Tom Gibson, plastic surgeon (1915-93): his life, the second set phenomenon, the host versus graft reaction, and the birth of tissue transplantation.

In the early 1940s Tom Gibson, a member of an MRC unit investigating infection in burns at the Glasgow Royal Infirmary, developed an interest in skin grafting. With Peter (later Sir Peter) Medawar, he described the 'Second Set' phenomenon which in 1943 laid the foundations for tissue transplantation. After war service (1944-47) he was the major force in the development of plastic surgery services in the West of Scotland. His researches at the Universities of Glasgow and Strathclyde earned him an international reputation.

Physical assaults in a psychiatric unit of a general hospital.

The authors collected data concerning assaults, assaultive patients, and victims in a psychiatric unit during a 12-month period and compared them with data from a control group of patients. Thirty-seven assaults by 25 patients were recorded. Fourteen of the victims were patients and 23 were members of staff. The assaultive group contained a significantly higher proportion of schizophrenic patients than did the control group and significantly larger numbers of patients from lower socioeconomic classes, patients admitted involuntarily under a section of the Mental Health Act, and patients with a history of assaults.

The treatment of psychosis: resetting the drug cost 'thermostat'.

Cost-effective means different, sometimes competing things to different observers. In addition to well-known clinical benefits, large payors such as state governments think clozapine and similarly effective antipsychotic medications will yield immediate dollar savings. They do not consider the need to shift existing resources to community follow-up, the time required to phase out hospital units, and the backlogs of new patients. In today's financial climate, legislators and other elected officials are reluctant to invest in expensive medicines and then wait for long-term savings. We must convince those who hold the purse strings that acceptable antipsychotic drugs will be expensive for at least several years to come, until more new and generic drugs appear. We must tell them firmly that our patients, doctors, and mental health systems cannot afford to rely on older medications, even though they seem inexpensive. The drug cost "thermostat" should be reset so that payors and budget reviewers realize that safe and adequate antipsychotic medications often cost $5 to $25 a day. If new dollars are not available, existing budgets may have to be restructured. For most patients, anything else is substandard.

New vs. old antipsychotics: the Texas experience.

A study was conducted in Texas state psychiatric facilities of 299 patients with schizophrenia who were taking clozapine, comparing them with 223 matched controls taking traditional neuroleptics. From 12 months before until 54 months after clozapine was begun, hospital bed days and the associated costs were determined for both groups. The clozapine group had appreciably fewer hospital bed days throughout the study period. Substantially fewer clozapine-treated patients than neuroleptic-treated patients required 180 continuous days of hospitalization during the study. By 48 months after initiation of clozapine, hospital inpatient costs were $27,850/patient/year lower in the clozapine group than in the traditional neuroleptic group. Agranulocytosis occurred in < 1% of patients taking clozapine; all recovered quickly. In a separate study, clozapine therapy was shown to produce a 5-fold decrease in the rate of suicide among patients with schizophrenia. Administration of clozapine appears to lower the overall cost of treating schizophrenia by reducing the costs associated with hospitalizations.

Psychiatric hospital utilization in patients treated with clozapine for up to 4.5 years in a state mental health care system.

OBJECTIVE: We wished to study long-term psychiatric hospital utilization in a large sample of patients with schizophrenia and/or schizoaffective disorders who were treated with clozapine for up to 4.5 years, and to determine whether or not the reduction in hospital utilization we previously observed in smaller groups for up to 2.5 years was sustained with larger groups and in the longer term. METHOD: Patients in Texas state hospitals who had schizophrenia and/or schizoaffective disorder took either clozapine or traditional antipsychotics for 1.5 to 4.5 years. The number of patients in the clozapine group ranged from 383 (1.5 years of treatment) to 29 (4.5 years). The group of patients who took traditional antipsychotics was made up of all patients (N = 233) with similar diagnoses, symptom severity, and duration of illness present in Texas state hospitals on an index day. RESULTS: The clozapine group showed a rapid and continuing decrease in hospital bed-days compared with controls who took traditional antipsychotics. The number of clozapine-treated patients who required little or no hospitalization during successive 6-month periods became significant (p < .0001) within 1.5 years, and continued to increase. Conversely, the number of patients taking clozapine who required virtually continuous state hospitalization decreased markedly compared with those taking traditional antipsychotics. CONCLUSION: Potential hospital cost savings are substantial, even though overall group results are diluted by clozapine nonresponders. Most treatment costs for clozapine nonresponders were related to hospital care; most or all of such costs would have been present in any event had these patients remained on traditional antipsychotic therapy. We believe a trial of clozapine therapy provides a low-cost opportunity for a highly effective and highly cost-saving outcome in those patients who will favorably respond to this therapy. We discuss clinical, social, and economic advantages of modern pharmaceutical treatments over traditional drugs.

ECT in Texas: 19 months of mandatory reporting.

BACKGROUND: Texas law requires that all non-federal clinical facilities providing electroconvulsive therapy (ECT) report every treatment to the state's mental health agency. The resulting data provide total population information about treating physicians and hospitals; payment source; patient age, sex, ethnicity, diagnosis, and admission/consent status; symptom severity and response; numbers and types of treatments; and untoward events occurring within 14 days after treatment. METHOD: We reviewed all reports of ECT between September 1993 and April 1995 (2583 reports, approximately 15,240 treatments). RESULTS: About 6% (N = 117) of Texas psychiatrists performed ECT during the period, at 50 hospitals. One of 13 state-funded mental institutions performed ECT on-site; some occasionally contracted with private hospitals. Almost all patients (88.1%) were white. Some older age groups received proportionately more ECT than younger groups, but no sharp increase was associated with eligibility for Medicare. Five patients were less than 18 years of age; 70.3% were female. Virtually all patients (99.0%) consented to the treatment themselves (rather than by guardian), including committed-but-consenting patients (1.5%). Reports (5.8%) described multiple-monitored treatment (MMECT, not depatterning). Group data indicated generally good-to-excellent response, as measured by a five-point symptom-severity scale. Eight patients died within 14 days of a treatment, 2 possibly of anesthesia complications and 3 others in accidents or by suicide. Four were receiving maintenance treatments (generally about every other week). No death appeared related to ECT stimulus or seizure. CONCLUSION: ECT in Texas is performed by a small minority of psychiatrists and is unavailable to many patients who need it. It is most accessible to white patients who receive care outside the public sector. Our data support the common finding that ECT is generally safe and effective.

Chondroitin-6-sulphate incorporated into collagen gels for the growth of human keratinocytes: the effect of cross-linking agents and diamines.

This study demonstrates the effect of the glycosaminoglycans, hyaluronic acid and chondroitin-6-sulphate (Ch6SO4), diamines and a carbodiimide cross-linking agent on the growth of human epidermal cells on collagen gels. Ch6SO4 incorporated into collagen gels stimulated cell growth rate, but the effect was found to be inconsistent. We found that approximately 50% of the incorporated Ch6SO4 in the gels leached out into the growth medium after the first 3 d in culture, and this is thought to lead to the inconsistent cell growth response. In order to minimize the elution of Ch6SO4 from the gels and thereby maximize its effect on the growth of the keratinocytes, 1-100 micrograms ml-1 Ch6SO4 was added in the medium. The results showed that Ch6SO4 at these concentrations in the medium did not stimulate the cell growth on either plain collagen gels or gels containing 20% Ch6SO4. As an alternative strategy, 1-ethyl-3-(3-dimethylaminopropyl) carbodiimide and diamines (putrescine or diaminohexane) were used to immobilize Ch6SO4 onto the collagen gels and to cross-link the gels. The cross-linking process partially prevented the elution of Ch6SO4 from the gels. Interestingly, only putrescine, not diaminohexane, promoted the growth of keratinocytes on the cross-linked plain collagen gels. We proposed to develop an artificial skin substitute containing putrescine as a growth factor for the human epidermal cells.

Investigation into the biological stability of collagen/chondroitin-6-sulphate gels and their contraction by fibroblasts and keratinocytes: the effect of crosslinking agents and diamines.

Artificial skin substitutes based on autologous keratinocytes cultured on collagen-based substrata are being developed for grafting onto patients with severe burns. The properties of the substratum can be manipulated by crosslinking the collagen with the glysocaminoglycan, chondroitin-6-sulphate (Ch6SO4), carbodiimides and polyamines. Biological stability, assessed by resistance to collagenase, was increased by incorporation of Ch6SO4, but crosslinking with the carbodiimides, 1-ethyl-3-(dimethylaminopropyl)carbodiimide and 1,1-carbonyldiimidazole or the polyamines, putrescine or diaminohexane, had little further benefit. Contraction of the collagen gels occurred to a greater extent when seeded with fibroblasts than with keratinocytes. The extent of contraction by either cell type was not influenced by the presence of Ch6SO4 in the gel, but the carbodiimides, and to a lesser extent the polyamines, limited cell-mediated contraction, particularly that mediated by fibroblasts. Optimum substratum composition for artificial skin substitutes will involve a compromise between the desired attributes of biological stability, rate of contraction, mechanical strength, biocompatibility and promotion of cell growth.

The preclinical evaluation of the water vapour transmission rate through burn wound dressings.

The control of evaporative water loss, following burn injury, is of major importance to the overall condition of the patient, whether this control is by natural eschar or by a dressing. It is therefore important to preclinically determine the water vapour transmission rate of these dressings, firstly to make comparisons between different materials and secondly to screen prototype materials, under controlled conditions. A preclinical (in vitro) technique is described and the results are given for several commercially available dressings which encompass foam, film and hydrogel material categories.

An in vitro assessment of wound dressing conformability.

An in vitro assessment technique has been developed to determine the conformability of wound dressings. The technique employed is based on an inflation technique which provides a measurement of the minimum radius of curvature which a specific dressing will adopt under pressure. A pressure of 40 mmHg was chosen as this had been shown to be the maximum tolerable pressure before the occurrence of tissue breakdown. This radius is then matched to the natural radii of the body surfaces and an assessment of conformability can be made. A series of commercially available dressings have been assessed with respect to their conformability, and to the enhancement of their conformability due to viscoelastic creep behaviour.

Water vapour transmission rates in burns and chronic leg ulcers: influence of wound dressings and comparison with in vitro evaluation.

One of the main functions of wound dressings is to control water vapour transmission rate (WVTR) from wounded skin. In this paper, the influence of hydrocolloid, knitted viscose and gauze dressings was evaluated through in vivo measurement of WVTR in burns and chronic leg ulcers utilizing an evaporimeter. The results suggest that the evaporative water vapour loss from exposed skin wounds depends mainly on the wound depth, and that chronic leg ulcers have the same level of the WVTR as full thickness burns. Compared with the knitted viscose and gauze dressings, hydrocolloid dressing has a greater effect on reducing evaporative water loss, with WVTR being 20-30% of that of exposed wounds under the conditions used in this study. This result is in agreement with that obtained in an in vitro evaluation.

Principles of burn dressings.

Throughout history burn wounds have been treated by covering with dressings of many different materials. The successful application of a burn dressing remains an objective for biomaterial development. This paper examines how the burn wound differs from other skin injuries, the requirements of the ideal burn wound dressing, and reviews the type of dressings available. The dressings in common use in the treatment of burns are compared with the 'ideal' dressing, in so far as it can be defined.

Changes in alveolar macrophage, monocyte, and neutrophil cell profiles after smoke inhalation injury.

Thirty two fire victims with smoke inhalation, with or without burns, and 26 control subjects had bronchoalveolar lavage performed. Cell yields and differential cell counts were assessed. All patients and controls were cigarette smokers. Patients with smoke inhalation (SI) injury generally showed higher total bronchoalveolar lavage (BAL) cell yields, and this was significant on repeat lavage from 12 patients. The increase was almost entirely due to an increase in the proportion of neutrophils in patients with smoke inhalation alone (S) and those with cutaneous burns as well as smoke inhalation (S + B). On sequential lavage of 12 patients with smoke inhalation (SI) the proportion of neutrophils had increased; this was significantly higher than on initial lavage. Using various macrophage markers, the proportions of macrophage subgroups were determined. There was an increase in UCHM1 and RFD9 positive cells in each subgroup: the increase in UCHM1 positive cells was significant in patients with burns as well as smoke inhalation, and the increase in RFD9 positive cells was significant in patients with smoke inhalation alone. Assessment of the role of such cells in the development of acute lung injury (such as adult respiratory distress syndrome) may be important in our understanding of the mechanisms entailed.

Clinical evaluation of the violent patient.

Violence is a generic behavior whose evaluation must consider medical, emotional, social, and environmental factors. The evaluation setting should allow privacy (but not isolation), security (but not constriction), comfort (but not fragility), and respect (but not vulnerability). In addition to one's routine complete history, a very complete description of events and feelings before, during, and after the violent episode is critical. Organic causes and correlates of violent behavior must be carefully sought. Evaluation of future risk of violence is difficult but often necessary. The environment in which the patient will be placed, time limits of the prediction and stability of the patient's clinical condition are important factors. Acute risk is greater when certain conditions, such as acute psychosis, persecutory delusions, or intoxication, are present in an already-violent patient. The legal aspects of evaluation are briefly discussed, including basic recommendations for documenting one's good-faith efforts to weigh the risks and benefits of clinical actions and adhering to applicable laws.

The use and reliability of psychiatric diagnosis in forensic settings.

The clinical professional encounters conflict whenever he or she enters the courtroom. The psychiatrist's approach must not be simply diagnostic or simply legal. We cannot shed our clinical identity; indeed, the court depends on our clinical identity and expertise in its search for the truth. The psychiatric expert must be able to translate his or her findings for the court, but these findings must come from clinical experience, not some solely legal perspective. The legal system needs our knowledge about the interfaces of mental illness, function, and behavior. After we provide our opinions, however, the legal issues must be left to the lawyers and the final determinations left to the judge or jury.

Suicide prevention effects associated with clozapine therapy in schizophrenia and schizoaffective disorder.

OBJECTIVE AND METHODS: Suicide is a significant cause of death among patients with schizophrenia and schizoaffective disorder, affecting some 10 to 15 percent of these patients. This study examined annual suicide rates over a two-year period (1993-1995) among more than 30,000 patients with schizophrenia and schizoaffective disorder who received services from the Texas Department of Mental Health and Mental Retardation and suicide rates over a six-year period (1991-1996) among a subgroup of patients treated with clozapine. RESULTS: The annual suicide rate for all patients with schizophrenia and schizoaffective disorder was 63.1 per 100,000 patients, approximately five times higher than in the general population. In contrast, only one suicide occurred in six years among patients treated with clozapine who were of similar diagnosis, age, and sex, for a suicide rate of about 12.7 per 100,000 patients per year. This rate is similar to the 15.7 per 100,000 patients per year for all U.S. patients treated with clozapine, calculated from data reported as of June 1996 to the clozapine national registry system maintained by Novartis Pharmaceuticals Corporation, the U.S. manufacturer of clozapine. CONCLUSIONS: The study results suggest that clozapine therapy is associated with a reduced risk of suicide among patients with schizophrenia and schizoaffective disorder.

An analysis of reported deaths following electroconvulsive therapy in Texas, 1993-1998.

Since 1993, Texas law has required that all deaths that occur within 14 days of electroconvulsive therapy (ECT) be reported to the Texas Department of Mental Health and Mental Retardation. This study attempted to differentiate deaths that may have been due to ECT or the associated anesthesia from those due to other causes. Among more than 8,000 patients who received 49,048 ECT treatments between 1993 and 1998, a total of 30 deaths were reported to the mental health department between 1993 and 1998. Only one death, which occurred on the same day as the ECT, could be specifically linked to the associated anesthesia. An additional four deaths could plausibly have been associated with the anesthesia, for which the calculated mortality rate is between two and ten per 100,000, but probably not with the stimulus of the ECT or seizure. The mortality rate associated with ECT (less than two per 100,000 treatments) in Texas is extremely low.

Trends in burn admissions in Scotland during 1970-92.

This retrospective study involved analysis of the data of the inpatients discharged with a diagnosis of burns, from various hospitals in Scotland, during the period 1970-92. There were 51,350 such inpatients all over Scotland, with an average annual rate of 2233 cases. Overall burn incidence in actual numbers was 43.7 per cent in < 15 year olds, 41.2 per cent in 15-64 year olds and 15.1 per cent in > or = 65 year olds. Burn rates per 100,000 population were highest in < 15 year olds and lowest in 16-64 year olds. The pattern of burn admissions has changed. Since 1987 the highest numbers of burn inpatients were the 16-64 year olds, followed by children, then the elderly. There has been a gradual but sustained fall in burns admissions in all age categories. The downward trend was statistically significant (t = 8.48, 21 d.f., P < 0.001). Though the population of the elderly (> or = 65 year olds) increased by about 13 per cent, the burn admissions and all deaths due to burns did not reveal an upward trend. The population of the old (81+ year olds) increased by 60 per cent during the same period. The incidence of burns was above average when > 80 year olds were considered separately, approaching the levels found in children. However the rate and incidence of burns in the 65-80 year olds resembled that of the younger age group (16-64 year olds). The total number of deaths due to burns and/or smoke inhalation has declined in all age groups and the decline has been statistically significant (chi-squared = 19.62, 1 d.f., P < 0.001). Maximum number of deaths occurred in > or = 65 year olds (44 per cent), followed closely by 16-64 year olds (43.5 per cent), and 12.5 per cent of deaths in adolescents and children. The decline was due to improved management of burns and a decrease in the number of patients having large body surface area burns.

Flame burn admissions and fire fatalities in Scotland with particular reference to the Strathclyde (Glasgow) region, and their prevention.

Scotland has the highest rate of fire fatalities in the UK. Nearly 50% of the population and fire deaths in Scotland are in the Strathclyde region. The data from the burns unit at Glasgow Royal Infirmary were studied to find the number of admissions due to flame burns and see how it compared with the fire deaths. During 1981-1993, amongst 2771 admissions to the burns unit, 1181 (43%) were due to flame burns and out of these flame burn victims, 69% were adults, 16% elderly and 15% children. The distribution of cases according to the total body surface area (TBSA) involvement was 866 (73%) with 1-15%, 165 (14%) with 16-30%, and 150 (13%) with > or =31% TBSA burns. The annual number of flame burn admissions declined during 1981-1993. In the Glasgow region 50% of the domestic fires leading to non-fatal burns or to death were started by misuse of smoking materials. Chip pan fires were responsible for 8% of admissions to the burns unit. The annual number of fire fatalities when reviewed for a longer period 1973-1995 also showed a decreasing trend. Further educational and legislative measures to prevent flame burns are discussed.

Oral health of institutionalized individuals with mental retardation.

A random 10% (n = 702) of the residents of the Texas Department of Mental Health and Mental Retardation (TXMHMR) institutions were given dental examinations by the first author. Findings were compared with results from a similar survey of 1,077 residents by the same investigator 9 years earlier. Data were analyzed for oral pathology, unmet dental needs, contribution of dental care to habilitation, and effectiveness of the dental service system. Some improvements were found in dental condition, although the results were sometimes difficult to interpret. Some differences may be related to changes in client age and average length of stay and to a shift toward institutionalization of individuals with more severe disabilities. Other differences appear to be the result of better dental care in state institutions.