Tom Gibson, Plastic Surgeon (1915-93): Allograft rejection by the immune system and prediction of free tissue transplantation.

Tom Gibson made enormous contributions to the modern development of Plastic and Reconstructive Surgery. His key 1943 paper 'The fate of skin homografts in man' described the 'second set' phenomenon attributing graft rejection to an immunological phenomenon. Later in his career he visualised the concept of microvascular tissue transplantation and inspired many young surgeons through his various roles of Director of the unit at Canniesburn Hospital, Professor of Bioengineering and President of the Royal College of Physicians and Surgeons of Glasgow.

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.

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.

Recognizing and dealing with impaired clinicians, Part 1: Recognition and reporting.

Medical licensing boards and clinical societies encourage (and most boards require) physicians to report colleagues reasonably suspected of not practicing safely and competently. Failure to report unsafe, incompetent, or illegally acting clinicians can seriously damage patients, the profession, and the doctor himself/herself. Good-faith reporting is generally protected from law-suit. This article discusses how you can recognize and deal with clinicians in this situation.

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.

Recognizing and dealing with impaired clinicians: Part II--Treatment options.

Medical licensing boards and clinical societies encourage (and most boards require) physicians to report colleagues reasonably suspected of not practicing safely and competently. Failure to report unsafe, incompetent, or illegally acting clinicians can seriously damage patients, the profession, and the doctor himself/herself. Good-faith reporting is generally protected from lawsuit.

Treatment of antisocial personality, psychopathy, and other characterologic antisocial syndromes.

Treatment of antisocial personality disorder (APD) and ";core" psychopathy is usually considered a pessimistic clinical exercise. This paper reviews the importance of accurate diagnosis (including differences between APD and other antisocial syndromes), limited techniques for predicting and preventing adult antisocial syndromes, several kinds of treatment that have been attempted with varying success, management of specific antisocial behaviors, and the frustrations-even dangers-of working with severely antisocial patients.

Licensure requirements for out-of-state forensic examinations.

Forensic clinicians, including psychiatrists, are sometimes asked to perform solely forensic (e.g., court- or litigation-related) assessments or interviews outside states in which they are licensed. A short survey was sent to all U.S. state medical licensing agencies asking whether or not a psychiatrist licensed in another state must also be licensed in the surveyed state before performing a purely forensic interview or examination. Of the 45 states responding, 21 said that no additional "local" license would be required; 6 gave unclear responses; and 18 said a local license would generally be required. At least 7 of the 18 states that generally require a local license accept unlicensed out-of-state physicians when they are requested by or consulting to an in-state physician. The state's definition of "medical practice" figured heavily in many responses. No pattern of state size (area), population density, or geographic location was discerned. The materials received, comments by board staff and attorneys, and interpretations or assumptions by the author are not to be construed as "official" for any state.

Electroconvulsive therapy in psychiatrists and their families.

In answer to allegations by electroconvulsive therapy (ECT) detractors that psychiatrists never prescribe the treatment for themselves or their families, I sought clinicians with personal or family experience as ECT patients. A letter inviting first-hand accounts of treatment was published in a commonly read psychiatric publication (Psychiatric News) and mailed to selected American Psychiatric Association District Branches. Forty-two psychiatrists responded. Ten practicing psychiatrists had received at least one ECT series, five during their training years, and one had taken one treatment for personal educational reasons ("to see what my patients were experiencing"). More than 80 series and maintenance courses of ECT were described among 11 psychiatrists, nine parents, five siblings, and 18 other relatives of psychiatrists. Almost all patients had moderate to excellent improvement; no serious adverse effects were reported. Inability to get ECT for depressive relapses years after earlier, positive responses may have contributed to two suicides. Three psychiatrists published their personal or family experience with ECT in medical journals. A number of brief case reports are presented. It appears that psychiatrists and their families are consumers of ECT in much the same way as are patients from the general population.

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.

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.

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.

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.