few.33 The ICC statute limited the jurisdiction of the court to "the most serious crimes of concern to the international community as a whole,"41 which suggests that the parsing of such crimes would be detrimental to the mission of international prosecution.2 The agreed upon mental element language in the initial ICC statute states that "a person shall be criminally responsible...if the material elements are committed with intent and knowledge."42 Partial Responsibility Variant In the partial responsibility variant, the criminal defendant does not use mental abnormality evidence to rebut the prosecution's case as seen in the mens rea variant. Instead, the defendant uses the evidence to put forth a form of lesser legal insanity. This variant is a less circumscribed version of the English rule of diminished responsibility and, as in England, the inquiry is essentially a moral one. It is the same as diminished responsibility but is broader in scope because it may apply to crimes other than homicide. The defendant claims that, as a result of mental abnormality, he is not fully responsible for the crime proved against him and uses expert testimony about his mental abnormality to show that he may have been less responsible than other defendants. Thus, the prosecution's prima facie case against the defendant is not challenged; rather, the defendant claims that he is less culpable and either seeks conviction of a lesser crime or seeks to have his punishment reduced. In some European legal systems in which this variant is used, the trier-of-fact may reduce the criminal defendant's punishment if the defendant is seen as less blameworthy.21 For example, the Italian criminal code43 provides for reduced punishment if a defendant's responsibility is greatly reduced at the time of the crime by virtue of "partial mental deficiency." French law gives lessening of individual criminal responsibility for a "psychic or neuropsychic disorder, which impairs understanding or interferes with the control of his or her acts...." The court shall take this into "account...when it determines the penalty and fixes its regime."44 In both instances, however, evaluation of social dangerousness accompanies the sentencing decision, which may include order to a judicial psychiatric hospital.45 In The Netherlands, the area between full responsibility and total nonresponsibility is referred to as "diminished responsibility" and is the most direct example of partial responsibility and correlative punishment. The term is not in the statutes but is based on Article 37A of the Criminal Code, which states that a person may be sentenced to TBS (placement under a hospital order) when he commits an offense while suffering from "developmental deficiencies and pathological disturbance." The mental disturbance must be one of the factors that led to the offense, and the stronger the connection, the lower the responsibility. There are five levels of responsibility, ranging from fully responsible to not responsible. A distinction is drawn in the gradations of diminished responsibility in relation to the intensity of the role played by the psychological disorder in the offense. A prison sentence is imposed for the part for which the perpetrator may be held personally responsible. The greater the personal responsibility imputed by the court, the longer the sentence. TBS is always enforced after the prison sentence has been served, which need not, however, be served in full.46,47 Germany has a similar dual system, whereby offenders found to have partial responsibility can be given a prison sentence as well as compulsory treatment. Here, however, the committal to a psychiatric hospital precedes the prison term, and the time spent under compulsory treatment is counted toward the prison sentence.48 Diminished responsibility in sentencing has also been recognized in South African law. Primarily, it appeared in relation to psychopathy and mental deficiency, but now is clearly considered in various cases short of legal insanity. While this allows a finding of extenuating circumstances, it does not have the effect of reducing the crime category as in England. During sentencing, the court must take into account mental responsibility even if short of insanity.49 This was enacted into the Criminal Procedure Act of 1977: [I]f the court finds that the accused at the time of the commission of the act in question was criminally responsible for the act, but his capacity to appreciate the wrongfulness of the act was diminished by reason of mental illness or mental defect, the court may take the fact of such diminished responsibility into account when sentencing the accused [Ref. 50, 78, art. 7]. Within the Canadian and Swedish legal systems, a formal provision for partial criminal responsibility does not exist.51,52 The partial-responsibility variant is a reaction to the all-or-nothing approach that traditionally recognized only two classes of defendants: the sane and the insane.53 In some U.S. jurisdictions, diminished capacity, ostensibly an investigation of a defendant's capacity for intent, has become a disguised version of partial responsibility.39 To add to the confusion, it continues to be called diminished capacity. This practice has received criticism, including pleas for its elimination.39,54 Although Celebici defense lawyers paid homage to the English diminished-responsibility variant, they hoped to make Mr. Landzo less culpable in the eyes of the judges due to his "mental disorder." The sentencing provisions of the ICTY statute include the "individual circumstances" of the offender as a potential mitigating factor, and mandatory minimum sentences are absent.2 At trial, despite the ministrations of the Celebici Chamber, the practical application of the Landzo defense was more in keeping with the partial-responsibility variant than with the English Homicide Act. The Celebici Chamber cited Esad Landzo's mental condition as a mitigating circumstance in their sentence pronouncement. In particular, it is noted that the Chamber had earlier concluded that Mr. Landzo satisfied the "abnormality of mind" prong of the diminished-responsibility test but not that of "substantial impairment."7 Sentence Mitigation In the United States, sentence mitigation based on the fact-finder's (or sentencer's) perception that the offender's criminal responsibility is diminished is unique in capital cases, in that mitigating reasons (or "factors") are typically set out in the statute, and their consideration, if present, is mandatory (although nonenumerated mitigating factors may also be considered). Many states list mental impairment, by one designation or another, as among statutory mitigating factors. The complexity of the state's current death penalty schemes is a reaction to the case of Furman v. Georgia.55 In Furman, the U.S. Supreme Court struck down Georgia's death penalty statute, because it left the jury with unfettered discretion in applying the statute. When the states redesigned their statutes in the wake of Furman, their dominant pattern was one in which the jury's discretion was now appropriately guided (or "channeled") by explicitly stated sets of aggravating and mitigating factors.56 Ten U.S. jurisdictions and the Model Penal Code allow for the admission of mental-abnormality evidence in sentencing by statute when deciding between imposing death or life imprisonment.21 At least one jurisdiction considers such evidence for imposing a probationary sentence.57 Contemporary death penalty jurisprudence requires the sentencing authority to consider any relevant mitigating evidence that a defendant offers as a basis for a sentence less than death.58 Despite support for allowance of mitigating factors in Lockett v. Ohio59 and Eddings v. Oklahoma,60 recent judicial trends have placed limitations on mitigation evidence.61 According to some theorists, the use of mental illness in a capital punishment penalty phase may have a double edge, because such testimony raises questions of unpredictability and dangerousness, perhaps suggesting to the jury that the defendant poses a continuing threat to society.58,62 The Capital Juror Project in South Carolina, a study of 41 capital murder cases belied this hypothesis, however, reporting that 29.5 percent of jurors were slightly less likely and 26.7 percent much less likely to vote for the death penalty if the defendant had a history of mental illness.63 The burden of proof varies according to jurisdiction. For example, depending on the state, an insanity defense may need to be proved by a preponderance of the evidence, while sentencing hearings may only require the defendant to produce evidence "sufficient to support a finding" of a mitigating factor.64 In England, the Criminal Justice Act of 1991 encouraged sentencers to take into account a wider range of considerations when mitigating than when aggravating penalties. It is only "information about the circumstances of the offense" that can aggravate, but a court may mitigate an offense "by taking into account any such matters as in the opinion of the court are relevant...."65 In 2001, however, the government published a White Paper that addressed a wide range of issues related to the criminal justice system, including sentencing provisions. One conclusion underscored the presence of too narrow a focus on the circumstances of the specific offense during sentencing, to the exclusion of other probative information.66 As a result, the Criminal Justice Act of 2003 expanded aggravating factors to allow for more consideration of prior transgressions of the defendant. Also, motives for the offense based on racial, religious, sexual orientation, and/or disability of the victim may be considered aggravating factors.67 These changes have been accompanied by both longer commensurate sentences and community supervision. Morse39 argues that there are simply no normative or factual criteria to guide the determination of how mental disorder in its various manifestations affects responsibility. In jurisdictions with indeterminate sentencing schemes (e.g., ICTY, ICC), where the range of sentences for each crime may be wide, Morse concludes that sentence mitigation inevitably creates arbitrary practices and unequal punishments. Conclusion Before the establishment of the ICTY, the question of a mental-incapacity defense received little attention in anticipation of international criminal prosecution. Accordingly, in 1993, when the mental-incapacity defense was made possible by the ICTY's unvarnished statement in the rules of procedure and evidence allowing "any special defense, including that of diminished or lack of mental responsibility" the application of that provision became preeminent. Because the textual content of the mental-incapacity defense in the ICTY statute is slim, the possibilities for its use became expansively wide; this, despite the fact that these defenses have long been the subject of debate in various national jurisdictions, with periodic calls for their elimination or, at least, restriction, particularly after high-profile trials. As exemplified by the Celebici Trial, "excuse" defenses will undoubtedly play a paradoxical role in international prosecution. They are often seen as posing a threat to the attainment of the objective of justice, redress, protection, and prevention associated with the principle of accountability for serious humanitarian law violations. And yet, they are made available because they serve fundamental fairness and are viewed as an essential component of a culture of legality. Because of the complexity of the issues and the high visibility in municipal legal systems, it can be expected that the mental-incapacity defense will have an impact on pursuit of all these goals. At the Celebici Trial, the effort to equate the diminished-responsibility defense called for in the ICTY statute with British doctrine seemed to have little practical applicability. In fact, it is my premise that the Trial Chamber unwittingly considered all four variants of the use of reduced mental capacity without settling on one measure. While this flexibility may allow for some creative uses of the defense, pressing questions arise regarding normative standards for its use in international law. For example, should the defense be an affirmative one raised by the defendant, a failure-of-proof defense, or should it be a sentencing mitigation factor to be considered by the trier-of-fact? What are the consequences of a determination of either full mental incapacity or of reduced capacity? There is an implicit suggestion in the Celebici case that the accused's mental condition, even if not amounting to full "mental incapacity," can still serve as a basis for mitigation of punishment. Partial responsibility has never been accepted in the United States, primarily because of fear of runaway "excuses" and because such systems are considered by some to be cumbersome and expensive.68 At the ICC Preparatory Commission, drafting material elements of crimes was emphasized with a somewhat inconsistent approach to mental elements.69 There was also an understanding not to address grounds for exclusion of criminal responsibility in the elements of each crime and a widespread reluctance to embark on burden-of-proof considerations. Concepts such as specific and general intent were discarded as well. Agreed upon grounds for excluding criminal responsibility in the ICC Statute now include mental disease or defect that "destroys...[a] person's capacity to appreciate the unlawfulness or nature of his or her conduct, or capacity to control his or her...conduct to conform to the requirements of law."70 Reduced capacity is not mentioned, but it is certain to have future adherents both because of its international ubiquity and because it is often intricately linked with mens rea. At the Celebici Trial, the introduction of a reduced-mental-capacity defense highlighted its procedural difficulties, not the least of which was a quasi fishing expedition by the defense to find a suitable psychiatric diagnosis for the defendant. While proportionality in sentencing is a laudatory goal, it often loses something in the implementation, particularly in adversarial systems. Assessment of mens rea, long considered a cornerstone of national legal systems, provides the most familiar, albeit narrow, way for those with reduced mental capacity to be adjudicated in the international setting. In most national systems, the accused is permitted to rebut evidence that he or she had the requisite criminal intent or mens rea to commit the crime charged. Both diminished responsibility and the partial-responsibility variant, often confuse responsibility and culpability, and the specific contours of the doctrines are not always clear. They should be dropped from international criminal jurisprudence in favor of a strict mens rea formulation that has the potential advantage of simplicity and fairness. Before this can be accomplished, however, the cataloging of mental elements for international crimes must proceed. Mens rea terms do not have to be confusing and may be collapsed into relatively few categories.39 Downward departure, a hallmark of both the U.S. diminished-capacity and British diminished-responsibility systems, is not essential for all categories of crimes. Consideration of mens rea may result in a lesser charge if appropriate, but also may be deliberated in isolation when lesser charges are not available. Psychiatric testimony suggesting that a defendant lacks mens rea often focuses on the presence or absence of self-awareness (e.g., perception of intent) rather than the ability to form intent at the time of the crime and, as a result, is not relevant. Even the most psychiatrically ill often have the capacity to form intentions by thinking, planning, and executing an action—capacities that usually satisfy any mens rea requirement. At trial, if it is determined by the jury that the defendant possesses mens rea but the usual control structures are significantly compromised, the evidence could be admitted into court for the purpose of sentence mitigation as in, for example, the U.S. Sentencing Guidelines.71 With the ICC in the formative stage and with continual ethnic strife on the horizon, these issues are nascent. Nearly every commentary on diminished capacity (or diminished responsibility) begins with the statement that the subject is confusing.54 If direction is not offered, adverse publicity that has shadowed both "excuse" and "failure-of-proof" defenses in national jurisdictions could conceivably generate a negative sociopolitical backlash, creating unsure footing on the predictably slippery slope of international criminal prosecution. Acknowledgments The author wishes to thank Ms. Jackie Lockwood, Ms. Liz Lynch, and Ms. Michele Sparr for their invaluable assistance in manuscript preparation. References United Nations S. C. Res., 827, U.N.S.C.O.R., 48th Sess., 3217th meeting on May 25 (1993) Krug P: The emerging mental incapacity defense in international criminal law: some initial questions of implementation. Am J Int Law 94:317–35, 2000 Prosecutor v. Delalic, Mucic, Delic, Landzo. U.N. Doc. IT-96-21-T, March 21, 1996 International Tribunal for the prosecution of persons responsible for serious violations of international humanitarian law committed in the Territory of the former Yugoslavia since 1991 (1993) Statute, UN Doc S/25704 annex reprinted in 32 ILM 1192. The Statute was amended on May 13, 1998, by S. C. Res. 1166 (1998) Indictment: Delalic, Mucic, Delic, Landzo ("Celebici"). UN International Criminal Tribunal for the former Yugoslavia. Case No. IT-96-21-T, March 21, 1996 ICTY Rules of Procedure and Evidence, IT/32. Adopted February 11, 1994 ICTY "Celebici" Judgement. (Prosecutor v. Delalic, Mucic, Delic, Landzo.) Case No. IT-96-21-T. (November 16, 1998) MacKay RD: Mental Condition Defences in the Criminal Law. New York: Oxford University Press, 1996 Bassiouni MC: Historical survey: 1919–1998, in Crimes Against Humanity in International Criminal Law (ed 2, rev.). Edited by Bassiouni MC. Boston: Kluwer Law International, 1999, pp 597–634 Bassiouni MC: A functional approach to general principles of international law. Mich J Int Law 11:768–818, 1990 Turns D: The International Criminal Tribunal for the Former Yugoslavia: the Erdemovic case. Int Comp Law Q 47:461–74, 1998[Free Full Text] Rome Statute of the International Criminal Court. Articles 31-33 (July 17, 1998) Schrag M: The Yugoslav War Crimes Tribunal: an interim assessment. Transnatl Law Contemp Problems 7:15–22, 1997 Report of the Secretary General, United Nations Document S/25704 at ? 58 Yee S: The Erdemovic sentencing judgement: a questionable milestone for the International Criminal Tribunal for the former Yugoslavia. Ga J Int Comp Law 26:263–309, 1997 Kadish H, Schulhofer SJ: Criminal Law and its Processes: Cases and Materials (ed 7). New York: Aspen Publishers Inc., 2001 Hart HLA: Punishment and Responsibility. Oxford: Clarendon Press, 1968 Roth LH: Preserve but limit the insanity defense. Psychiatr Q 5:91–105, 1986 Morissette v. U.S., 342 U.S. 246, 252 (1952) Model Penal Code, 1.12(2)(a). Appendix (Official Draft 1962) Compton JK: Expert witness testimony and the diminished capacity defense. Am J Trial Advocacy 20:381–407, 1996 Austin JL: A plea for excuses. Proc Aristotelian Soc 57:1–3, 1956–7 Fourth Geneva Convention, 1977, art. 32 (p 222) and art. 85, Additional Protocol I, Commentary Prosecution response to defense motion to dismiss. (Prosecutor v. Delalic, Mucic, Delic, and Landzo (RP D5672)), (1997) Fourth Geneva Convention, 1977, art. 85, Additional Protocol I, ? 3474 English Homicide Act of 1957, 2(1) R. v. Byrne, 3 W.L.R. 440 (1960) Steinmetz G: Her way: a daughter-in-law of 'Ol Blue Eyes' takes a tough case. Wall Street Journal, July 8, 1999, pp A1, A8 Sparr LF: Personality disorders and international criminal law. Presented at the 34th Annual Meeting of the American Academy of Psychiatry and the Law (APPL), San Antonio, Texas, October 2003 Prosecutor v. Delalic, Mucic, Delic, Landzo, Case Number IT-96-21-T. Trial transcript pp 14126–7, 14632–3, 14143–4 (July 15, 1998) La Fond JQ, Gaddis KA: Washington's diminished capacity defense under attack. Univ Puget Sound Law Rev 13:1–39, 1989 Hermann DHJ: Criminal defenses and pleas in mitigation based on amnesia. Behav Sci Law 4:5–26, 1986 English Homicide Act, 5 and 6 Eliz. 2, C.II, 2 (1957) Clark RS: The mental element in international criminal law: the Rome Statute of the International Criminal Court and the elements of offenses. Presented at the Annual meeting of the German Society of Comparative Law, Hamburg, Germany, September 19–22, 2001 Schabas WA: Sentencing by international tribunals: a human rights approach. Duke J Comp Int Law 7:461–517, 1997 Prosecutor v. Erdemovic Judgement. U.N. Doc. IT-96-22-A, (October 7, 1997). (Separate and dissenting opinion of Judge Li, ?? 18–27) Weinstock R, Leong GB, Silva A: California's diminished capacity defense: evolution and transformation. Bull Am Acad Psychiatry Law 24:347–66, 1996 Clark CR: Specific intent and diminished capacity, in Handbook of Forensic Psychology (ed 2). Edited by Hess A. New York: John Wiley & Son, 1999, pp 350–78 Morse SJ: Criminal law: undiminished confusion in diminished capacity. J Crim Law Criminol 75:1–55, 1984 Kelt M, von Hebel H: General principals of criminal law and the elements of crimes, in The International Criminal Court: Elements of Crimes and Rules of Procedure and Evidence. Edited by Lee RS. Ardsley, NY: Transnational Publishers Inc., 2001, pp 19–40 Rome Statute of the International Criminal Court. Article 5(1) (July 17, 1998) Rome Statute of the International Criminal Court. Article 30 (Mental Elements) (July 17, 1998) Italian Codice Penale, 89 The French Code Pénal, Ch. 2, Art. 122-1(2) (1994) Ciccone JR, Ferracuti S: Comparative forensic psychiatry: commentary on the Italian system. Bull Am Acad Psychiatry Law 23:449–66, 1995 van Marle HJC: Forensic services in The Netherlands. Int J Law Psychiatry 23:515–31, 2000 van Marle HJC: The Dutch Entrustment Act (TBS): its principals and innovations. Int J Forensic Ment Health 1:83–92, 2002 Hoeve M, Blaauw E, van Marle H, Sheridan L: International comparisons with regard to treatment, in Mentally Disordered Offenders. Edited by Blaauw E, Hoeve M, van Marle H, et al. The Hague, The Netherlands: Elsevier, 2002, pp 171–89 Zabow T: Psychiatric evidence in extenuation: assessment and testimony in homicide defendants. Med Law 8:631–9, 1989 South African Crim. Proc. Code, 78(7) (1977) Viljoen J, Roesh R, Eaves D: Canadian mentally disordered offender legislation: obstacles and advances, in Mentally Disordered Offenders. Edited by Blaauw E, Hoeve M, van Marle H, et al. The Hague, The Netherlands: Elsevier, 2002, pp 39–72 Dernevik M: Mentally disordered offenders in Sweden, in Mentally Disordered Offenders. Edited by Blaauw E, Hoeve M, van Marle H, et al. The Hague, The Netherlands: Elsevier, 2002, pp 125–44 Boland F: Anglo-American Insanity Defence Reform: The War Between Law and Medicine. Brookfield, VT: Ashgate, 1998 Slovenko R: Diminished capacity, in Psychiatry and Criminal Culpability. Edited by Hess A. New York: John Wiley & Sons, 1995, pp 151–67 Furman v. Georgia, 408 U.S. 238 (1972) Brakel SJ, Brooks AD: Law and Psychiatry in the Criminal Justice System. Littleton, CO: Rothman Publications, 2001 State v. Spawr, 653 S.W.2d 404 (Tenn. 1983) Perlin ML: The sanist lives of jurors in death penalty cases: the puzzling role of "mitigating" mental disability evidence. Notre Dame J Law Ethics Public Policy 8:239–79, 1994 Lockett v. Ohio, 438 U.S. 586, 604 (1978) Eddings v. Oklahoma, 55 U.S. 104, 114 (1982) Kirchmeier JL: Aggravating and mitigating factors: the paradox of today's arbitrary and mandatory capital punishment scheme. Wm Mary Bill Rights J 6:345–459, 1998 Tomes J: Damned if you do, damned if you don't: the use of mitigation experts in death penalty litigation. Am J Crim Law 24:359–99, 1997 Garvey SP: Aggravation and mitigation in capital cases: what do jurors think? Columbia Law Rev 98:1538–76, 1998 Marlowe DV, Lambert JD, Thompson RG: Voluntary intoxication and criminal responsibility. Behav Sci Law 17:195–217, 1999 English Criminal Justice Act, 3, 28 (1991) English Criminal Justice Act, Ch. 44, Pt 12 (2003) Criminal Justice: The Way Ahead, 2001. Available at www.archive.officialdocuments.co.uk/document/cm50/5074 Feinberg J: Sickness and wickedness: new conceptions and new paradoxes. J Am Acad Psychiatry Law 26:475–85, 1998 von Hebel H : The making of the elements of crimes, in The International Criminal Court: Elements of Crimes and Rules of Procedure and Evidence. Edited by Lee RS. Ardsley, NY: Transnational Publishers Inc., 2001, pp 3–18 Rome Statute of the International Criminal Court. Article 31 (Grounds for Excluding Criminal Responsibility), 1998 U.S. Sentencing Guidelines Manual 5K2.13 (1997)...查看详细 (59779字节)

☉ 11326921:全腹腔镜结直肠癌根治术的临床护理
关键词腹腔镜；结直肠癌切除术；护理腹腔镜结直肠癌根治术是近年开展的微创外科新技术，具有术后出血少、疼痛轻、恢复快、切口小等优点，易被患者接受[1]。尤其是超声刀的应用，使腹腔镜结直肠癌根治技术更安全、可靠、更精确。我院于2003年8月～2004年5月，使用美国Stryker公司生产的Sonoca190型超清晰度超声刀，为23例结直肠癌患者行全腹腔镜结直肠癌根治术。缩短了患者的住院时间，效果满意...查看详细 (3611字节)
☉ 11326922:舒血宁注射液治疗老年缺血性脑血管病的临床观察及护理
摘要目的观察舒血宁注射液治疗老年缺血性脑血管病的临床疗效及护理中的注意事项。方法将60例脑梗死患者随机单盲分为治疗组和对照组，通过比较两组治疗前后的实验室指标和神经功能缺损程度评分及生活能力状态分级，进行统计分析。结果舒血宁注射液治疗组较对照组的疗效显著，两组有显著差异(P 1 临床资料 11 对象选择我院2004年10月～2005年4月住院治疗的65岁以上的老年急性脑卒中患者60例...查看详细 (4404字节)
☉ 11326923:Narcissistic Dimensions of Expert Witness Practice
Dr. Gutheil is Professor of Psychiatry, Harvard Medical School, and Co-Director, Program in Psychiatry and the Law, Massachusetts Mental Health Center, Harvard Medical School, Boston, MA. Dr. Simon is Clinical Professor of Psychiatry, and Director, Program in Psychiatry and Law, Georgetown University School of Medicine, Washington, DC. Abstract The authors review narcissism as it relates to expert witness practice. The review addresses stable versus unstable narcissism, normal confidence, perspective taking, the effect of flattery, the will to win, mirror transference, narcissistic excitement, narcissistic rage, narcissistic injury, and post-traumatic stress disorder (PTSD). The article closes with recommendations for resisting narcissistic pitfalls and achieving the egoless state. The expert witness is a hood ornament on the vehicle of litigation, not the engine. —Robert I. Simon [personal commumication, 1997] An expert testifying in court faces a number of external and internal stressors deriving from that experience: stresses of public speaking, withering cross-examination, internal anxiety and uncertainty, the need for preparedness, the pressure to think on one's feet, and so on. Among the internal stressors are elements of the dynamics of narcissism. As the epigraph to this article suggests, humility is desirable, but the very nature of the courtroom experience poses stresses. The concept of "being the engine" that drives the courtroom procedure captures the expert's grandiosely wishful (but unfounded) fantasy of being in control of the process. Note also that the very term "expert" conveys a sense of specialness and of separation from the common herd, in terms of knowledge, skill, training, and experience.1 The attorney's detailed eliciting of one's qualifications before testimony also may feed this image of the expert as an exceptional individual. Familiar narcissistic fears—of exposure; of humiliation; of shame; and of being made to look foolish, incompetent, or unprepared—are emotions that keep many practitioners from venturing into court at all. Yet all these fears must be faced by the testifying expert. A tension appears to exist between stable narcissism (in the form of self-esteem, self-confidence, and realistic self-assessment of one's abilities) and fragile narcissism, which is dependent on external praise and validation, reinforcement, or idealization by others. The latter represents a significant biasing factor, which may lead the vulnerable expert to shape, slant, or distort testimony to win approval from the retaining attorney or to "win" at any cost. In addition, experts who personalize the experience are in danger of narcissistic injury from aspects of cross-examination or when the decision of the fact-finder goes against the retaining side. This review explores narcissistic aspects of expert witness practice. All vignettes were composed by the authors from actual or consulting experiences. Normal Confidence In normal development, a person may be described as moving from infantile self-involvement through self-esteem to a (preferably stable) self-concept (Goldwater RP, personal communication, 2004). Kohut2 described how the later residue of infantile grandiosity is ordinary adult confidence. The average expert's development is likely to be no different. The human trait of narcissism can be metaphorically likened to blood pressure: too much or too little is a problem, just enough—an average level—is just right. In more practical terms, a normal level of confidence or self-esteem is an element of the credibility with which the expert witness on the stand is viewed by juries and others. Confidence by the expert is explicitly sought by attorneys: A novice expert would glance nervously at his retaining attorney before answering a question on cross-examination. This made the expert seem lacking in confidence at best (or slavishly cued by the attorney as a "hired gun" at worst). The attorney cited this apparent lack of confidence as a basis for not accepting a subsequent referral to this expert. The expert's confidence in testifying, of course, is not only a product of internal dynamics but also a product of careful preparation and thought. Developing Perspective No matter which is the retaining side, the experienced expert can analyze both sides of the case with dispassion, rather than demonizing the opposing side to feel more righteous about his or her own work. Maintaining this balanced view aids the expert in avoiding excessive narcissistic investment in, or idealization of, his or her side of the case. An extreme opposite example is the expert who is never willing to admit being wrong about any aspect of the testimony, even factual matters. This is a posture quite distinct from that of attorneys who can be intensely partisan without conflict. As an example, in the pretrial tribunal in a famous case, the defense attorneys kept referring to the plaintiff as "that asshole." Flattery A cross-examining attorney puzzlingly brought out many obscure and marginal honors and achievements from the expert's curriculum vitae. The expert was very flattered, until learning from the retaining attorney that this was a strategy designed to make the expert appear a "jack of all trades, master of none." In another example, after a grueling cross-examination, the opposing attorney's female associate smiled at the expert when he left the stand. When her law firm sought to retain the expert in a later case, he told the associate how flattered and supported he had felt when she smiled. She indicated that she had merely enjoyed and had been amused by the shellacking the expert had just endured. One of the most gratifying experiences for some experts is to be called by an attorney who worked for the opposing side to be retained for a subsequent case, as in the just-described example. Though flattering, such an event poses a threat of a kind of narcissistic seduction. "After all," the expert is in danger of reasoning, "this attorney sought me out, after I had been on the opposing side. Therefore, surely he or she has a high opinion of me. I should try to do my best for this attorney." More overt and explicit flattery, of course, is not uncommon: "We came to you, Dr. Jones, because we think you are the best in the business." A recent discussion of flattery noted a similar point: ...[A]n expert may be flattered when an attorney asks her or him to become part of the trial team; however, joining such a team, and participating in the team's us-versus-them mentality, may become a slippery slope for the expert. [The danger is that] [f]irst the expert advocates for her or his opinion, later the expert advocates for the team's—that is, the attorney's—opinion [Ref. 3, p 407]. The Will to Win One of the most important goals for the expert is to achieve the professional detachment required to achieve the necessary objectivity and neutrality. Ideally, the expert reaches a Zen-like level of dispassion, so that the actual outcome of the case is a matter of complete indifference. Especially for the beginning expert, the "will to win" is a significant biasing narcissistic factor that impairs the neutrality of the opinion and creates an inappropriate investment in the case's outcome. Another way to envision the expert's objectivity is to define the expert's role as protecting the truth from both attorneys.4 The satisfaction the expert is fully entitled to enjoy from courtroom work is not derived from the outcome, but from the achievement of this goal; that is, the expert is satisfied that the opinion was successfully protected from distortion, misuse, subversion, and contamination by either attorney in the adversarial process. Winning a case results from multiple factors, most of which (e.g., jury demographics, the nature of the case, the locale, and the demeanor of the attorneys) are entirely outside the expert's control. As a result, the expert whose narcissism leads to the claim, "I won that case," is demonstrating narcissistic grandiosity in most cases. Note that those same experts rarely admit, "I lost that case," when the decision goes the other way. Exhibitionism Expert witness trial testimony is often performed in a kind of intense public focus that may be perceived as the limelight—a limelight that shines brighter for some when the cases are high-profile and widely publicized. Indeed, some experts seek out high-profile cases and call the attorney, volunteering to serve. A variation on this theme is the expert who displays style over substance, providing colorful, catchy, dramatic—but unsubstantiated—testimony. The image here is of the peacock's tail. Mirror Transference and the Attorney Identification and overidentification with the retaining attorney are recognized pitfalls of expert witness work.5,6 An expert may want, consciously or not, to curry favor, even with the opposing attorney, and may be tempted to give weak testimony to avoid offending the opposing side. Searching for love and admiration in this manner does not succeed; in litigation, "love" is a four-letter word. The search for approval may produce a kind of mirror transference, as Kohut2 described, manifested as a kind of mutual admiration society. Such a search may create a phenomenon described in sexual misconduct cases as the "magic bubble." In sexual cases, the magic bubble begins as a sphere of mutual admiration containing super-patient and wonder-doctor,7 and ultimately becomes impervious to supervision, consultation, good judgment, and common sense.7 In the forensic equivalent, the magic bubble contains super-expert and wonder-lawyer and may become impervious to reality and the actual facts of the case. Narcissistic Excitement Under the stress of attack during cross-examination, a witness may succumb to a particular defense mechanism called narcissistic excitement. Compelled by competitive striving against the attorney, exhibitionist tendencies, and the adrenaline rush of combat, the witness may be drawn into a verbal fencing match at high levels of speed and energy, which may lose, distract, or alienate the jury: A highly histrionic attorney was peppering an expert witness with rapid-fire questions on cross. The expert later recalled feeling at the time that this was a battle of wits based on speed and began to fire back responses. Viewing the videotape of that testimony later, the expert realized that the speed of response made the testimony seem pressured and defensive—and far less credible. Recall that pausing to think about one's answer is not a failure of technique, nor should it damage self-esteem. The same dynamics may lead an expert to enter into a combat stance, refusing to concede even valid points to the cross-examining attorney—a posture that seriously impairs credibility. This resistance to conceding the obvious, refusing to "throw a position away" when that is the proper response, is one of the most common problems for the novice expert. Narcissistic Rage Every experienced expert expects cross-examination at trial, even a vigorous, aggressive, hostile, contemptuous, and demeaning cross. Experts also recognize these styles as theatrical ploys by the attorney to sway juries. However, a narcissistically vulnerable expert may take the attorney's attitude in cross more personally and as threatening to the self-esteem. Some experts fly into a narcissistic rage in such a situation8 and lose credibility by seeming to be personally invested (and thus biased or partisan) in the case. Since the expert's task is merely to protect the truth from both attorneys,4 a rage-filled reaction is never called for and always compromises one's objectivity. Narcissistic Injury Closely related to rage is the narcissistic injury some experts receive from actions of the legal system that they did not or could not influence. A clinical practitioner serving for the first time as an expert witness testified truthfully, but was horrified to discover that the defendant received a very harsh sentence. This practitioner chose never to go to court again. To enter into the legal system is usually to give up, to some extent, the narcissistic wish for control of circumstances, since different rules and procedures, unrelated to clinical reasoning or assumptions, now apply. On the witness stand, narcissistic injury may result from the revelation of some defect in the expert's preparation, reasoning, and familiarity with relevant data or presentation. Given that everyone has areas of narcissistic vulnerability, every witness must face the possibility of narcissistic injury. The wounded expert who consequently becomes angry, provocative, combative, or defensive may lose credibility in the eyes of the jury or judge. When the attorney is abusive in cross-examination, narcissistic injury can be averted or at last minimized by paying attention only to the content of the queries, not to the related aggressive or bombastic affect. This focus also preserves a more valuable written record of the exchange. Recall that in the lasting transcript, the affect is not recorded, merely the stupid things one says when one flies into a rage. It may also be helpful to remind oneself that the attorney is merely honoring the ethical duty to represent the client zealously. "Post-dramatic" Stress Disorder One expert pointed to a forensic Cinderella phenomenon: that after the case is over, the expert becomes a pumpkin again. This image is intended to capture the letdown that can strike expert witnesses in the aftermath of trial testimony, when the tension, drama, and exercise of one's skills (or failure to exercise them) in the courtroom have all run their course, and experts return to whatever reality they left when they entered the courtroom. Recall that relationships with attorneys can endure for years as cases drag through the system. Thus, a termination may also be a part of the letdown. While this letdown is expected and normal, it constitutes a narcissistic frustration of its own. Recommendations The expert whose narcissism is affected by all the above pressures faces the danger of becoming cynical about attorneys and the legal system. Such cynicism exposes the expert's narcissistic views of the work instead of those that produce pleasure. The ideal embodiment of a witness free of narcissistic difficulties is the egoless expert who accepts that the task, not the person, is essential. As Steven King expressed it, "It is the tale, not he who tells it" (Ref. 9, p 460). This egoless state includes avoiding grandiosity, resisting the appeal of the limelight, avoiding taking personal credit for the outcome of a case, and avoiding gratuitously disparaging the opposing expert10 for one's own narcissistically competitive motives. Another way to express the challenge for the expert is adherence to forensic boundaries. This implies avoiding: straying beyond the parameters of one's task; attempting to control the case's outcome; inflating one's resume; claiming greater expertise than one actually has; and, when testifying, claiming to know with certainty those facts that are not knowable by a person who was not on the scene at the time. The metaphor of the expert as a "hood ornament," with which we began, should offer relief to the expert in removing some of the burden of the proceedings from his or her shoulders, as should the realization that, all too often, the experts on the two sides of a case merely cancel each other out, leaving the jury, as is so often true, to vote their viscera. More pragmatically, experts may play roles of greater or lesser import, depending on the nature of the case: less importance in a competence-to-stand-trial case, say, and more in a complex medical malpractice claim. The expert always strives to teach the jury but should do so without pomposity or condescension, since those alienate the lay listener. Attention to the narcissistic pitfalls herein described may protect the expert from bias, influence, and loss of credibility, a protection resulting in improvement of the value of the task performed for the legal system. Acknowledgments The authors thank members of the Program in Psychiatry and the Law, Massachusetts Mental Health Center; Richard P. Goldwater, MD, for critical comments; and Ms. Ellen Lewy for assistance with the manuscript. References Fed. Rules Evid. 702 Kohut H: The Analysis of the Self. New York: International Universities Press, 1971 Friend A: Keeping criticism at bay: suggestions for forensic psychiatry experts. J Am Acad Psychiatry Law 31:406–12, 2003[Free Full Text] Gutheil TG, Hauser M, White MS, et al: The "whole truth" vs. the "admissible truth": an ethics dilemma for expert witnesses. J Am Acad Psychiatry Law 31:422–7, 2003 Gutheil TG: The Psychiatrist as Expert Witness. Washington, DC: American Psychiatric Press, Inc., 1998 Gutheil TG, Simon RI: Mastering Forensic Psychiatric Practice: Advanced Strategies for the Expert Witness. Washington, DC: American Psychiatric Press, Inc., 2003 Gutheil TG: Patients involved in sexual misconduct with therapists: is a victim profile possible? Psychiatr Ann 21:661–7, 1991 Kohut H: Thoughts on narcissism and narcissistic rage. Psychoanal Study Child 27:460–500, 1972 King S: The breathing method, in Different Seasons. New York: Viking Press, 1982, p 460 Gutheil TG, Commons ML, Miller PM: "Telling tales out of court": a pilot study of experts' disclosures about opposing experts. J Am Acad Psychiatry Law 28:449–53, 2000...查看详细 (17903字节)
☉ 11326924:糖尿病神经病变的药物治疗进展
摘要本文阐述了严格控制血糖对治疗糖尿病神经病变的作用，论述了使用三环化合物、抗惊厥药物、利多卡因和慢心律、辣椒素及神经节苷脂等可治疗糖尿病神经病变的疼痛症状，并介绍了在防治该病的神经病变方面可试用血管扩张剂、必需脂肪酸、抗氧化剂、甲基维生素B12及神经生长因子等。关键词糖尿病；神经病变；药物疗法；血糖糖尿病神经病变是糖尿病最常见的慢性并发症，近几年来大量的临床和实验研究显示代谢异常及血管损害对糖尿病神经病变的发生具有重要的作用...查看详细 (7765字节)
☉ 11326925:Commentary: The Challenge of Training Police Officers
Dr. Price is Clinical Assistant Professor, Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI. Vermette et al.1 offer significant observations about the training of police officers working with individuals who have a mental illness. The need to have effective training that meets the expectations of line officers as well as supervisors and police chiefs is readily apparent. Law enforcement officers are routinely the first responders in situations involving mentally ill persons in crisis. The findings provide guidance in crafting a training program that will address areas that officers regard as the most relevant to their work. Considering the needs and requests of officers is an essential step in developing a partnership with law enforcement to support training efforts. Training programs are needed to provide officers with the information and skills to interact more effectively with persons suffering from mental illness.2,3 Need for Training With the advent of deinstitutionalization, tightening of civil commitment statutes, and cutbacks in psychiatric treatment programs, a greater number of individuals with mental illness are living in the community. These changes have resulted in an increase in the number of contacts between individuals with mental illness and the police.4,5 There have been estimates by medium and large police departments that seven percent of their contacts, including both investigations and complaints, concern persons believed to have mental illness.2 Police are a major source of referrals for psychiatric emergency services. Redondo and Currier found that 26 percent of patients evaluated by the psychiatric emergency service of the University of Rochester Medical Center were brought in by police.3 Police are usually the first and often the only community resource called on to respond to crisis situations involving persons with mental illness4 and have been termed "de facto mental health providers."5 Officers are expected to act as the primary gatekeepers for the criminal justice and mental health systems. They must either recognize an individual's need for treatment and divert that person to an appropriate mental health facility or make the determination that the individual's illegal activity is the primary concern and that the person should be arrested.5,6 The task is typically accomplished with little training. The good news is that the survey by Vermette et al.1 suggests that police officers are interested in learning more about interacting with the mentally ill, and officers consider it an important aspect of the job. Over 90 percent of respondents reported that mental health training was either fairly or very important, and 68 percent preferred yearly training. Over half of the police officers had volunteered to attend, indicating an appreciation of the importance of the subject.1 Similarly, Cotton7 found that most of the Canadian police officers in her study were not, in fact, averse to accepting a significant role in working with individuals with mental illness. Rather, officers viewed their involvement as an integral part of community policing, as part of their jobs, and as an area in which they should receive specialized training. These encouraging findings are consistent with the shift from the traditional enforcement model to a community-policing model that embraces a problem-solving orientation to operational problems and the use of community partnerships to accomplish operational objectives. Application of these principles has fostered initiatives to improve the effectiveness of response to mental health crises in the community.8,9 Mental Health Training Programs Despite this new focus on community policing, most departments still do not provide specialized mental health training. Patrol officers are on the front line, but they generally receive little post-academy mental health training. Cotton7 surveyed police officers of three different police forces in Canada. These forces had not devoted significant time or resources to mental health training. None of these police forces had any particular specialized training for officers or a dedicated mental health program. Only a brief (one-hour), in-service session had been offered, even though senior officers identified mental health as an area of concern, and officers were interested in obtaining more information about working with and understanding individuals who are mentally ill. Police colleges in Ontario had provided a brief exposure to mental health subjects; but, unfortunately, only a few departments in large metropolitan areas had organized more extensive training. The sample provided by Vermette et al.1 is unusual, in that the majority (73%) had attended at least some post-academy training. Departmental Policy for Dealing with the Mentally Ill and Implications for Training In addition to the lack of specialized mental health training, most departments lack a formal policy for dealing with the mentally ill. Most departments do not have specialized mental health teams to respond to calls.2 Deane et al.2 surveyed 174 police departments serving cities with populations of over 100,000. They found that 55 percent of the departments lacked a specialized response for handling incidents involving persons with suspected mental illness or emotionally disturbed persons (EDPs). Those departments that have a formal policy use one of three models in crafting a specialized response to handling calls involving EDPs2: a police-based specialized police response, a police-based specialized mental health response, and a mental-health-based specialized mental health response. The amount and type of training offered by a department is often related to the strategy used in dealing with persons with mental illness. Intensive specialized training is provided to officers in departments using a police-based specialized police response. This strategy involves having sworn officers with specialized mental health training provide crisis intervention services and act as liaisons to the formal mental health system. Deane et al.2 found that only three percent of departments use this approach—among them, the Memphis Crisis Intervention Team (CIT). CIT officers make up about 15 to 20 percent of patrol officers and receive 40 hours of training that focuses on scenarios derived from actual incidents. Officers receive extensive training in de-escalation techniques.9 The second approach, a police-based specialized mental health response, was used by 12 percent of the departments. Mental health consultants, who were not sworn officers, were hired by the police department to provide on-site and telephone consultation to officers in the field. The third approach, a mental-health-based specialized mental health response, was used by 30 percent of the departments. This strategy involved reliance on mobile crisis teams. The teams were part of the local community mental health service system. The teams had developed a relationship with the local police departments to provide assistance on the scene.2 The crisis intervention officers in departments using the police-based specialized police response reported feeling the most prepared to handle calls involving mentally ill persons in crisis compared with officers in departments using a different strategy.8 These officers had volunteered for their positions and received specialized training. This finding supports the view that training and preparation can improve officers' comfort and confidence in responding to mental health emergencies. All three approaches had a relatively low arrest rate when a specialized response was made.10 Goals and Benefits of Training Improving Interaction with Mentally Ill Persons There are numerous benefits to providing at least some basic mental health training to all patrol officers, regardless of the strategy of response. Mental health training can provide guidance in identifying and managing persons with mental illness. Training can provide a framework for distinguishing which persons with mental illness who have committed a minor crime can best be managed by diversion to the mental health system. Training in de-escalation techniques can improve communication between officers and persons with mental illness and lead to improved handling of violent or potentially violent encounters. The training can decrease the risk of harm to officers and to persons with mental illness. De-escalation training can aid officers in managing a person who is threatening suicide. Training can also help in identifying and gaining access to available community resources. Changing Attitudes and Combating Stereotypes Changing attitudes about persons with mental illness also should be a fundamental goal of training. Police officers encounter persons with mental illness in a variety of situations, not just those persons who are experiencing a psychiatric crisis. In fact, persons with mental illness are more likely than others to become victims of crime,11 and persons with mental illness can be witnesses to a crime. Because of stereotypes, persons with mental illness who are victims may not be seen to be as credible as those without a history of mental illness.12 Wahl12 conducted a nationwide study of 1,301 persons with mental illness solicited through the newsletter of the National Alliance for the Mentally Ill (NAMI) and by members of NAMI's consumer council. Almost 80 percent of the sample reported direct experience with stigma and discrimination in a variety of settings, including communities, families, churches, coworkers, and mental health caregivers. Respondents reported trying to conceal their disorders and worrying a great deal that others would find out about their psychiatric status and treat them unfavorably. They urged public education to be a means of reducing stigma. Link et al.13 found that 75 percent of the general public view persons with mental illness as being more dangerous and Kimhi et al.14 found that police continue to share this belief. In contrast, Cotton7 found that police were actually more positive in their attitude toward the mentally ill than was the general public. Very few officers favored isolation of mentally ill individuals from society, and most officers supported the view that society should learn to be more tolerant. There was a belief in the therapeutic value of the community, the importance of integrating the mentally ill into normal neighborhoods, and a general acceptance of the principle of deinstitutionalization. Corrigan et al.15 studied perceptions of discrimination by 1,824 persons with serious mental illness. The authors found that 37.7 percent of the study participants who were recruited from community mental health centers reported some experience of discrimination due to their mental disability. Respondents stated that one of the areas in which discrimination frequently had occurred included interactions with police. The researchers suggested targeting police as a category of power group whose discrimination is particularly problematic for persons with mental illness.15,16 Watson and colleagues17 examined whether the knowledge that a person has a mental illness actually influences police perceptions, attitudes, and responses. Police officers attending one of 30 in-service training sessions were randomly selected and given one of eight vignettes describing a person in need of assistance, a victim, a witness, or a suspect who was either labeled as having schizophrenia or for whom no further information about mental illness was mentioned. Police officers viewed persons with mental illness as being less responsible for their situation, more deserving of pity, and more worthy of help, but, at the same time, more dangerous than persons for whom no mental illness information was available. The information that a person had schizophrenia significantly increased the perception of violence across all role vignettes. Watson et al.17 hypothesized that this heightened sense of risk could cause an officer to approach persons with mental illness more aggressively and escalate the situation and evoke unnecessary violence. The mental health label did not affect the credibility rating of a suspect or a witness. Unfortunately, there was a lower perceived credibility of a victim with a mental illness. Since victims with mental illness have higher rates of victimization, Watson and colleagues17 recommended education to counter this perception of lower credibility. They cautioned that assuming a person who has a mental illness is incapable of providing credible information could lead to the loss of valuable leads and the neglect of persons who have been victimized. The authors recommended combating exaggerated perceptions of dangerousness by education and opportunities for positive contact with persons with mental illness who are stable in the community. Encouraging a Dialogue Between Psychiatrists and Law Enforcement Officers Another goal of mental health training would be the encouragement of a dialogue between psychiatrists and law enforcement officers. Vermette et al.1 recommended that courses be jointly taught by a mental health professional and a law enforcement officer. This approach offers a level of comfort for officers who are often suspicious of psychiatrists and other mental health professionals, and it would allow an opportunity for mental health professionals and officers to explain their own perspective and solve problems together. Topics to be Covered in Training While there is clearly a need for training, one needs to ask what topics should be covered when time for training is limited. The findings by Vermette and colleagues1 raise questions about what topics should be included in mental health training. The authors pointed out that their sample might not be representative, as over half of the officers volunteered to attend and 70 percent had already received some post-academy training. Therefore, the sample may have over-represented officers with an interest in mental health training. The authors did not provide information about the topics to which officers were exposed in their earlier mental health training. This could have influenced the officers' choice of further subjects. Vermette et al. found that all topics were rated as important but the subjects of Dangerousness, Suicide by Cop, Decreasing Suicide Risk, Mental Health Law, and Your Potential Liability for Bad Outcomes were given the highest ratings. Police appeared to be most interested in these more advanced topics related to safety and liability.1 The police officers may have been interested in Mental Health Law because this topic included discussion about laws governing commitment. There were written comments requesting more information about civil commitment laws and how to communicate with mental health professionals. Police complained about being frustrated when they take persons with suspected mental illness to the emergency room for assessment only to have them rapidly released. Redondo and Currier3 found differences between persons referred by police to a psychiatric emergency room and persons referred by other sources. Persons referred by police were significantly more likely to be male, to have been referred because of violent behavior, to exhibit violent behavior in the emergency room, and to have a lifetime history of violence. Persons referred by police were rated as having more severe psychosocial stressors and spent more time in the emergency room than did those referred by other sources. However, patients referred by the police were not more likely to be admitted to inpatient psychiatric units. If persons referred by police indeed do exhibit more violent behavior, then it should not be surprising that officers might question why violent behavior does not always lead to hospitalization. Officers in the study by Vermette and colleagues1 ranked the topic of Mental Health Law very high, perhaps because the officers wanted to understand the laws governing commitment and why persons brought in for psychiatric admission were not admitted. Explaining what occurs in the decision-making process would be helpful in forming a partnership with law enforcement. In light of the challenges faced by patrol officers, one might have expected that patrol officers would rate high topics such as Effective Communication With Persons With Mental Illness and Overview of Specific Types of Mental Illness. Vermette et al. pointed out that for the training programs attended by study respondents, police chiefs and training coordinators were specifically asked to design curricula that included education about the types and manifestations of mental disorders. They noted that learning about the basic differences between specific mental illnesses would be useful in improving communication and understanding of persons whom they encounter. Therefore, one should consider including those topics most likely to result in improved interaction between police officers and persons with mental illness, while still taking into account the requests of patrol officers. It is of concern that Role-playing was rated significantly lower than other training modalities, whereas Videos and Small Group Discussion had the highest mean scores. Officers who receive advanced training in crisis negotiation are routinely exposed to all three modalities. There is a great deal of emphasis on enacting scenarios to ensure that officers practice their skills. In addition, officers are often encouraged to improve their skills further by volunteering for suicide hot lines. Practicing skills is an accepted part of firearm training and SWAT training. While role-playing can be an uncomfortable experience, it is a good way to improve skills and learn de-escalation techniques. Conclusion Vermette et al.1 have approached the question of what topics and what modalities to use in mental health training by surveying patrol officers about their opinions. This is an important effort because training should address the topics considered of importance to patrol officers. Vermette and colleagues suggest a collaboration between mental health providers and law enforcement officers in designing a program that is useful and relevant to the target audience, but at the same time meets the goals of improving the interaction between law enforcement officers and persons with mental illness. References Vermette HS, Pinals DA, Appelbaum PS: Mental health training for law enforcement professionals. J Am Acad Psychiatry Law 33;42–6, 2005 Deane MW, Steadman HJ, Borum R, et al: Emerging partnerships between mental health and law enforcement. Psychiatr Serv 50:99–101, 1999 Redondo RM, Currier GW: Characteristics of patients referred by police to a psychiatric emergency service. Psychiatr Serv 54:804–6, 2003[Free Full Text] Lamb HR, Weinberger LE, Gross BH: Mentally ill persons in the criminal justice system: some perspectives. Psychiatr Q 75:107–26, 2004 Patch PC, Arrigo BA: Police officer attitudes and use of discretion in situations involving the mentally ill. Int J Law Psychiatry 22:23–35, 1999 Lamb HR, Weinberger LE: Persons with mental illness in jails and prisons: a review. Psychiatr Serv 49:483–92, 1998 Cotton D: The attitudes of Canadian police officers toward the mentally ill. Int J Law Psychiatry 27:135–46, 2004 Borum R, Deane MW, Steadman HJ, et al: Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness. Behav Sci Law 16:393–405, 1998 Dupont R, Cochran S: Police response to mental health emergencies: barriers to change. J Am Acad Psychiatry Law 28:338–44, 2000 Steadman HJ, Deane MH, Borum R, et al: Comparing outcomes of major models of police response to mental health emergencies. Psychiatr Serv 51:645–9, 2000 Marley JA, Buila S: Crimes against people with mental illness: types, perpetrators and influencing factors. Soc Work 46:115–24, 2001 Wahl OF: Mental health consumers' experience of stigma. Schizophr Bull 25:467–78, 1999 Link BG, Phelan JC, Bresnahan M, et al: Public conceptions of mental illness: labels, causes, dangerousness, and social distance. Am J Public Health 89:1328–33, 1999 Kimhi R, Barak Y, Gutman J, et al: Police attitudes toward mental illness and psychiatric patients in Israel. J Am Acad Psychiatry Law 26:625–30, 1998 Corrigan P, Thompson V, Lambert D, et al: Perceptions of discrimination among persons with serious mental illness. Psychiatr Serv 54:1105–110, 2003 Corrigan PW, Watson AC, Warpinski AC, et al: Implications of educating the public on mental illness, violence, and stigma. Psychiatr Serv 55:577–80, 2004 Watson AC, Corrigan PW, Ottati VO: Police officers' attitudes toward and decisions about persons with mental illness. Psychiatr Serv 55:49–51, 2004...查看详细 (21193字节)
☉ 11326926:浅析高技术战争对军人心理影响与应对策略
关键词高技术战争；军人心理；影响；对策实践证明，战争的进程和结局很大程度上取决于军人的心理稳定程度，取决于军人承受不断加大的心理负荷。因此，研究在高技术战争条件下对军人作战心理的影响，并采取有效措施加以克服，对增强军人个体和集体心理素质，夺取高技术条件下作战的胜利具有十分重要的意义。 1 高技术战争对军人心理的影响随着科学技术的不断发展，核生化武器、军用卫星、航天飞机、激光武器、智能武器、隐形兵器...查看详细 (6755字节)
☉ 11326927:Commentary: A Multidisciplinary Approach to Developing Mental Health Training for Law Enforcement
Dr. Keram is Assistant Clinical Professor of Psychiatry, Psychiatry and the Law Program, Department of Psychiatry, University of California San Francisco School of Medicine, San Francisco, CA. Vermette et al.1 address a topic that affects many mental health clinicians and their patients. Policy changes, including deinstitutionalization, inadequate funding of outpatient treatment, and stringent commitment requirements, may have contributed to an increase in the frequency of police contacts with mentally ill citizens.2 Law enforcement officers often act as paramedics for psychiatric emergencies in the community. In a survey of law enforcement professionals in three U.S. cities, officers reported that within the previous month they responded to an average of six calls that involved a person with mental illness who was in crisis.3 Mentally ill patients report high rates of contact with the police. A survey of 360 psychiatric outpatients at an urban mental health clinic demonstrated that 48.6 percent of them had a history of arrest.4 Officers working in jails and prisons also have contact with mentally ill citizens. It has been estimated that the prevalence of severe mental illness in jails and prisons is three to five times higher than that in the community.5 Statistics have not been compiled regarding the frequency of police contacts with the mentally ill in the context of interviewing crime victims or witnesses. Similar Responsibilities and Experiences Mental health clinicians and law enforcement officers have similar responsibilities and experiences in their daily work with the mentally ill. Both professions engage in crisis management, risk assessment, and disposition of patients too dangerous or disabled to remain in the community. Both deal with a workload that is increased by inadequately funded systems of care. Both may be held liable for harm that they may not have been able to foresee or forestall. Despite these similarities of experience, tension and distrust may exist between the disciplines. For example, mental health clinicians typically do not respond in person to their patients who are imminently dangerous in the community (where weapons and intoxicants are available). Clinicians may also be fearful of the potential for force to be used against their patients if the police are called for assistance with management of the crisis. Similarly, law enforcement officers may be frustrated by repeated intervention with reportedly dangerous patients, only to have those patients released into the community by the evaluating emergency psychiatrist. The need for the police to respond appropriately to the mentally ill creates a unique opportunity for collaboration between mental health clinicians and law enforcement professionals. To develop effective mental health training programs for law enforcement officers, members of both disciplines must learn something substantive about the other’s professional and legal responsibilities. This increased awareness may ultimately lead to the delivery of improved clinical and law enforcement services to mentally ill citizens. Working Together: A California Experience In my experience, a multidisciplinary approach has been the most effective in creating training that best anticipates and responds to the needs of patrol officers. The development of the training program "Police Response to People with Mental Illness or Developmental Disability" by the California Commission on Peace Officer Standards and Training (POST) is an example of one such collaborative effort. In response to several high profile cases in which mentally ill Californians had been shot and killed by police officers, the California State Legislature passed Assembly Bill (AB) 1718 in 2000, requiring that POST establish and keep updated a training curriculum relating to law enforcement contacts with mentally ill and developmentally disabled citizens. The underlying premise of the legislation was that improving law enforcement training in these areas would lead to improved outcomes in contacts between law enforcement and mentally ill citizens. POST, overseen by 11 Commissioners and an Executive Director, carries out its mandate to "continually enhance the professionalism of California law enforcement in serving its communities" by researching nationwide trends in law enforcement, including crime statistics, legislative developments, tactical equipment, and training. POST uses this information to develop standards and training in the more than 600 subject matter areas in which all California law enforcement officers must develop and maintain proficiency. In 2000, the year AB 1718 was passed, 8 of the 11 POST Commissioners were career law enforcement officers. The others included the district attorney of a Bay Area county, a specialist in education and training, and a member of the public. The California Attorney General is an ex officio member of the Commission. POST’s first task in fulfilling its responsibility under AB 1718 was to appoint a law enforcement officer with recent patrol and supervisory experience as Project Manager (PM). The PM then appointed members with experience in law enforcement contacts with mentally ill citizens to serve on an advisory committee that would develop the POST training. Despite the fact that mental health issues comprise just one of more than 600 subject matter areas covered by POST, the work the Commission does in carefully monitoring developments in all areas meant that POST already had good relationships with several professionals working at the interface of law enforcement and mental health care. The final advisory committee comprised 28 members: 3 current law enforcement officers with doctoral degrees in psychology, 7 police officers assigned to either patrol or supervisory positions, 1 police officer with previous experience in developing a successful mental health training curriculum, 11 mental health clinicians with experience in subjects involving law enforcement, 3 citizens who worked in patient advocacy, 2 attorneys with experience in defending law enforcement officers and agencies in wrongful death and inadequate training suits, and 1 expert in developing training programs for law enforcement agencies. Problems in Curriculum Development AB 1718 did not specify the training’s content, format, length, or faculty, nor did it require POST to collect data on those officers who underwent this training and their subsequent interactions with the mentally ill. The committee as a whole met three times, with various subcommittees convening separately to develop and finalize various aspects of the training. To develop familiarity with the approach other agencies have taken, the committee surveyed the mental health training programs of law enforcement departments throughout the United States. Committee members attended classroom and field training at law enforcement agencies in New York City; Memphis, Tennessee; and Phoenix, Arizona. Written materials and other training aids from several other agencies were reviewed as well. Members of the committee found a two-day training program developed by New York State to be particularly well designed, as it presented the mental health material simply and effectively. Committee members without a law enforcement background quickly became familiar with factors that shape the development of a training program that could be used by all law enforcement agencies in California. The training had to be long enough to be substantive, but short enough that it would not create a hardship in small departments to allow officers leave time to attend it. It had to be relevant to officers in urban Los Angeles and the nearly deserted county of Siskiyou. It had to be realistic in what it offered and what it recommended across a wide range of populations, geography, and mental health resources. To that end, the committee decided to offer an eight-hour program. The program consists of six lessons, covering introductory concepts that emphasize destigmatization and the biological basis of mental illness, developmental disabilities, major mental illnesses, verbal intervention strategies, alternatives to lethal force, and community and state resources. Each discipline contributed to the curriculum and worked with the others to refine their priorities for final inclusion. Law enforcement professionals emphasized the importance of providing material that would be immediately transferable to the street. Mental health clinicians explained the importance of including California Welfare and Institutions Code sections governing involuntary commitment, to help officers understand clinical decision-making and improve their report-writing when requesting commitment of a citizen. Advocates for the mentally ill helped the committee to understand the sometimes frightening experience of family members in their interactions with the police. Material was incorporated to respond to this concept. The attorneys supported the inclusion of relevant California case law in written materials provided during the training, as well as broadening the material to include areas that were often cited in lawsuits brought against a law enforcement agency alleging inadequate mental health training. Law enforcement professionals told the clinicians the training had to be "action-oriented," "hands-on," and "portable." The committee incorporated videotape simulations and role-play into the training materials. Excellent suggestions, such as providing the virtual-reality hallucination experience offered by a pharmaceutical company or bringing a human brain to the training to emphasize the medical nature of mental illness were ultimately rejected as impractical. However, in my experience, both techniques have been very successful in other training formats. Conclusion The final product of the committee, the training entitled, "Police Response to People with Mental Illness or Developmental Disability" consists of an Instructor’s Guide, a DVD of the videotaped simulations, a field guide for officers attending the training, a laminated wallet card containing principles of communicating with the mentally ill and suicidal individuals, and a second card with the names of common psychotropic medications. The training is designed to be co-taught by a law enforcement professional and a mental health clinician, as the committee felt strongly that both disciplines should be present to provide appropriate answers to participants’ questions. Committee members agreed that having different disciplines work together resulted in a more thoughtful and complete training program. They also felt they would take knowledge gained in working with other disciplines back to their communities to initiate new relationships and opportunities for collaboration. The content and format of effective mental health training will vary to some extent with the characteristics of an individual law enforcement agency. Vermette et al.1 provide a useful starting point for officers and mental health clinicians who develop or update training curricula. Assessing the mental health training priorities and preferred teaching formats of their target audience would allow them to create more effective and relevant training. References Vermette HS, Pinals DA, Appelbaum PS: Mental health training for law enforcement professionals. J Am Acad Psychiatry Law 33;42–6, 2005 Engel RS, Silver E: Policing mentally disordered suspects: a reexamination of the criminalization hypothesis. Criminology 39:225–52, 2001 Borum R, Deane MW, Steadman HJ, et al: Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness. Behav Sci Law 16:393–405, 1998 Frankle WG, Shera D, Berger-Hershkowitz H, et al: Clozapine-associated reduction in arrest rates of psychotic patients with criminal histories. Am J Psychiatry 159:270–4, 2001 Lamb HR, Weinberger LE: Persons with severe mental illness in jails and prisons: a review. Psychiatr Serv 49:483–92, 1998 California Assembly Bill 1718 (2000), available at http://www.leginfo.ca.gov/pub/99-00/bill/asm/ab_1701-1750/ab_1718_bill_20000724_chaptered.html...查看详细 (12348字节)
☉ 11326928:浅谈医学图书馆的知识管理
关键词医学图书馆；知识管理近20年来，现代信息技术的发展和普及，从根本上动摇了医学图书管传统的管理模式和服务方式，传统的管理模式在医学图书馆数字时代已变得不再适应，正在转向以知识导航和知识评价、信息咨询等为主要内容的知识管理模式。把以知识为核心的知识管理理论引入医学图书馆是其获得自我生存和发展的必要条件。医学图书馆如何引进知识管理体系，是当前迫切需要我们研究和解决的课题。本文就此谈几点看法。 1 转变思想观念...查看详细 (4512字节)
☉ 11326929:Mental Health Training for Law Enforcement Professionals
Dr. Vermette is Director, Mental Health Access Clinic, North Texas VA, and Assistant Professor of Psychiatry, UT Southwestern Medical School, Dallas, Texas. This work was completed while she was a fellow with the University of Massachusetts Law and Psychiatry Program. Dr. Pinals is Director, Forensic Psychiatry Education and Training, and Associate Professor of Psychiatry Dr. Appelbaum is A. F. Zeleznik Distinguished Professor and Chair, Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA. Abstract The purpose of this pilot study was to determine topics of interest and preferred modalities of training for police officers in their work with persons with mental illness. Police officers across Massachusetts attending in-service mental health training were asked to rate the importance of potential mental health topics and the effectiveness of potential training modalities on a Likert-type scale. Additional data collected included the officer's experience, level of education, motivation for attendance, previous attendance of post-academy mental health training, and preferences for length, frequency, training site, and trainer qualifications. A t test was used to determine if there were significant differences (p < .05) between those who volunteered and those who were mandated to attend the training. Repeated-measures ANOVAs were used to determine if there were significant differences (p < .05) between mental health topics and lecture formats and to determine the effect of education and experience on the results. Although all topics suggested were rated, primarily, as fairly important, the topics of Dangerousness, Suicide by Cop, Decreasing Suicide Risk, Mental Health Law, and Your Potential Liability for Bad Outcomes were given the highest ratings. Role-playing was rated significantly lower than other training modalities, while Videos and Small Group Discussion had the highest mean scores. Level of prior education had no significant effect on the ratings, but officers with more experience rated the importance of mental illness as a training topic significantly higher than officers with less experience. This survey suggests that police officers are interested in learning more about working with persons with mental illness and view it as an important aspect of the job. Law enforcement professionals provide up to one-third of all emergency mental health referrals.1 They interact with more persons with mental illness than any other occupational group outside the mental health field.2 They are often the first to respond to a mentally ill person in crisis and are called on to determine if and when a person should be referred for mental health treatment; yet, in general, their training in mental illness is limited.1 Some jurisdictions have developed intervention models that include officers who are specially trained in mental health.3–6 Officers in the field, however, commonly encounter citizens with mental illness without any more specialized training than they received in their initial academy training. A 1995 survey of California law enforcement agencies found that the average number of mental health training hours in the academy was 6.3, only 83 of 158 agencies provided mental health training after the academy, and only seven percent of departments reported they had specific training on suicide prevention for custody officers.7 Deinstitutionalization, more stringent commitment criteria, and cutbacks in treatment programs have resulted in an increase in the number of mentally ill persons involved with the police.8 When combined with increased demand for intervention, this limited amount of training has become a great source of frustration for law enforcement professionals. The risk of morbidity and mortality related to encounters between law enforcement and persons with mental illness has the potential to be quite high9,10; therefore, it has been suggested that it would be in the best interest of all parties to educate officers about ways to manage persons with mental illness with an eye toward decreasing the risk of harm.9,11 Recognizing a need, police officers have been turning to mental health professionals to provide training in mental health.12 In this pilot study, we sought to examine preferred topics and modalities of mental health training from the police officer's perspective. Methods Subjects Approval for this study was obtained from the Institutional Review Board of the University of Massachusetts Medical School. Data were collected from police officers across Massachusetts who attended one of two in-service training seminars about mental illness. The first seminar was a full-day training seminar titled "Reducing Risk of Death in Custody." It was divided into medical causes of death and suicide risk reduction for persons in custody. It took place 18 times from October 2001 to June 2002. The second seminar was a three-hour seminar titled "Mental Health Issues for Law Enforcement Officers." It took place 18 times from October 2001 to June 2002. Subjects were among those who attended from January to May 2002. All seminar participants were presented with a written survey prior to the beginning of the training seminars. The survey began with a description of the study and information related to consent, including the notation that consent would be indicated by returning the survey to the seminar instructor. Data Collection Surveys were distributed to all police officers attending the training (n = 150). The survey incorporated questions about the officer's background, including years of law enforcement experience, prior post-academy mental health training, level of education, and motivation for attendance. Subjects rated the importance of knowledge about mental illness and 14 potential mental health topics on a scale of 1 to 4, with 1 representing "completely unimportant" and 4 representing "very important." They rated seven presentation formats on a scale of 1 to 4, with 1 representing "completely ineffective" and 4 representing "very effective." They rated their preference for length, frequency, training site, and trainer qualifications and had the opportunity to provide a written response for additional topics of interest. Analyses The mean rating and the percentage of subjects responding to each rating1–4 were calculated for each mental health topic and lecture format. Repeated-measures ANOVA was used to determine if there were significant differences (p < .05) between mental health topics and lecture formats. Repeated-measures ANOVA was also used to determine the effect of education and experience on the ratings. A t test was used to determine if there were significant differences (p < .05) between those who volunteered and those who were mandated to attend the training. Results Of the 150 surveys distributed, 126 were returned, representing a response rate of 84 percent. According to a census taken in 2000, this sample represents less than 1 percent of the total number of local police officers (n = 16,718) in Massachusetts.13 Over half (55.4%) of the police officers attending the training volunteered to attend. The majority (73.4%) of police officers reported they had previously attended post-academy mental health training. Regarding highest level of education, 28.8 percent had taken some college classes, 32 percent had graduated from college, 9.6 percent had some post-graduate training, and 19.2 percent had completed post-graduate training. Regarding experience, 19.2 percent had 1 to 5 years, 22.4 percent had 6 to 10 years, 20.8 percent had 11 to 15 years, 14.4 percent had 16 to 20 years, and 14.4 percent had over 20 years of law enforcement experience. Over 90 percent of respondents reported that the topic of mental illness was either fairly or very important. Interest in particular topics varied, although all topics were rated by a majority of respondents as fairly or very important. Table 1 identifies those topics ranked as of significantly greater and lesser interest, along with an intermediate group. The topics of Dangerousness, Suicide by Cop, Decreasing Suicide Risk, Mental Health Law, and Your Potential Liability for Bad Outcomes were rated significantly higher (repeated-measures ANOVA, p < .05) than the topics of Management of Problem Behaviors, Mental Health Resources in Your Area/Institution, Personality Disorders, Overview of Specific Types of Mental Illness, and Types of Medication and Their Side Effects, which, although considered important, were ranked lower in an overall preference list. The topics of Effective Communication With Persons With Mental Illness, Drug and Alcohol Abuse, and Stress Management received intermediate ratings (Table 1). Level of education did not have a significant effect on the ratings, but police officers with more law enforcement experience rated the importance of learning about mental illness significantly higher (repeated-measures ANOVA, p < .05) than officers with less experience. Subjects who volunteered to attend the training rated Importance of Mental Illness as a training subject and the topics of Overview of Specific Types of Mental Illness, Personality Disorders, Mental Health Resources in Your Area/Institution, Suicide by Cop, Management of Problem Behaviors, and Stress Management significantly higher (t test, p < .05) than those who were required to attend. With the exception of Role-playing, which was rated significantly lower (based on repeated-measures ANOVA with p < .05), there were no significant differences among training modalities. Responses ranking presentation formats as very effective were 37.7 percent for Video, 29.9 percent for Small Group Discussion, 29.0 percent for Handout, 25.0 percent for Lecture, 22.7 percent for Role-playing, 22.3 percent for Slides, and 22.5 percent for Panel Discussion. Responses ranking presentation formats as completely ineffective were 0 percent for Video, 1.7 percent for Small Group Discussion, 0.8 percent for Handout, 0.8 percent for Lecture, 5.0 percent for Role-playing, 0.8 percent for Slides, and 1.7 percent for Panel Discussion. The average ratings for teaching formats were 3.34 for Video, 3.21 for Small Group Discussion, 3.17 for Handout, 3.15 for Lecture, 2.87 for Role-playing, 3.21 for Slides, and 3.12 for Panel Discussion. Regarding training frequency, 68.3 percent of respondents preferred yearly training, 18.7 percent preferred training once every five years, 11.4 percent wanted training every six months, and 1.6 percent wanted training on a monthly basis. Regarding training length, 55.7 percent preferred a half day of training, 22.1 percent wanted a full day of training, 19.7 percent wanted two hours of training, and 2.5 percent wanted one hour of training. There were 12 written comments about additional topics for training. Three respondents requested more information about civil commitment laws. Other requested topics included jail diversion, feedback from mental health professionals regarding performance, juvenile issues, death in police station "lock-ups," dealing with family members of mentally ill persons, dispatcher's role in suicide attempts, mental health issues within police departments, video examples of persons with mental illness, how to communicate with mental health professionals, and visiting community mental health facilities. Conclusions In this study, we conducted a preliminary analysis of the topics, presentation formats, and frequency of mental health training preferred by police officers. Although the officers were from police departments across Massachusetts, only a small percentage of Massachusetts police officers were surveyed. Because of the small sample size and potential bias of the study population, it is not clear whether the findings from this survey can be generalized to all police officers; thus, the results must be interpreted with caution. Although just over half of respondents volunteered to attend the training, over 90 percent of respondents reported that the topic of mental illness was either fairly or very important to their work. In addition, the responses for interest in topics and lecture modalities were compressed in the three to four range. When taken together, these data suggest that many police officers are interested in learning more about working with persons with mental illness and view it as an important aspect of their job. In this survey, over 70 percent of officers reported receiving post-academy mental health training. It is possible that the high percentage of officers who received post-academy mental health training reflects a self-selected population, in that officers with pre-existing interest in mental health training may have chosen to attend the training sessions where the survey was administered. Similarly, the officers who were mandated to attend the training may have been sent from individual police departments that emphasized mental health in-service training for their officers. Officers may be receiving such mental health training as a consequence of recent litigation related to officer performance in crisis situations (see for example, Palmquist v. Selvik and the Village of Bensenville14) or based on a recognition of the frequency with which officers encounter persons with mental illness in the course of their work. Police officers are not asked to oversee the management of persons with mental illness on a long-term basis. This may explain why the topics of Management of Problem Behaviors, Mental Health Resources in Your Area/Institution, Personality Disorders, Overview of Specific Types of Mental Illness, and Types of Medication and Their Side Effects, although still desired by respondents, were not rated as high as the other topics. Although correctional officers were not included in this survey, they may have more interest in these particular areas. Given the current interest in mental health training, it is likely that many mental health professionals will be asked to speak to law enforcement professionals about mental illness. When time is limited for training, this study suggests that officers would choose the topics of Dangerousness, Suicide by Cop, Decreasing Suicide Risk, Mental Health Law, and Your Potential Liability for Bad Outcomes as topics of interest. Additional topics could include Effective Communication With Persons With Mental Illness, Drug and Alcohol Abuse, and Stress Management. Based on the written comments from this study, there may also be a need for less formal, more specific discussions on topics such as how to communicate with mental health professionals or jail diversion. Training in some of these areas may warrant the addition of legal professionals to the training team. Regarding the topics selected by study subjects, however, these personal preferences must be balanced with the mental health topics that training and commanding officers would select for their departments. For example, for the training programs attended by study respondents, police chiefs and training coordinators were specifically asked to design curricula that included education about types and manifestations of mental disorders. Although the individual officers in this study did not rank the topic of Overview of Specific Types of Mental Illness as high as other topics, teaching officers to understand basic differences between specific mental illnesses may be useful in improving communication and understanding of the persons whom they encounter. In this regard, police departments could also solicit advice from mental health professionals and local agencies in selecting prioritized topics. Although attitudes of police officers may be more difficult to change,9,12 providing training topics aimed at increasing knowledge may be a first step. Further study is needed to identify the effectiveness of such training in improving outcomes in law enforcement encounters with persons with mental illness. Regarding training modalities, Role-playing was rated significantly lower than the others, but the percentage of respondents rating it as extremely effective was similar to that for both Slides and Panel Discussion. The percentage of respondents rating Role-playing as completely ineffective, however, was higher. This most likely reflects extreme views toward Role-playing, with fewer respondents giving mid-range ratings. For some officers, role-playing may be considered a very useful training modality, but other officers may not prefer this training technique. Thus, when considering role-playing as a training modality, we recommend asking about the level of comfort with it prior to including it as a part of the training. Regardless of the method, when developing training for police officers, it is important to keep in mind that many police officers may have completed college and engaged in post-graduate studies. Therefore, the level of the information should be presented to suit their needs. Officers and mental health professionals come from different vantage points in their exposure to persons with mental illness. In our experience, using mental health and law enforcement professional co-trainers allowed the officers to learn from the perspective of each discipline. It has been noted that, in working together, police and mental health providers must be mindful of the limits of their expertise.11 By collaborative teaching or by having a designated law enforcement leader in attendance, mental health professionals in the instructor role can defer questions related to police procedure to someone with expertise in that area, and vice versa. This approach to teaching may also serve as a model for effective communication between a law enforcement officer and a mental health professional.15 Such efforts may assist mental health professionals in joining forces with law enforcement to provide the most effective means of managing persons with mental illness in crisis. References Borum R, Deane MW, Steadman HJ, et al: Police perspectives on responding to mentally ill people in crisis: perceptions of program effectiveness. Behav Sci Law 16:393–405, 1998 Kadish J: Mental Health Training of Police Officers. Presented at the 18th Annual Meeting of the World Federation for Mental Health, Bangkok, Thailand, November 19, 1965 Deane MW, Steadman HJ, Borum R, et al: Emerging partnerships between mental health and law enforcement. Psychiatr Serv 50:99–101, 1998 Steadman H, Deane MW, Borum R, et al: Comparing outcomes of major models of police responses to mental health emergencies. Psychiatr Serv 51:645–9, 2000 Dupont R, Cochran MS: Police response to mental health emergencies: barriers to change. J Am Acad Psychiatry Law 28:338–44, 2000 Cordner GW: A community policing approach to persons with mental illness. J Am Acad Psychiatry Law 28:326–31, 2000 Husted JR, Charter RA, Perrou B: California law enforcement agencies and the mentally ill offender. Bull Am Acad Psychiatry Law 23:315–29, 1995 Teplin LA, Pruett NS: Police as streetcorner psychiatrist: managing the mentally ill. Int J Law Psychiatry 15:139–56, 1992 Borum R: Improving high risk encounters between people with mental illness and the police. J Am Acad Psychiatry Law 28:332–7, 2000 Fyfe J: Policing the emotionally disturbed. J Am Acad Psychiatry Law 28:345–7, 2000 Lamb HR, Weinberger LE, DeCuir WJ: The police and mental health. Psychiatr Serv 53:1266–71, 2002 Godschalx SM: Effect of a mental health educational program upon police officers. Res Nurs Health 7:111–17, 1984 Reaves BA, Hickman MJ: Census of State and Local Law Enforcement Agencies, 2000. Washington, DC: Bureau of Justice Statistics Bulletin NCJ 194066, October, 2000, p 1–14 Palmquist v. Selvik and the Village of Bensenville, 111 F.3d 1332 (7th Cir. 1997) Klyver N, Reiser M: Crisis Intervention in Law Enforcement. Counsel Psychol 11:49–54, 1983...查看详细 (20145字节)
☉ 11326930:浅析护患纠纷的原因及对策
关键词护患纠纷；原因分析；护理管理护患关系是在护理过程中，护士与患者之间产生和发展的一种工作性、职业性、帮助性的人际关系[1]。在日常护理工作中护士与患者接触最多，是医疗护理活动的直接参与者，建立起诚信和谐的护患关系非常重要，护理人员要掌握一定的技巧。 1 影响护患关系的因素 11 法律意识淡薄患者的维权意识和自我保健意识不断增强，对医疗服务提出更高的要求，而护士缺乏自我保护意识...查看详细 (3544字节)

☉ 11326931:皮瓣联合外固定架治疗小腿骨折伴软组织缺损的护理体会
摘要总结106例皮瓣联合外固定架治疗小腿骨折及软组织缺损病人的护理经验，提出术前、术后护理要点，尤其是术后对皮瓣的成活起关键作用。护理者要严密观察皮瓣的血运状况，及时发现病情变化，解除血运障碍，保证皮瓣的成活。关键词外科皮瓣；外固定架；护理小腿因各种外伤造成的胫骨开放性骨折、骨缺损或骨髓炎同时伴有小腿软组织缺损，是临床上常常遇到的难题之一。自1990年5月至2005年12月，我们共收治此类病人106例...查看详细 (4741字节)
☉ 11326932:前纵隔骨髓脂肪瘤一例
关键词骨髓脂肪瘤；重症肌无力；纵隔骨髓脂肪瘤又叫髓样脂肪瘤，亦称髓脂瘤，是一种少见的良性肿瘤。有报道的病例多发生于肾上腺，但以往文献认为其尸检的发现率也仅为008%～0.2%[1]，临床多无症状；原发性纵隔骨髓脂肪瘤少见，而以重症肌无力为临床症状者，更为罕见。我科遇见一例，现报道如下。 1 病历报道患者，女，58岁，维族。三年前无明显诱因出现双下肢行走无力，双上肢亦疲乏...查看详细 (2505字节)
☉ 11326933:浅谈高原地区糖尿病患者的健康教育
关键词高原糖尿病；健康教育糖尿病是一种内分泌代谢性疾病，其发病率有逐年增高趋势。糖尿病教育是糖尿病防治中的一个重要措施[1]，1996年国际糖尿病联盟已把糖尿病教育列为糖尿病治疗的五项基本措施之一。但由于大多数糖尿病患者缺乏相关糖尿病的知识，导致了各种急、慢性并发症的发生，降低了糖尿病患者及其家庭的生活质量。对糖尿病患者及高危人群进行健康教育可降低糖尿病发病率，减少糖尿病急、慢性并发症和致死率...查看详细 (5379字节)
☉ 11326934:Commentary: The Impact of Surgical Castration on Sexual Recidivism Risk Among Civilly Committed Sexual Offenders
Dr. Berlin is Associate Professor of Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD. The article entitled, "The Impact of Surgical Castration on Sexual Recidivism Risk Among Sexually Violent Predatory Offenders," which appears in this edition of the Journal, takes up several important subjects of both a psychiatric and a forensic nature.1 There are two fundamental questions: first, what does the scientific evidence have to say about the likely impact of surgical castration on sexual drive and the enactment of sexually motivated behavior—most specifically, sexual behavior that is criminal in nature? Second, how heavily should the impact of a testosterone-lowering intervention, such as surgical castration, be weighted when attempting to determine the likely risk of future sexual recidivism by a previously civilly committed sexual offender who is seeking possible release into the community? It should be emphasized that the authors have conducted a retrospective review that attempts to predict the possible effects of surgical castration on civilly committed sexual offenders, rather than a prospective study capable of actually demonstrating its impact. Because, in my judgment, Weinberger et al.1 appear to be most concerned that the castration data reviewed not be too heavily weighted in support of a possible release into the community, this commentary is meant to balance that argument by cautioning against underestimating its possible importance when it comes to supporting such a release. I also argue that both public safety and fairness to those who have been civilly committed are likely to be better served by the community-based provision of psychiatric follow-up interventions capable of decreasing any potential risks that may be of concern. Effective risk management both at the time of release and following re-entry into the community, may better serve the interests of both patients and the public, than continuing to emphasize the current questionably accurate "crystal ball approach" of long-term risk prediction. The literature review conducted by the authors of the accompanying article appears to establish firmly that lowering testosterone by means of surgical castration is generally associated with a marked decline in sexually motivated behavior, including that of a criminal nature. In virtually all species of animals that have been studied, including humans, castration has generally been associated with either a reduction or a complete elimination of sexual activity and interest. As documented by the authors, studies of medical patients who were castrated because of testicular or prostate cancer, have consistently reported a significant decline in both the intensity of sexual drive (libido) and the frequency of sexually initiated behavior. That has been so despite the fact that some men have maintained their ability to perform genitally (i.e., they have maintained some degree of erectile capacity) following castration. As a consequence, some have also maintained their ability to become at least somewhat aroused genitally in response to visually presented stimuli, such as sexually explicit photographs. Weinberger et al. seem quite concerned about the potential preservation of some degree of erotic erectile capacity after surgical castration. However, it should be emphasized that the intended goal, when utilizing testosterone-lowering interventions to treat sexually disordered patients (and clearly many who have been civilly committed are sexually disordered), is to decrease the intensity of their paraphilic cravings. Such cravings can function as a motivational factor, which arguably would be of far greater importance in influencing their behavior than would be the capacity to sustain some degree of penile function. The critical question, at least in the case of the sexually disordered patient who is working to succeed, is not whether he still manifests some capacity for erotic arousal, but rather whether he is now better able to suppress it, and, if inappropriate, to resist acting on it. Whether a would-be dieter who has been prescribed an appetite suppressant is going to be successful in changing his behavior, would probably depend, not so much on the capacity of any such drug to eliminate his ability to eat, but more so on its ability to lower the intensity of his cravings to do so. The authors’ literature review correctly notes that many of the early studies involving surgical castration have suffered from several methodological shortcomings. Nevertheless, all the studies reviewed by them have reported impressively low rates of subsequent criminal sexual recidivism. Those studies have included individuals with a history of rape, as well as individuals with a history of pedophilic misconduct. The most recently reported study, a 1991 investigation by Hansen,2 included a group of sexually violent offenders, arguably similar to at least some of those now categorized as sexually violent predators. Those offenders had committed a variety of serious crimes involving severe bodily injury, rape, attempted murder, and murder. Not one of those castrated sex offenders (n = 21) had recidivated over several years, although two had done so more than 15 years later, but only after having been administered testosterone-replacement therapy. Thirty-six percent of men in the comparison control group, who had not been castrated, did recidivate. In yet another study reported by the authors, Sand et al.3 examined the records of more than 900 castrated individuals. Eighty-two percent had been documented sexual offenders—many, repeat offenders—prior to castration. Some of the individuals in that research had subsequently been tracked for periods as long as 30 years, and the reported overall sexual recidivism rate following castration was less than 2 percent. Weinberger et al.1 argue that several of the studies reviewed by them may have contained populations that differ significantly in their makeup from civilly committed sexual offenders. However, the fact remains that many studies from a variety of locations, involving a variety of samples, have documented consistently low rates of sexual recidivism following castration. Thus, it is difficult to see why one would expect currently committed patients, many of whom are likely to be similar to many others not under commitment in jurisdictions that do not legislatively allow for it, to be the exception. Weinberger and colleagues summarize a study by Wille and Beier4 documenting that castration was most effective in reducing libido, as well as any sort of sexual activity, among those aged 45 years and older. Although older men who have not been castrated do not necessarily have significantly lowered levels of testosterone, nor do they necessarily have lowered sexual libido, castrated elderly men do show such reductions. In their study, Wille and Beier report that more than 92 percent of castrated men over the age of 60 years had reported virtually extinct libido and sexual activity following surgery. In addition, according to Wille and Beier, even within the youngest groups of castrated men (ages 30–49 years), only 33 percent had indicated that they could still function sexually following castration. Of those, many had required extensive stimulation to be able to do so. Approximately 67 percent of that younger group had reported that their sexual activity was virtually extinct six months following the surgery. Thus, castration appeared to be generally effective in lowering both libido and sexual activity across a broad age range of sexual offenders. Wille and Beier reported that only 3 percent of those castrated had engaged in recidivistic criminal sexual misconduct following surgery. Weinberger et al.1 suggest that one should not depend solely on the subjective self-reports of sexual offenders in assessing persons for "deviant" sexual interests. Rather, they argue that penile plethysmography (PPG) is a technology that can be useful in making such an assessment and that it can be helpful when evaluating previously committed sexual offenders who are seeking community release. In terms of group data, more persons in a group of individuals who show evidence of deviant arousal (e.g., erotic arousal in response to children as assessed by PPG) are likely to engage in pedophilic sexual misconduct than would be the case in a comparison group of persons showing no such arousal.5 In contrast, when it comes to making predictions about the long-term risk of sexual recidivism for a given individual, there is evidence documenting that "deviant" arousal, as demonstrated in the PPG laboratory, is not necessarily an accurate predictor of long-term behavioral outcome in the community.6 To put it bluntly, what is important in terms of treatment outcome is not how the penis behaves in the laboratory, but rather how the man himself behaves over time when back in society. The fact that some castrated sexual offenders may continue to show some degree of penile tumescence in the PPG laboratory in response to deviant stimuli should not necessarily be construed as evidence of a high risk of subsequent recidivism in the future. The authors present two hypothetical clinical vignettes discussing how to go about predicting the likelihood of future recidivism in the case of civilly committed sexual offenders who have been surgically castrated. In both vignettes, they seem to infer that a high risk is still present. Certainly, aspects of the hypothetical vignettes that they have elected to present (e.g., the discovery of a stash of pictures of young boys in a patient’s locker six months following castration) would be cause for concern. Clearly, one would want to give weight to post-surgical evidence suggestive of continued sexually problematic acts. How might the authors’ opinions about risk have changed had the pictures not been discovered or had there been reason to doubt that they did actually belong to the patient in question? The difficulty relates to how to determine with confidence whether the authors’ suggested methods of predicting future risk have validity, in the absence of any data regarding their ability to do so successfully. Clearly, caution is necessary when making predictions about future recidivism with persons who have committed sexual offenses. In the past, 24 convicted sex offenders treated at a specialized hospital facility in California and released as "cured" had a 20.8 percent (5/24) re-arrest rate within a follow-up period of six and one-half years.7 Seventeen men characterized as "unamenable to treatment" did better rather than worse, with a lower 11.8 percent (2/17) re-arrest rate over a comparable follow-up period. In addition, contrary to what might have been expected, five of six other patients discharged from treatment as "nonamenable and dangerous" did not recidivate during subsequent follow-up. Weinberger and colleagues1 have rightfully pointed out the obvious—in assessing risk, all factors thought to be relevant should be considered. That would include not only the presence or absence of sexual deviation, as well as knowledge about any interventions such as surgical castration that may have been performed, but also the question of whether any comorbid Axis I or Axis II diagnoses that may be present have been adequately addressed. That admonition not withstanding, based on the data currently available, the fact remains that in all reported instances in which sexual offenders have been surgically castrated, subsequent sexual recidivism rates have consistently been impressively low. Some researchers have argued that the best way to assess the risk of recidivism with respect to sexual offenders is to make use of statistical actuarial data.8 I do not necessarily subscribe to that argument, because such actuarial methods are intended to make predictions about the behavior of groups, rather than about the behavior of specific individuals.9 For example, insurance companies can make use of actuarial data to predict the percentage of individuals within a given group, perhaps made up of obese, hypertensive, cigarette-smoking males manifesting high levels of cholesterol, who are likely to have a heart attack. However, they cannot utilize such actuarial data to predict accurately which specific individuals within that group are more or less likely to do so. Nevertheless, should one elect to take such an actuarial approach in making predictions, as is often done at civil commitment hearings, the data available regarding castrated sex offenders seem to suggest that that intervention is generally associated with a very low risk of future sexual misconduct. Beyond that fact, unlike research involving actuarial data, conclusions regarding the expected outcome of castration are based on a well-documented scientific understanding of hormonal biophysiology. Where would the issue of predicting future recidivism be left, were the data regarding the likely effects of either surgical or chemical castration not to be heavily weighted? Arguably, recidivism rates following cognitive behavioral interventions, long-term institutional treatment, and relapse prevention therapies have all been associated with higher rates of subsequent sexual recidivism than have been reported in the case of castration.10 If castration data should not be weighted heavily when considering possible release into the community, in general are there any other treatment data that might more powerfully and validly predict a safe re-entry into society? Weinberger et al.1 argue that factors unrelated to testosterone levels can be important in effecting the likelihood of future sexual recidivism. While that is undoubtedly true, there is every reason to believe that such factors were also present in the case of those groups of sexual offenders who have undergone surgical castration and have not recidivated. Castration addresses a fundamental element that has been used to justify the civil commitment of sexual offenders in the first place—that is, the element of volitional impairment.11 The repeat bank robber is not civilly committed because his behavior is not thought to be related to a psychologically impairing mental disorder. However, it is now generally accepted that powerful biologically based cravings, be they related to overeating, alcohol, drugs, sex, pain, or the need for sleep, can sometimes overcome even stern resolve. By decreasing the intensity of sexual cravings capable of wearing down such resolve, castration can concomitantly increase the volitional capacity to maintain appropriate self-control. The article provides much useful information, and a sound literature review of data, both from the United States and abroad, related to surgical, and in some instances chemical, castration. Weinberger et al.1 have also discussed some of the considerations related to ethics. From a treatment standpoint, the data presented seem to suggest clearly that lowering testosterone can provide many sexually disordered patients with the equivalent of a sexual appetite suppressant, thereby facilitating better behavioral control. Parenthetically, it should be noted that there seems to be little reason to favor surgical castration, given the fact that the same testosterone-lowering effects can be induced pharmacologically. The problem, in the case of the civilly committed sexual offender, lies not in the rationale underlying the use of castration as a form of treatment, nor necessarily even its likely effects on subsequent behavior, but rather in deciding how much weight to give to the fact that it has been done, when trying to predict future risk. Psychiatrists and other mental health providers are better equipped to manage risk—that is, to reduce it—rather than trying to predict it in the abstract. Most civilly committed sexual offenders are sexually disordered. Sexually disordered offenders—that is, those with a paraphilic disorder—cannot be cured. However, research evidence suggests that many can be successfully treated.12,13 In general, the treatment of any chronic behavioral disorder, be it drug addiction, alcoholism, or a paraphilia, depends on the availability of adequate community-based resources, in some instances following a period of residential care. As noted earlier, rather than predicting how the castrated sexual offender is likely to fare following release into the community, it may be more crucial to manage effectively any risk that may be present at the time of his re-entry. Perhaps that could be accomplished best by insuring that all such releases are conditional (as is the case in several states), as opposed to unconditional, so that ongoing support, treatment, and monitoring can be regulated. In that way, one could guard against the surgically castrated sex offender’s reversing his status by means of the ingestion of exogenous testosterone. A simple mandated blood test could quickly detect any attempt to do so. A variety of other safeguards would then also be possible, including electronic surveillance, and prophylactic recommitment, if indicated. If, in the meantime, predictions must nevertheless still be made, then the available scientific research seems to suggest that, in general, low rates of sexual recidivism can ordinarily be expected following surgical castration. References Weinberger LE, Sreenivasan S, Garrick T, et al: The impact of surgical castration on sexual recidivism risk among sexually violent predatory offenders. J Am Acad Psychiatry Law 33; 16–36, 2005 Hansen H: Treatment of dangerous sex offenders. Helsinki, Finland: Ministry of Justice, Government Printing Centre, 1991, pp 33–8 Sand K, Dickmeiss P, Schwalbe-Hansen P: Betaenkning om Sterlisation og Kastration [Report on sterilization and castration]. Herstedvester Hospital Publication 353. Copenhagen, 1964, pp 46–57 Wille R, Beier KM: Castration in Germany. Ann Sex Res 2: 103–33, 1989 Hanson RK, Bussiere M: Predicting relapse: a meta-analysis of sexual offender recidivism studies. J Consult Clin Psychol 66: 348–62, 1998 Rice M, Quinsey V, Harris G: Sexual recidivism among child molesters released from a maximum security psychiatry institution. J Consult Clin Psychol 59: 381–6, 1991 Dix GE: Determining the continued dangerousness of psychologically abnormal sex offenders. J Psychiatry Law 3: 327–44, 1976 Hanson RK, Thornton D: Improving risk assessments for sex offenders: a comparison of three actuarial scales. Law Hum Behav 24: 119–36, 2000 Berlin FS, Galbreath NW, Geary B, et al: The use of actuarials at civil commitment hearings to predict the likelihood of future sexual violence. Sex Abuse 15: 377–82, 2003 Hanson RK, Gordon A, Harris AJ, et al: First report on the collaborative outcome data project on the effectiveness of psychological treatment for sex offenders. Sex Abuse 14: 169–94, 2002 Fabian JM: Kansas v. Hendricks, Crane and beyond: "mental abnormality," and "sexual dangerousness": volition vs. emotional abnormality and the debate between community safety and civil liberties. Wm Mitchell Law Rev 29: 1367–443, 2003 Hall GCN: Sexual offender recidivism revisited: a meta-analysis of recent treatment studies. J Consult Clin Psychol 63: 802–9, 1995 Berlin FS, Hunt WP, Malin HM, et al: A five-year plus follow-up survey of criminal recidivism within a treated cohort of 406 pedophiles, 111 exhibitionists and 109 sexual aggressives: issues and outcome. Am J Forensic Psychiatry 12: 5–28, 1991...查看详细 (19736字节)
☉ 11326935:急性胰腺炎与全身炎症反应综合症
关键词急性胰腺炎；全身炎症；反应综合症急性胰腺炎(AP)尤其是重症急性胰腺炎(Severe acute pancreatitis，SAP)并不仅仅是局限于胰腺及胰腺周围的炎症，而常常与低血压、ARDS、急性肾功能不全等联系在一起。急性胰腺炎多数病情较轻、呈自限性，但其中约有15%～30%表现为SAP，后者的治疗一直是困扰广大医务工作者的难题，病情重、住院时间长、并发症多、病死率高(达20%～30%)是其明显的特点[1]...查看详细 (12330字节)
☉ 11326936:颈椎损伤患者行颅骨牵引的护理体会
关键词颈椎损伤；颈骨牵引；护理体会颅骨牵引适用于颈椎骨折和脱位患者，尤其是骨折、骨折脱位伴有脊髓损伤者。颅骨牵引常作为颈椎损伤非手术治疗的重要方法，也是作为术前、术中牵引复位的重要手段。我科自2000年至今行颅骨牵引治疗颈椎损伤患者98例，经及时准确的治疗，精心护理，大部分患者均取得满意的疗效。 1 临床资料本组男性82例，女16例，男：女比例6∶1。年龄18～64岁...查看详细 (4762字节)
☉ 11326938:拉萨地区藏汉族成人与儿童血清蛋白检测分析
关键词高原；正常人群；血清蛋白关于西藏拉萨正常人群血清蛋白的调查，20世纪70年代曾有关于成人的报道，但儿童正常血清蛋白未见有文献报道。由于摄入营养的改善和检测方法的变化，结果是否有改变，笔者就此进行了调查分析。 1 对象及方法 1.1 对象门诊体检的正常健康人，其中汉族男女成人62人，藏族男女成人66人，汉族男女儿童60人，藏族男女儿童60人，藏汉族成人年龄最大的39岁...查看详细 (2965字节)
☉ 11326939:高原病实施整体护理的几点体会
关键词高原病；整体护理；体会整体护理的模式作为临床实践已有数年，我院驻地海拔3500米，由于高原环境具有大气压及氧分压低，气候干燥，紫外线辐射强等特有的环境特点[1]。对居住在高原的人群必然产生特有的病理生理现象，出现不同于平原的高原性疾病(急慢性高原病)对移居高原的开拓者，建设者及旅游者已造成了极大的威胁。人们常说：“三分治疗，七分护理”可见在对病人的治疗和康复进程中，护理工作起到了极为重要的作用...查看详细 (3256字节)
☉ 11326940:Subspecialization in Psychiatry: Third-Generation Programs
Dr. Bloom is Dean, Drexel University College of Medicine, Philadelphia, PA, and Emeritus Dean and Professor, Department of Psychiatry, Oregon Health and Science University, Portland, OR. Dr. Benson is Emeritus Dean and Professor of Medicine at Oregon Health and Science University, and Professor of Internal Medicine at the University of Nebraska College of Medicine, Omaha, NE. Abstract Psychiatry, unlike internal medicine, was slow to develop subspecialty certification. For many years, child and adolescent psychiatry was the only major subspecialty recognized by the American Board of Psychiatry and Neurology (ABPN). The situation changed in the early 1990s with the recognition by the ABPN of additional subspecialties of psychiatry including forensic psychiatry. Using the experience of the American Board of Internal Medicine as a guide, this commentary asks what comes next? What are our options as it becomes clear that there is a deepening of knowledge in the field of forensic psychiatry? Are we ready for, or interested in, the development of so-called third-generation certification programs? This commentary is meant to raise a question. What happens when the knowledge base and skills of a recognized medical subspecialty evolve to the point that further subspecialization becomes reasonable? We intend to focus this discussion on the field of forensic psychiatry, but will look at what has been done in the field of internal medicine as an example of a medical field with experience in the area of subspecialization, to provide guidelines for forensic psychiatry. The American Board of Internal Medicine (ABIM) has had long experience with subspecialty certification and now has significant experience with sub-subspecialty programs (third-generation certifications). The American Board of Internal Medicine As a primary certifying specialty board, the ABIM has had a long-standing policy requiring training and certification first in the general field, before certification in a subspecialty. The goal has been to keep internal medicine integrated as a practice specialty and academic discipline. Having certified qualified ABIM diplomates in three subspecialties since the early 1940s, and in six more since 1972, the ABIM has been petitioned many times, usually by academicians and subspecialty societies, to issue certificates in branches of the subspecialties—a third tier of standard-setting in internal medicine. The ABIM recognizes that specialized, concentrated domains of internal medicine will continue to differentiate, both to assure optimal medical care and to advance knowledge. Logic and fairness required a rational and uniform policy for handling requests for third-tier certifications. Guiding principles and legitimate reasons employed by the ABIM to make decisions that a sub-subspecialty has sufficiently "matured" are as follows1,2: The new discipline must have a distinct and unique body of knowledge within internal medicine. Certification in a new discipline should provide greater benefit to patient care than is provided by incorporating that discipline into existing subspecialty certification processes. The new area should be a recognized branch of medical practice. There should be a reasonable number of potential candidates in practice (and therefore a feasible fee for certification). There must be accreditation by the Accreditation Council for Graduate Medical Education (ACGME) of formal training in the sub-subspecialty, often obtained with the help of ABIM more or less concurrently with the development of the new certification process. The member certifying boards of the American Board of Medical Specialties (ABMS) must be satisfied with the request and formally approve it. Integration of both the parent specialty and its subspecialty and the significance of their certificates should not be compromised. To accommodate the new process, the ABIM created the term "added qualifications" to refer to competencies added to certification in the specialty or subspecialty. It insisted on at least one year of added training (i.e., no grandfathering solely on the basis of experience), and only time-limited certificates were offered. Policy requires an internist-diplomate to maintain certification in both the added qualification and the parent discipline (i.e., internal medicine or the subspecialty). Trying to avoid fragmentation, as an alternative to creating an added qualification, the board preferred to incorporate new science into the certification of existing and inevitably evolving subspecialty disciplines, even if training in the latter must be extended. The board has also added to the name of a subspecialty the desired new emphasis (e.g., the addition of diabetes to the subspecialty of endocrinology, diabetes, and metabolism). That said, new third-tier Certificates of Added Qualifications (CAQs) are currently offered in clinical cardiac electrophysiology (after certification in cardiology), interventional cardiology (after cardiology), critical care medicine (after pulmonary disease), and transplantation hepatology (after gastroenterology). Others are under consideration by ABIM and ABMS. The impact of this phenomenon on practice and training is closely monitored by ABIM. The board assiduously avoids endorsing the use of its certificates as required credentials for granting clinical privileges, even though hospital credentialing bodies do use certificates for this purpose. New certificates impose new costs, both for the board and for those seeking such recognition. These costs may ultimately be borne by the patient or the public, but the public is protected by a widely recognized certification process from either wanton, self-declared competence or from credentials offered by specialty societies with their inherent conflict of interest. The American Board of Psychiatry and Neurology: Forensic Psychiatry The American Board of Psychiatry and Neurology (ABPN) was founded in 1934,3 two years earlier than the ABIM, but the ABPN, unlike the ABIM, certified relatively few subspecialties until recently. Today, the ABPN certifies a wide variety of competencies including certification in the "Subspecialty of Forensic Psychiatry."4 Its first certificates in forensic psychiatry were awarded in 1994. The subspecialty is currently supported by 42 forensic psychiatric training programs approved by the ACGME.5 The ABPN describes the content of its multiple-choice examination in forensic psychiatry as covering, in essence, the whole field of forensic psychiatry: Candidates will be assessed in legal regulation of psychiatry, civil law, criminal law, corrections and correctional health care, legal systems and basic law, children and families, special diagnostic and treatment issues, special procedures in forensic psychiatry, special consultations and investigations, and risk assessment (including violence, dangerousness, criminology, suicide, and psychiatric autopsy), and forensic psychiatry practice issues [Ref. 6, p 31]. This broad approach is as it should be. A year of added training in a subspecialty should attempt to cover the entire subspecialty. Not surprisingly, in a sample of forensic psychiatry training program Web sites, the training program statements mirror the areas outlined by the ABPN. Again, we should be clear that we have no argument with this approach. However, it is within this approach that the seed of this commentary was developed. Third-Generation Competencies As a subspecialty develops and as the number of academic and clinical practitioners increases, the knowledge base of a field in turn expands. As this occurs, the ability to maintain expertise in all of the areas of the subspecialty is likely to, of necessity, decrease. In a one-year training program, an individual trainee can develop the knowledge base promised by the program, and can indeed begin to function as a subspecialist. But what does the trainee do if he or she wants to become an expert in a segment of forensic psychiatry? How is this problem addressed? Before attempting to answer this question, let us briefly illustrate the question with two examples. We provide these examples of what might be considered potential sub-subspecialty areas within forensic psychiatry that might be worthy of Certificates of Added Qualifications. Public Psychiatry and the Law One of us (J.D.B.) came to forensic psychiatry with an interest and having received a fellowship in community psychiatry. It became obvious, as the federal effort in community psychiatry slowed7 and as deinstitutionalization gained momentum, that knowledge of the laws regulating the care and treatment of severely mentally ill individuals was an absolute necessity for an individual interested in this area of psychiatry. Hence, over the years the Oregon Health and Science University (OHSU) Public Psychiatry Training Program developed a subsection8 focused on public psychiatry and the law. This program explored a range of forensic interests related to the care and treatment of severely mentally ill individuals. The program originated with a focus on public policy and the treatment of severely mentally ill individuals in hospitals and community mental health centers. As the forensic aspects of the program grew, it focused on the involvement of severely mentally ill individuals in forensic psychiatric hospitals, jails, and prisons. Along with this focus, the OHSU program developed empirical research related to those laws that influence the care and treatment of severely mentally ill individuals, including civil commitment, the right to refuse treatment, and the insanity defense.9 Evaluation and Treatment of Sexual Offenders The evaluation and treatment of sex offenders is an area of great complexity and an area of forensic psychiatry that is underemphasized in most forensic programs, most likely because of the paucity of model treatment programs for this population in most areas of the country. There is an extensive body of literature in this area, and the extent of the problem has become more clear in the last two decades.10 A training program in this sub-subspecialty could very easily be designed. Other Examples Other potential sub-subspecialty areas include correctional psychiatry with a subfocus on offenders with substance abuse, sexual abuse, or antisocial personality. A program could also be developed with a focus on civil law. This is an area that is greatly underemphasized in many training programs and an area that could be combined with a major focus on traumatology. Discussion What are the potential solutions to the problems we have defined? Is forensic psychiatry ready for third-generation programs of training and certification? It is our contention that, if we are not at that point now, then we will soon be there. Having some experience with the development of the certification process in forensic psychiatry, we know that forensic psychiatry, as a subspecialty of the ABPN, has had its opponents, both in psychiatry and among other medical specialists. The criteria defined by the ABIM earlier for its new certificates provide some of the reasons. Forensic psychiatry has had a difficult time justifying to others that it is a branch of medical practice and that it benefits patient care. Many forensic psychiatrists have had to go to great lengths to overcome these objections; but the field has overcome the objections and may be able to do so again in regard to third-tier programs. However, the greatest objection, and probably one that is quite justifiable, is that there may not be a reasonable number of potential candidates to warrant the development of a new, very costly certification process. If this objection is substantiated, what alternatives are there for the development of third-tier training and certification programs? Three potential options come to mind. Encourage diversity among existing training programs. Forensic psychiatry is a popular subspecialty. There does not seem to be too much difficulty in attracting excellent candidates into the already existing programs. There is every reason to believe that additional training programs will be developed in the near future. There is, however, probably a limit to the potential number of applicants for certification. In 2003, 916 medical students matched to psychiatry training programs, while in 2004 there were 979 matches.11 If 100, or about 10 percent, of graduates of psychiatric residencies enter forensic fellowships, is it reasonable to expect that about 12 to 15 percent of residency program graduates will become forensic psychiatrists? Thus, with the number of forensic training programs increasing and the number of applicants perhaps also increasing modestly, training programs may want to differentiate themselves one from the other by offering general training in forensic psychiatry along with focused expertise in one or more specific areas of forensic psychiatry. Encouraging diversity among programs, which to some extent is occurring now, would serve programs well in regard to recruitment and training individuals with third-tier expertise. Extend training in certain programs to two years. The certificate awarded by the ABPN in forensic psychiatry following one year of subspecialty training was changed in 1997 from "Added Qualifications" in forensic psychiatry to "Certification in the Subspecialty of Forensic Psychiatry."12 All newer certifications of the ABPN have this designation. At the subspecialty level, however, child and adolescent psychiatry still requires two years of subspecialty training, but awards a certificate entitled "Certification in the Subspecialty of Child and Adolescent Psychiatry." One solution to the dilemma presented in this commentary is for certain forensic training programs to develop two-year programs that offer a second year of training in one of the third-tier areas. This proposal would mean that the second year of these training programs would not meet the exact lock-step goals of the other two-year programs, but they would produce unique training experiences in the third-tier areas. This would be a highly unusual approach, but one that would embrace the best features of the two other proposals in this section. The certificates (and corresponding examinations) awarded for one- and two-year training could be differentiated. The two years of training would be accredited by the ACGME. Pair unaccredited sub-subspecialty programs with accredited training programs. This third option is one that is unorthodox and may be regarded by established accrediting agencies and the ABMS as a dangerous precedent. It involves the use of an unaccredited sub-subspecialty fellowship paired with an ACGME-approved forensic psychiatry fellowship. This option would preserve the training in the subspecialty of forensic psychiatry and would, in very selected programs, add a non-ACGME accredited fellowship in some particular area of forensic psychiatry, such as those suggested earlier. Although typically non-ACGME accredited fellowships are clinically oriented, we also recommend that these programs not be mere apprenticeships and that they have a healthy component dedicated to research. In this option, such programs may be accepted by some substantial national authority (such as the chairs of academic departments of psychiatry) as selected training programs in a given sub-subspecialty of forensic psychiatry. The operative credential for graduates might be a certificate of satisfactory completion of such training in a nationally recognized institution. Certification in forensic psychiatry as a subspecialty of psychiatry is a success story. From the early days of the specialty examination originally organized by the American Academy of Psychiatry and the Law to the success of the ABPN examination, the subspecialty has enjoyed steady positive momentum. Trying to figure out how to handle matters associated with third-generation certification is certainly not a bad problem to have. We believe that it is time to begin to focus on these questions. The trick will be to avoid the undue proliferation of recognition of third-generation competencies by other certifying boards, or specialty societies, especially recognition involving only technical skills. But the march of medical knowledge and practice demands that serious deliberation address new policy considerations governing training and standards. Acknowledgments The authors appreciate the thoughtful review by Lynn Langdon, Senior Vice President of the American Board of Internal Medicine References The ABIM Task Force: The Future Internist. The Task Force on the Future Internist, American Board of Internal Medicine.Ann Int Med108:139–411988 American Board of Internal Medicine: Report of the Advisory Committee on Recognizing New and Emerging Disciplines in Internal Medicine. Philadelphia:ABIM1993 Hollender MH, ed: The American Board of Psychiatry and Neurology: the First Fifty Years. Deerfield, IL: ABPN1991 The American Board of Psychiatry and Neurology: www.abpn.com (accessed August 2,2004) Graduate Medical Education Directory,2004–2005: Chicago: American Medical Association,2004 pp 610–13 The American Board of Psychiatry and Neurology: http://www.abpn.com/downloads/2005subspec_cert_ifa.pdf (accessed August 2,2004) Foley HA, Sharfstein S: Madness and Government. Washington, DC: American Psychiatric Press, 1983 Bloom JD, ed: State-University Collaboration: The Oregon Experience. New Directions for Mental Health Services. San Francisco: Josey-Bass,1989 Bloom JD, Williams MH: Mental health services research with forensic populations, in State-University Collaboration: The Oregon Experience. Edited by Bloom JD. San Francisco: Josey-Bass,1989, pp 73–82 Abel GC, Osborn C: The paraphilias: the extent and nature of sexually deviant and criminal behavior.Psychiatr Clin North Am15:675–87,1992 Association of American Medical Colleges: Results and Data, 2004 Match: National Resident Matching Program. Washington, DC: Association of American Medical Colleges,2004, p 3 The American Board of Psychiatry and Neurology: Information for Applicant for Certification in the Subspecialties of Addiction Psychiatry, Clinical Neurophysiology, Forensic Psychiatry, Geriatric Psychiatry, Neurodevelopmental Disabilities, Psychosomatic Medicine, Vascular Neurology. www.abpn.com (accessed August 2,2004)...查看详细 (18711字节)
☉ 11326941:高原脑水肿患者行留置导尿的护理探讨
摘要目的探讨高原脑水肿(High aktitude cerebrak edema HACE)患者行留置导尿的护理要点。方法回顾我院收治的217例护理资料完整的HACEU病例，并对行留置导尿的HACE患者的护理进行总结。结果 217例HACE病例中轻型119例、中型65例、重型33例，发生尿路感染的有11例，占507%。结论 HACE患者应尽量不插管或缩短留置导尿时间；在准确记录尿量和预防褥疮的同时...查看详细 (7359字节)
☉ 11326942:护生从学校到临床角色行为适应的影响因素与对策
关键词护生；角色行为；适应护生从学校到医院学习是大学生活的重要组成部分，它是理论与知识相结合，对知识融会贯通的基石，也是走出校园，迈上神圣的“白衣天使”工作岗位的第一步，对护生的人生观、价值观、世界观具有重要影响的一个阶段。为让护生在实习期间尽快适应角色，更好的完成实习任务，全面的提高自身素质，成为一个高素质的护理人才，必须从思想上高度重视，从行为上对护生临床实习加以引导和规范。促进护生角色的适应...查看详细 (4753字节)
☉ 11326943:Commentary: Quality Improvement and Psychiatric Fitness-for-Duty Evaluations of Physicians
Dr. Wettstein is Clinical Professor of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA. A physician’s fitness for duty is of great importance to a variety of parties, including the general public, yet it is not often addressed in the professional literature. Requests for mental health evaluations of a physician’s fitness for duty originate from state medical boards, hospital medical staffs, human resource departments of hospitals, impaired-physician or other diversion programs, or individual physicians and their attorneys. Some evaluations are voluntary, and others are mandatory. Litigation at the medical board level regarding a physician’s medical license is often hotly contested, given the high stakes of a medical license sanction. Thus, the publication of the American Psychiatric Association’s Resource Document on the Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians1 is a welcome contribution. Referrals for evaluations of allegedly impaired physicians relate to a variety of matters. Although comprehensive data regarding the frequency of various referral questions are unavailable, evaluations conducted on referrals to Alabama’s Physicians Recovery Network between 1991 and 1997 yielded primary clinical diagnoses of chemical dependency (55%), chemical abuse (6%), affective disorders (29%), and personality disorders (10%).2 In Georgia, of the 1000 physicians evaluated between 1975 and 1986 for suspected impairment, 92 percent had a primary diagnosis of chemical dependence, and 6 percent had a psychiatric diagnosis, with or without chemical dependence.3 Existing literature and practice in this area reveal that recognition of impaired physicians is often challenging because of their varied presentations.4 Health care professionals, especially physicians, greatly value their careers and work and therefore attempt to mitigate, delay, deny, or hide their work impairment from others. Thus, personal and family relationships are usually affected before impairment affects work. Hospital nurses can become expert at concealing hospital drug diversion, given that hard evidence of such is typically unavailable. The physician with a personality disorder is skilled at externalizing responsibility for behavior. Physicians are notoriously considered to be poor patients and not infrequently attempt to diagnose and treat themselves and family members, often because they have no personal physician for themselves.5 They may seek special status and privilege and demand to be treated differently from others. Beyond this, outrageous or abnormal behavior is often tolerated in physicians due to their professional, economic, or social status in the community or health care organization. There may be rationalization of disruptive behavior, with faulty attribution to sleep deprivation, stress, or overwork. Yet, the prognosis for substance-abusing physicians is described as generally good, when the patient is adequately motivated and treatment is available and accepted.6,7 The guidelines are also useful for evaluators of health care professionals other than physicians. Nurses greatly outnumber physicians and are not immune to mental disorder and substance abuse. Other health care providers, such as psychologists, respiratory therapists, dentists, podiatrists, and chiropractors, also come to the attention of hospital employers and state boards. Initially, it should be noted that guidelines are recommended practices and are distinguishable from standards that are regarded as mandatory or required. Nevertheless, guidelines are intended to assist the evaluator in conducting the evaluation and preparing the report, to make the procedure more uniform across evaluators, and to assist the less experienced evaluator. Existing empirical literature on the quality of forensic evaluations generally indicates that the work of forensic and nonforensic specialists is deficient in data sources, extrapolation of the data, and provision of detailed support for expert opinions in the evaluation report.8,9 Further, the quality of forensic evaluations conducted by nonforensic specialists is especially lacking.10 In many hospital and general medical settings, increased volume of patient care activity is sometimes associated with improved quality of care as measured by morbidity and mortality.11,12 In psychiatry, there is a similar association between volume of mental health services and its quality.13 General psychiatrists, as well as psychiatrists with forensic training and expertise, conduct fitness-for-duty evaluations. It is expected but unknown whether adoption and implementation of these practice guidelines would ultimately increase the quality and reduce the variability of fitness-for-duty evaluations of physicians conducted by nonforensic or forensic mental health specialists. The evaluation approach adopted by the APA fitness-for-duty guidelines is that of a general forensic evaluation. Yet, some differences exist and should be discussed. As noted in the document, evaluations differ depending on the referral source. An evaluation of a physician for diversion to an impaired physician’s program can be quite different from an evaluation for discipline of a physician by a state medical board. Though practice guidelines are desirable and can improve the quality of evaluation and treatment in health care, many problems with practice guidelines have been described.14,15 Organizations that create and publish them do not uniformly articulate and execute a development process.16 Guidelines are often not empirically based, but only assemble the collective wisdom or opinion of the sponsoring group and development committee, as in the present fitness-for-duty guidelines. Physicians may not agree with the guidelines’ recommendations. Guidelines can be oversimplified or written generally with limited specificity, depending on the topic area. They can become outdated in a few years, especially in rapidly changing practice areas.17 Practice guidelines are not conclusive with regard to determining the standard of care in professional liability cases, but can be used as inculpatory or exculpatory evidence.18 Dissemination of the guidelines is often lacking, and many practitioners may not even be aware of their existence. Practice inertia makes it difficult for many physicians to alter their practices, despite the presence of the guidelines. Other barriers to implementing guidelines include financial cost and intrusion into physician autonomy. Application of the guidelines may also be cumbersome. With this in mind, it is important that the resource document be adequately publicized, and we welcome its present publication in the Journal; it should also be distributed electronically. The Agency for Health Care Research and Quality (AHRQ) publishes professional health care practice guidelines through the website of the National Guidelines Clearinghouse, and the guidelines should be accessible through that website.19,20 A strategy to implement and operationalize the guidelines is lacking and would be welcome. All practice guidelines are works in progress. At this stage in the development of the APA fitness-for-duty guidelines, they are not evidence- or empirically based guidelines. We have no empirical data on the frequency of fitness-for-duty evaluations of any health care providers, the resources (i.e., time, funding) needed to conduct these evaluations, and the types of interviews and testing procedures typically used in practice or their results. We do not know what fitness-for-duty evaluators actually do, or what they say that they do, or what they think should be done. We do not have data regarding the quality of such evaluations as assessed by the referral sources or anyone else. Additional specificity in the guidelines would be useful. While we note that special expertise is needed to conduct such evaluations, we deem it especially important in conducting evaluations of physicians that the evaluator have experience in evaluating and treating other physicians. Evaluators must understand that protection of the public is the most important underlying principle of fitness-for-duty evaluations of physicians, whether for diversion or discipline.21 Evaluators may too easily overidentify with another physician and thereby lack the necessary objectivity required by the Ethics Guidelines of the American Academy of Psychiatry and the Law (AAPL). Those evaluators who are readily intimidated by antagonistic or narcissistic personality pathology in physicians may also have difficulty conducting an objective evaluation. In addition, evaluators should be familiar with substance-abuse problems in physicians and have specific knowledge of available treatment, rehabilitation, and diversion programs in the respective geographic areas. Evaluators may too easily accept the evaluee’s self-report of symptoms, functioning, or drug use as valid. Additional expertise may be necessary in bipolar, personality, and endocrine disorders and their comorbid illnesses. Evaluators must be able to assess the evaluee’s treatment to determine if it is appropriate and likely to control the evaluee’s symptoms adequately and render him or her capable of the safe practice of medicine.21 Other important substantive areas omitted from the guidelines are relapse; recidivism; prognosis of psychiatric disorders, including substance abuse and dependence; and time until reentry into the work place. Fitness-for-duty evaluators should be familiar with the growing empirical literature in these areas. Last, the guidelines do not detail what psychological instruments, symptom validity testing, or other tests are useful or valid in these evaluations.22,23 It is to be hoped that publication of these guidelines will improve the quality of fitness-for-duty evaluations of health care professionals. Medical boards and other groups should become familiar with this document, distribute the guidelines to their evaluators, and expect evaluators to adhere explicitly to them in their contracted work. Further refinement of the guidelines, with greater specificity and empirical base, should be undertaken. References Anfang SA, Faulkner L, Fromson J, et al: The American Psychiatric Association’s Resource Document on Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians. J Am Acad Psychiatry Law 33:85–8, 2005 Summer GL, Ford CV,Lightfoot WM: The disruptive physician, I:the Alabama physicians recovery network. Fed Bull 84:236–43, 1997 Talbott GD, Gallegos KV, Wilson PO, et al: The Medical Association of Georgia’s impaired physicians program. JAMA 257:2927–30, 1987 Boisaubin EV, Levine RE: Identifying and assisting the impaired physician. Am J Med Sci 322:31–6, 2001 Gross CP, Mead LA, Ford DE, et al: Physician, heal thyself? Arch Intern Med 160:3209–14, 2000 Mansky PA: Physician health programs and the potentially impaired physician with a substance abuse disorder. Psychiatr Serv 47:465–7, 1996[Free Full Text] Coombs RH: Drug-Impaired Professionals. Cambridge, MA:Harvard University Press, 1997 Nicholson RA, Norwood S: The quality of forensic psychological assessments, reports, and testimony: acknowledging the gap between promise and practice. Law Hum Behav 24:9–44, 2000 Skeem JL, Golding SL, Cohn NB, et al: Logic and reliability of evaluations of competence to stand trial. Law Hum Behav 22:519–47, 1998 Tolman AO, Mullendore KB: Risk evaluations for the courts: is service quality a function of specialization? Prof Psychol 34:225–32, 2003 Peterson ED, Coombs LP, DeLong ER, et al: Procedural volume as a marker of quality for CABG surgery. JAMA 291:195–201, 2004 Esserman L, Cowley H, Eberle C, et al: Improving the accuracy of mammography: volume and outcome relationships. J Natl Cancer Inst 94:369–75, 2002 Druss B, Miller CL, Pincus HA, et al: The volume-quality relationship of mental health care: does practice make perfect? Am J Psychiatry 161:2282–6, 2004 Shaneyfelt TM, Mayo-Smith MF, Rothwangl J: Are guidelines following guidelines? JAMA 281:1900–5, 1999 Cabana MD, Rand CS, Powe NR, et al: Why don’t physicians follow clinical practice guidelines? JAMA 282:1458–65, 1999 American Psychological Association: Criteria for practice guideline development and evaluation. Am Psychol 57:1048–51, 2002 Shekelle PG, Ortiz E, Rhodes S, et al: Validity of the Agency for Healthcare Research and Quality clinical practice guidelines. JAMA 286:1461–7, 2001 Hyams AL, Brandenburg JA, Lipsitz SR, et al: Practice guidelines and malpractice litigation: a two-way street. Ann Intern Med 122:450–5, 1995 National Guideline Clearinghouse http://www.guideline.gov (accessed February 8, 2005) Furrow BR: Broadcasting clinical guidelines on the internet: will physicians tune in? Am J Law Med 25:403–21, 1999 Nye GS: Psychiatric evaluation for diversion program candidates. Fed Bull 83:95–101, 1996 Jansen M, Bell LB, Sucher MA, et al: Detection of alcohol use in monitored aftercare programs: a national survey of state physician health programs. J Med Licens Discipl 90:8–13, 2004 Skipper GE, Weinmann W, Wurst FM: Ethylglucuronide (ETG): a new marker to detect alcohol use in recovering physicians. J Med Licens Discipl 90:14–17, 2004...查看详细 (13510字节)
☉ 11326944:肺动静脉瘘介入治疗1例
关键词肺动静脉瘘；介入治疗患者男性，33岁，汉族，西藏拉萨市居民，因反复发作胸闷，气促16余年，加重1年，于2006年8月10日入院，患者自1990年4月无明显诱因出现胸闷，气促，乏力症状，每次发作自认为是高原反应，口服治疗高原反应的药物大都能缓解。自去年7月始胸闷、气促等症状发作频繁，今年6月到当地医院CT检查提示右肺动静脉瘘，今年8月来我院就诊，以肺动静脉瘘收入。体格检查；T365，P78次/分...查看详细 (1818字节)
☉ 11326945:肺霉菌感染16例影像学诊断分析
关键词肺霉菌；感染；影像学；诊断肺霉菌种类很多，常见的致病菌也有多种。肺霉菌病的致病菌最常见的有放线菌、奴卡氏菌、白色念球菌等，临床影像学表现较为复杂，现就工作中遇到的16例肺霉菌的影像学诊断问题探讨如下。 1 临床资料 1.1 一般资料 16例肺霉菌感染，男性9例，女性7例，均为成年人。职业情况：8例为农民，3例为环保工人，5例无职业，其中有养鸽嗜好。病程均在6个月以上...查看详细 (3802字节)
☉ 11326946:Commentary: The Clinical Implications of Doctors’ Evaluating Doctors
Dr. Wall is Clinical Associate Professor, Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI. The American Psychiatric Association Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians1 is a welcome resource document for forensic examiners who perform independent medical examinations of potentially impaired physicians. Anecdotal and published reports indicate that requests for such evaluations are growing2; hence, there is growing attention to the process of conducting these examinations and of highlighting important pitfalls and clinical concerns in evaluating fellow physicians. While there has always been a need for guidelines for fitness-for-duty evaluations of physicians, there have been emerging trends in who orders such evaluations of physicians and why. With the change from a fee-for-service system to a managed-care environment as well as the increasing complexity of the provision of health care, fewer physicians are their own bosses and increasingly must be able to participate cooperatively within a health care team. These changes can be in conflict with traditional expectations held by some physicians about the authority and autonomy of the profession. Physicians can be stressed by such changes, and that stress can sometimes translate into disruptive behavior.3 In addition to patients’ making complaints, paraprofessional employees (such as nurses and aides) may feel more empowered to make complaints about a physician’s behavior. Most hospitals have now created policies pertaining to disruptive behavior of physicians based on American Medical Association guidelines4 and Joint Commission on Accreditation of Health Care Organizations standards,5 which can prompt request for a fitness-for-duty evaluation of a physician. While hospitals and physician health committees of medical associations can request fitness-for-duty evaluations, complaints about the behavior of physicians and requests for such evaluations are now more frequently the province of state medical boards. Because state medical boards can revoke the license of the physician being examined, and because hospitals can revoke privileges, the results of the fitness-for-duty evaluation can have powerful financial and therapeutic impacts on the physician who has come to the attention of his or her employer or state medical board. The forensic psychiatric assessment can also have major implications for the examinee when the findings have the potential for public access, as described in the resource document. These days, medical associations typically have roles that are more therapeutic than sanctioning. In the past, however, this was not always the case. For example, it was not uncommon for the American Psychiatric Association’s district branch, state association, or national ethics committees to have a role in evaluating the conduct of psychiatrists. These assessments were internal, and so the reporting of the findings was sometimes less formal. However, with its increased focus on advocacy for patients and other broader agendas over the past few years, the Association has less time and fewer resources to pursue internal investigations of physicians. Further, the outcome of investigations by specialty societies have not always had the good impact desired by the physician community. Adverse findings have sometimes resulted in little more than the termination of membership in the specialty association, while allowing the evaluee to continue practicing medicine. Although the American Psychiatric Association’s procedures for handling complaints of unethical behavior now includes an educational option for less serious violations, instead of relying solely on an enforcement option,6 again, complaints about physician behavior and requests for such evaluations are now more frequently the province of state medical boards. Conducting the Evaluation The resource document discusses traditional reasons for referral, such as psychiatric disorders including substance abuse, and cognitive impairment. It discusses the need for behavior assessment to determine whether the behavior is attributable to mental illness, to maladaptive personality traits, or to unethical or illegal acts such as threatening behavior or sexual misconduct. The document also describes the need to define clearly the role of the examiner and the reason for the consultation. While the resource document provides general information on conducting the fitness-for-duty evaluation, other documents contain more specific recommendations for conducting the face-to-face interview.7,8 Although it may not be clinically required, it is often helpful from a clinical perspective to have the evaluee sign a consent form authorizing the release of the report to the requesting source in advance of the interview. Such a practice can help underscore the importance of the evaluation to the evaluee, who may have minimized its need, and can lead to a deeper discussion about the limits of confidentiality at the outset of the evaluation. Mandating the release of information in advance can also lead to the evaluee’s discussing the evaluation more fully with an attorney. Although this is largely helpful, there is a risk that doing so may result in the evaluee’s being less forthcoming during the interview. If the physician has a history of mental illness, it is important to consider compliance with medication as a factor in the current situation. Psychological testing may be of additional benefit in evaluating relevant personality issues. In addition to recommendations contained in the resource document, it may be important to discuss the evaluee’s personality characteristics, coping strategies, tolerance of frustration, and whether there have been similar instances of problematic behavior and, if so, how those instances relate to the current situation. When relevant, understanding the culture of the health care organization with which the physician is affiliated is helpful in conducting the clinical assessment as well. Implications of Clinical Recommendations Impaired physicians sometimes have little insight into their behavior or need for change and/or treatment, and they may persist in their belief that their behavior is not a problem. Providing detailed reasoning to support the findings in the fitness-for-duty report may be a tool in helping the evaluee come to terms with his or her impairment. If the physician’s license is suspended or revoked, the fitness-for-duty evaluation can become the first step toward a coordinated effort to treat and monitor an impaired physician. These evaluations can often translate into mandated, confidential treatment, which frequently has state medical association oversight.8 Describing the reason for the decompensation or disruption in behavior and the signs and symptoms of illness and noting whether the physician has the capacity to work collaboratively with the health care environment become all the more important when recommendations are used to guide treatment. If impairment is present, the evaluee’s clinical needs should be identified, and recommendations should include interventions necessary for the physician to return to work. Since treatment recommendations can sometimes help define how recovery will be gauged, the advice should be specific enough to help the referral source understand exactly how the physician will be found fit for duty in the future. It may also be helpful to define the behavioral expectations of the physician when he or she returns to work, which can include delineating reasonable and competent behavior. As such, recommendations may also include education in interpersonal skills or other efforts toward rehabilitation, particularly when there is a need to minimize or eliminate disruptive conduct.3 Credibility of the Process Ultimately, the outcomes and recommendations of these evaluations can be serious, life-changing, and/or career-changing events for physicians receiving them. While the fitness-for-duty evaluation is often a first step toward managing impaired physicians, it is important to remember that the major focus of the assessment and intervention to assist a potentially impaired physician is not the care of the physician, but the protection of the public.8 Politicians, the public, and even members of the state board may perceive that the physician evaluator has favorable bias toward the evaluee because of the perception that guild members protect their own.7 Providing a rational description of and justification for a declaration of impairment can help strengthen the credibility of physicians who assess their peers. A high-quality fitness-for-duty evaluation is the best defense against accusations of bias. Good reports, aided by good guidelines such as the APA’s resource document, help make medicine accountable for itself and strengthen the trust needed among organized medicine, our professional colleagues, governing agencies, and patients. References Anfang SA, Faulkner L, Fromson J, et al: The American Psychiatric Association’s Resource Document on Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians. J Am Acad Psychiatry Law 33:85–8, 2005 Harmon L, Pomm R: Evaluation, treatment and monitoring of disruptive physician behavior. Psychiatr Ann 34:770–4, 2004 Pfifferling J: The disruptive physician: a quality of professional life factor. Physician Exec 25:55–8, 1997 American Medical Association: Code of Ethics. Physicians with disruptive behavior. http://www.ama-assn.org/ama/pub/category/8533.html (accessed October 6, 2004) Youssi M: JCAHO standards help address disruptive physician behavior. Physician Exec 28:12–13, 2002 The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry, 2001 Edition (including November 2003 amendments). http://www.psych.org/psych-pract/ethics/ppaethics.pdf (accessed October 6, 2004) Brodsky C: Psychiatric aspects of fitness for duty. Occup Med 11:719–26, 1996 Wall BW, Appelbaum KA: Disabled doctors: the insurance industry seeks a second opinion. J Am Acad Psychiatry Law 26:7–19, 1998 Pomm R, Harmon L: Evaluation and posttreatment of the impaired physician. Psychiatr Ann 34:786–9, 2004...查看详细 (10411字节)
☉ 11326947:复方丹参加西咪替丁治疗过敏性紫癜临床研究
摘要目的探讨复方丹参加西咪替丁治疗过敏性紫癜(HSP)临床疗效。方法 60例患儿随机分为对照组和治疗组各30例。对照组常规治疗，治疗组加用复方丹参和西咪替丁治疗。观察临床效果。结果治疗组总有效率为90.00%，明显高于对照组(53.3%)。结论复方丹参加西咪替丁能提高HSP患儿疗效，改善其免疫功能。关键词过敏性紫癜；复方丹参；西咪替丁；疗效；免疫功能 Ckinicak Research of the Treatment to Anaphykactiod Purpura withSakviae Miktiorrhiaza Composita pkus Cimetidine Hong Chuanying...查看详细 (6963字节)
☉ 11326948:The American Psychiatric Association’s Resource Document on Guidelines for Psychiatric Fitness-for-Duty Evaluations of Physicians
Dr. Anfang is Assistant Professor of Psychiatry, University of Massachusetts Medical School, Worcester, MA. Dr. Faulkner is Dean, University of South Carolina School of Medicine, Columbia, SC. Dr. Fromson is Assistant Clinical Professor of Psychiatry, Harvard Medical School, Boston, MA. Dr. Gendel is Clinical Associate Professor of Psychiatry, University of Colorado Health Sciences Center and Medical Director, Colorado Physician Health Program, Denver, CO. Abstract The psychiatric evaluation of a physician’s fitness for duty is an undertaking that is both important to patients’ well-being and to the physician-subject of the evaluation. It is necessary that psychiatrists who agree to perform such evaluations proceed in a careful and thorough manner. This document was developed to provide general guidance to the psychiatric evaluators in these situations. It was prepared by the American Psychiatric Association (APA) Council on Psychiatry and Law and Corresponding Committee on Physician Health, Illness, and Impairment, of which the authors are members. The Resource Document was approved by the APA Joint Reference Committee in June 2004. APA Resource Documents do not represent official policy of the American Psychiatric Association. This Resource Document was edited to conform to Journal style and has therefore been modified slightly from the original document approved by the APA. Psychiatrists are often called on to evaluate a physician’s fitness for duty. Specific questions may center on the presence of psychiatric or neuropsychiatric impairment. In these cases, the psychiatrist may be asked to examine the physician, prepare a report of detailed diagnostic findings and treatment options, and offer an opinion regarding fitness for duty. Impairment is a related or corollary concept to "fitness for duty." The American Psychiatric Association’s (APA) document on fitness-for-duty evaluations defines impairment as the inability to practice medicine with reasonable skill and safety as a result of illness or injury. Illness may refer to psychiatric disorders, including substance use disorders, as well as physical disease or disability. Under certain circumstances, a physician’s problematic behavior leads to questions about fitness for duty. Boundary violations (such as sexual misconduct), unethical or illegal behavior, or maladaptive personality traits may precipitate an evaluation, but do not necessarily result from disability or impairment due to a psychiatric illness. A physician may have difficulty practicing safely based on a lack of adequate knowledge, training, or skill. Detailed evaluation of such problems is not within the scope of a psychiatric fitness-for-duty examination. If such knowledge or skill deficits are suspected, referral should be made to an appropriate assessment or peer review program. Further education, training, or remediation may be necessary. A fitness-for-duty evaluation must address the specific functional tasks of the particular physician’s duties. For example, a Parkinsonian tremor may impair the work performance of a neurosurgeon, but may not significantly impair a psychiatrist. Guidelines The examination and report should meet the standards of a high-quality psychiatric evaluation, with special attention given to obtaining a thorough history, collateral information, and job performance data and to performing appropriate psychometric and laboratory testing, as necessary. Specifically, a fitness-for-duty examination should include a careful history of the presenting complaint. It is essential that the evaluating psychiatrist make considerable effort to obtain and review all relevant documents and records. Some documents may be provided by the referral source. The evaluee may have to sign an appropriate release of information to obtain other pertinent records. Collateral information should be obtained from a spouse or significant other, the referral source, direct reports, and supervisors in the physician’s workplace and from anyone treating, evaluating, or monitoring the physician. A criteria-based job description or list of responsibilities, along with an organizational hierarchical schema can also be useful. A complete psychiatric evaluation and mental status examination should be performed, with emphasis on work history and any performance problems. Performance problems may be readily described by the physician being examined, but these can also be elaborated upon by asking about peer review problems, hospital actions resulting in privilege changes, professional liability experience, complaints to or actions by state licensing or specialty boards, or concerns voiced by others in the practice environment. Any relevant area of the history should be reviewed in detail—for example, history of any psychiatric illness or treatment, medical history, or sexual history in someone being evaluated for sexual misconduct (such as a professional boundary violation or child sexual abuse). The mental status examination should be expanded in cases in which the referral problem identified possible cognitive deficits or when the evaluator finds evidence of cognitive impairment. If indicated, the evaluating psychiatrist should refer the evaluee for psychological, neuropsychological, medical, laboratory, or other examinations or tests. Urine screening and other laboratory tests for substance abuse are often necessary. It is most helpful prior to the evaluation to clarify in writing the referring source’s specific questions. Reporting the evaluator’s findings and opinions will vary according to the intended audience—commonly, the state licensing board. Because the board has the ultimate authority regarding a physician’s ability to practice safely and is charged with the protection of the public, the board will typically require a comprehensive report. The report should be especially thorough in the areas that are in question. Sensitive personal information may be omitted or summarized in the report if it is not directly related to the fitness questions, but the evaluator and evaluee should both be aware that such omissions may raise concerns that the report has been sterilized or whitewashed. There may be a greater risk of this interpretation if the evaluator concludes that the examined physician has no impairment relevant to fitness to practice medicine. The evaluator should offer an opinion about whether the physician suffers from a psychiatric illness; whether that illness, if present, interferes with the physician’s ability to practice safely in his particular job; and the specific reasons and areas of impairment, including insight and judgment. If medical practice can safely take place under specific conditions—such as prescribed workplace conditions, consideration of specific risk factors, conditions of treatment and/or treatment monitoring—these should be outlined in detail. As noted earlier, the evaluator should limit her expert opinion to questions of psychiatric impairment. These examinations are not assessments of unsafe medical practice due to lack of skill, knowledge, or training. The evaluator may be asked to outline recommended treatment for the condition. If current treatment is not adequate for the condition, that should be clearly articulated. The evaluator may conclude that the physician does not have a significant psychiatric disorder, but is so emotionally distressed (e.g., by a recent event) that he is in an unsafe mental state to practice. Such a finding should also be reported, along with potential treatment recommendations or interventions. Within the report, it should be easy to follow the logical clinical connections between the illness, its impairing symptoms, and how the symptoms may affect the physician’s ability to practice. If no impairment is found, the data should also be articulated with a clear, logical explanation that substantiates the conclusions. The report should not just briefly conclude that there is no problem and therefore the physician is fit for duty. Licensing board complaints, investigations, findings, and actions may be publicly disclosed, depending on the situation or jurisdiction. While some modification of the report may be appropriate in states where there is extensive public access, it must be recognized that being granted a license to practice medicine is a privilege, not an inherent right. The laws that govern the ability of a licensing board to order an evaluation are known (or should be known) to the physician at the time of licensure and renewal (since these are delineated in the medical practices act of each state and are typically included with the licensing packet). For referral sources other than the state licensing board, there are a number of factors that could affect decisions about what information to include in the examiner’s report. In general, the smaller or more local the referral source, the more likely that medical and other personal information will be viewed by individuals who personally know or may have conflicts of interest with the physician being evaluated. Practice groups, hospitals, and health maintenance organizations (HMOs) may have varying degrees to which they can maintain confidentiality. In these cases, it may be appropriate to limit the detail of the report to the specific referral questions, with less emphasis on sensitive personal information. For example, an examiner might state that she collected detailed information about personal, medical, and social history that substantiated her opinions, and that she can provide a more detailed report of that data on request. This approach may require further discussion with the referral source—ideally, prior to conducting the evaluation. In all cases, it is important that the specific positive or negative findings about fitness for duty be well explained and substantiated. Practical Considerations The examiner should first explain the limits of confidentiality to the physician being examined. These limits include an explanation of the purpose and process of the evaluation, a list of those who will receive the report, and a statement that the doctor-patient treatment relationship does not pertain to this examination. To make collateral contacts, it is usually good practice to obtain signed releases of information from the physician being examined. If he refuses to allow the necessary collateral contacts, that refusal should be documented in the report, along with a comment that the conclusions may be limited by the lack of potentially useful information. Depending on the referral circumstances, releases for certain collateral contacts may be mandated or unnecessary. These details are best clarified at the outset of the examination. Although the examination does not establish a treatment relationship, the evaluator may have access to confidential health information and should be aware of any responsibility under federal or state privacy laws regarding the appropriate secure storage or disposal of such information and records. Prior to agreeing to perform the evaluation, the examining psychiatrist and referring source should both be comfortable that the examiner has sufficient expertise to conduct a competent evaluation. Often, the examiner provides her curriculum vitae as well as relevant prior experience in conducting similar examinations. Forensic training, experience, or certification may be helpful, but is not required. In certain circumstances, such as the presence or history of significant substance abuse or sexual misconduct, the evaluator may need specific expertise in those areas of evaluation and treatment. The evaluating psychiatrist should not have any current or past treatment or employment relationship with the physician being examined. Questions of potential bias or conflict of interest should be clearly addressed before the evaluator performs the examination. If specific additional examination is necessary (such as neuropsychological testing) and cannot be performed by the primary evaluator, appropriate further specialty consultation should be arranged with consent from the evaluee and the referring source. Payment for the evaluation should be clearly discussed and arranged prior to the evaluation. Often the physician being examined indirectly pays the cost (typically through an attorney or other third party), but the arrangement may vary, depending on the referral source. These evaluations are not customarily reimbursed by third-party health insurance. The examining psychiatrist should provide a reasonable estimate of the total cost of the evaluation and report preparation. Full or partial payment prior to completion of the report may be requested, to avoid any concerns about compensation—particularly if the physician being examined is responsible for payment and may be dissatisfied with the examiner’s conclusions. Psychiatrists who contemplate conducting these evaluations may be concerned about their own liability risk. An unfavorable outcome or medical error resulting in patients’ being harmed by a physician who has been recently found fit for duty could result in allegations of malpractice or negligence against the examining psychiatrist. Although the examining psychiatrist should clearly establish that there is no treatment relationship with the physician being evaluated, thus possibly precluding a successful medical malpractice claim, allegations of negligent evaluation can still be made, even if ultimately defended successfully. The evaluating psychiatrist should make sure that her own liability insurance covers defense of such potential allegations. It is essential to present a thoroughly documented report, including any limitations on the certainty of the opinion due to incomplete, inaccurate, or missing data. In evaluations performed for the state medical board, that board retains ultimate authority—and responsibility—for the licensure status of the physician being examined....查看详细 (14138字节)
☉ 11326949:地震致烧伤22例临床分析
关键词地震；烧伤；分析通过对2003年2月24日新疆巴楚县6.8级地震烧伤病员的临床治疗情况分析，探讨对地震致成批烧伤病员的救治的方法和措施，提高治愈率、降低致残率、死亡率[1]。此批22例住院病员全部治愈出院，三年随访，除1人生活需他人照顾外，余生活良好。 1 临床资料 1.1 一般资料此报道取自2003年2月24日新疆巴楚县发生6.8级地震，地震发生后6小时赶到灾区开展救援...查看详细 (5489字节)
☉ 11326950:低血钾引起心脏传导阻滞一例
病例介绍患者男性，69岁，因“突发四肢无力8小时”入院，临床表现为晨起后四肢无力，无其他伴随症状。查体：呼吸18次/分，血压120/60mmHg，心率48次/分。神经系统查体：四肢肌张力减低，肌力12级，腱反射(+)，余无明确定位体征。急诊头部CT未见异常。入院当日心电图示：长PR间期的Ⅱ度Ⅰ型房室传导阻滞(图1)，查血钾165mmok/L。诊断：低钾麻痹。入院当日晚出现呼吸减慢...查看详细 (2393字节)

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