An updated national survey on seclusion and restraint.

A survey of the use of seclusion and restraint during 1994 was conducted at 124 state psychiatric hospitals to update data from a survey of 108 such hospitals conducted for 1991. Rates of patients' placement in seclusion and restraint, hours spent in placement, and discrete incidents of seclusion and restraint were examined. The 1994 results were highly similar to those for 1991. Smaller hospitals providing acute care had higher rates of seclusion and restraint than their larger counterparts providing chronic care. Small positive correlations were found between seclusion and restraint and between the proportion of beds occupied by patients committed as criminally insane and the use of restrictive procedures.

Severe ascites: efficacy of the transjugular intrahepatic portosystemic shunt in treatment.

PURPOSE: To evaluate the transjugular intrahepatic portosystemic shunt (TIPS) as primary treatment in patients with cirrhosis and severe ascites. MATERIALS AND METHODS: A TIPS placement was attempted in 54 consecutive patients with intractable ascites. Clinical assessment findings, shunt patency, complications, and survival were analyzed. RESULTS: A TIPS was successfully placed in 50 patients (93%). Follow-up for clinical effectiveness in 51 patients was a mean of 285 days (range, 1-981 days). Forty patients (78%) gained clinical benefit from the shunt. Of these, 29 (57%) had a complete response (required no further paracentesis) and 11 patients (22%) had a partial response (required less frequent but additional paracentesis for control of ascites). The absence of preprocedure renal insufficiency (creatinine < 1.5 mg/dL [< 130 mumol/L]) was the only characteristic identified as an indicator of clinical success (P < .05). Eleven patients (22%) required shunt revision during follow-up to gain or prolong control of symptoms. Cumulative survival in the population evaluated for clinical efficacy was 53% at 6 months and 48% at 1 year. A complete response was the only variable that indicated increased survival (P < .05; R2 = 12%) with a 6-month survival rate of 76% and a 1-year rate of 71%. CONCLUSION: TIPS placement appears to be effective as a primary treatment of patients with cirrhosis and severe ascites.

A national survey on seclusion and restraint in state psychiatric hospitals.

OBJECTIVES: State psychiatric hospitals across the U.S. were surveyed to develop national normative data on the incidence of seclusion and restrain and of injuries to patients and staff resulting from aggression by patients. METHODS: A survey instrument was sent to 225 state hospitals requesting information for a one-year period on the number of patients placed in seclusion or restraint, the number of discrete incidents of seclusion and restraint, the number of hours patients spent in seclusion or restraint, and the number of injuries to patients and staff attributable to aggression by patients. Rates of seclusion, restraint, and injuries were calculated to control for variation in hospital censuses. Percentile ranks for the various rates were calculated to allow hospitals to compare their rates. RESULTS AND CONCLUSIONS: A total of 101 state hospitals in 44 states and the District of Columbia returned the survey. In general, smaller hospitals had higher rates of seclusion and restraint. However, large standard deviations in the mean rates suggested considerable variability between hospitals in the sample. Small positive correlations between rates of seclusion and rates of restraint suggested that the hospitals did not use of the two interventions exclusively.

When educators confront child abuse: an analysis of the decision to report.

Five scenarios of child abuse were used to study the recognition and reporting of child abuse in a sample of 664 teachers, counselors, school psychologists, principals, and district superintendents. The following results emerged: (a) Reporting tendency varied by type of abuse described, forming a 3-level hierarchy; (b) reporting tendency and reporting rate were unrelated to the gender of the victim or respondent; (c) reporting tendency was unrelated to the profession of the educator (i.e., principal, counselor, etc.), though certain types of abuse were suspected and/or reported significantly less often by classroom teachers; (d) for each scenario a linear composite of decisional items discriminated Reporters from Nonreporters with 75% to 84% accuracy. Most salient in distinguishing Reporters from Nonreporters were issues involving quality of suspicion and the respondents belief that schools should be a first line of defense against abuse and neglect; (e) educators were uniform in their high level of awareness of mandatory reporting laws; (f) educators preparedness to detect child abuse differed by profession, but most desired additional training. The implications of these findings are reviewed and suggestions made for revisions to social service policies and training for educators.

Portal vein: US-guided localization prior to transjugular intrahepatic portosystemic shunt placement.

To mark the portal vein prior to transjugular intrahepatic portosystemic shunt (TIPS) placement, metallic coils adjacent to (n = 18) and a wire within (n = 18) the portal vein were placed with ultrasonographic (US) guidance. The mean number of punctures for successful portal vein entry was 3.0 with coils and 2.9 with a wire, and the mean total procedure time was 127.5 and 110.0 minutes, respectively (differences, not significant), and mean time at US was 20 and 10 minutes, respectively.

Proposed revisions to mandatory reporting laws: an exploratory survey of child protective service agencies.

Mandatory reporting laws have created a difficult dilemma for many mental health providers (MHPs). Professional ethics, confidentiality, and the best interests of the client are often seen as conflicting with the legal obligation to report child abuse. The receptivity of child protective service (CPS) agencies to three alternative MHP reporting strategies was assessed in a national survey. The results indicate strong support for the current model of reporting and marginal support for alternatives that supply the MHP and the family with more latitude in determining when to report and how reports are handled. The results are discussed in relation to what many MHPs see as the need for more integrated, flexible, and cooperative approaches to the protection of abused and neglected children.

Child abuse and the limits of confidentiality: forewarning practices.

Confidentiality is widely considered to be of great importance in psychotherapy. With few exceptions, the breaching of confidentiality is an ethical violation and grounds for litigation. One such exception is the mandated reporting of known or suspected child abuse, representing a legally sanctioned limitation of confidentiality. Because clients generally expect unlimited confidentiality in therapeutic relationships, many therapists have begun to "forewarn" clients as a matter of informed consent. This research report: (a) briefly reviews issues surrounding mandatory reporting and confidentiality as they relate to forewarning, (b) defines and discusses forewarning as contrasted with "informing," (c) examines state statutes, case law and ethical guidelines relevant to forewarning, and (d) presents a survey of 428 mental health providers (MHPs) on their forewarning practices in which 36.9% forewarned all clients, 36.4% informed clients only upon suspicion of abuse, and 20.6% informed only after receiving a disclosure of abuse. The implications of these findings are discussed.