Evaluating the acceptability of an online patient decision aid for the surgical management of lower urinary tract symptoms secondary to benign prostatic hyperplasia.

INTRODUCTION: The growing number of surgical options available to treat benign prostatic hyperplasia (BPH), may overwhelm patients and urologists when deciding on an optimal treatment. Therefore, we developed an online patient decision aid (PtDA) that includes all guideline-approved surgical modalities. The objective of this study was to assess the acceptability of the PtDA among former BPH surgery patients and urologists that treat BPH surgically. METHODS: The International Patient Decision Aids Standards were used to develop a PtDA that includes monopolar transurethral resection of the prostate (TURP), bipolar TURP, GreenLight photovaporization, endoscopic enucleation of the prostate, Rezum, Urolift, Aquablation, open retropubic prostatectomy, and robotic simple prostatectomy as management options. Eleven urologists that regularly treat BPH and 19 patients who received BPH surgery were recruited. Alpha-testing was performed using a validated acceptability scoring system. RESULTS: For all sections of the PtDA, most urologists agreed that the language used was easy to follow (91.9%), that the amount of information provided was adequate (63.6%), that the length of the PtDA was appropriate (63.6%), and that the outcomes reported were correct (81.8%). All 19 patient participants agreed that the language used was easy to follow, and most found that the amount of information provided was adequate (84.2%), that the length of the PtDA was appropriate (84.2%), and that the outcomes reported were well-explained (89.5%). CONCLUSIONS: Our PtDA was found to be acceptable among urologists and patients. These results demonstrate that most of the participants either recommend the use of this tool or plan to incorporate it in their clinical practice.

Challenges in deactivating a total artificial heart for a patient with capacity.

The use of mechanical circulatory support (MCS) devices has increased sixfold since 2006. Although there is an established legal and ethical consensus that patients have the right to withdraw and withhold life-sustaining interventions when burdens exceed benefits, this consensus arose prior to the widespread use of MCS technology and is not uniformly accepted in these cases. There are unique ethical and clinical considerations regarding MCS deactivation. Our center recently encountered the challenge of an awake and functionally improving patient with a total artificial heart (TAH) who requested its deactivation. We present a narrative description of this case with discussion of the following questions: (1) Is it ethically permissible to deactivate this particular device, the TAH? (2) Are there any particular factors in this case that are ethical contraindications to proceeding with deactivation? (3) What are the specific processes necessary to ensure a compassionate and respectful deactivation? (4) What proactive practices could have been implemented to lessen the intensity of this case's challenges? We close with a list of recommendations for managing similar cases.

The World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the biological treatment of paraphilias.

OBJECTIVES: The primary aim of these guidelines was to evaluate the role of pharmacological agents in the treatment and management of paraphilia, with a focus on the treatment of adults males. Because such treatments are not delivered in isolation, the role of specific psychosocial and psychotherapeutic interventions was also briefly covered. These guidelines are intended for use in clinical practice by clinicians who diagnose and treat patients with paraphilia. The aim of these guidelines is to improve the quality of care and to aid physicians in clinical decisions. METHODS: The aim of these guidelines was to bring together different views on the appropriate treatment of paraphilias from experts representing different continents. To achieve this aim, an extensive literature search was conducted using the English language literature indexed on MEDLINE/PubMed (1990-2009 for SSRIs) (1969-2009 for antiandrogen treatments), supplemented by other sources, including published reviews. RESULTS: Each treatment recommendation was evaluated and discussed with respect to the strength of evidence for its efficacy, safety, tolerability and feasibility. CONCLUSIONS: An algorithm was proposed with six levels of treatment for different categories of paraphilias.

Mental illness that is difficult to classify: a case study.

A case is presented of a man who has been detained in secure psychiatric hospitals for the majority of his life. Although his index offence was minor he has a long history of violence. The patient has collected a vast number of diagnoses over the years. His treatment demonstrates a role for clozapine in ameliorating violent behaviour and aggression. We conceptualise this as being linked to the properties of this drug. From the patient's history we believe that reserpine may have had a similar effect to clozapine regarding mental state and reduction of violent behaviour. This case illustrates the consequences of inaccurate diagnosis and therefore the provision of adequate treatment. It highlights that the continuity of care and the communication of information is essential for the patient's quality of life. It also illustrates how the use of certain antipsychotics may prove essential in the control of violence so that institutionalisation can be prevented.

Legal frameworks and key concepts regulating diversion and treatment of mentally disordered offenders in European Union member states.

BACKGROUND: There is only limited research on the various legal regulations governing assessment, placement and treatment of mentally ill offenders in European Union member states (EU-member states). AIMS: To provide a structured description and cross-boundary comparison of legal frameworks regulating diversion and treatment of mentally disordered offenders in EU-member states before the extension in May 2004. A special focus is on the concept of criminal responsibility. METHOD: Information on legislation and practice concerning the assessment, placement and treatment of mentally ill offenders was gathered by means of a detailed, structured questionnaire which was filled in by national experts. RESULTS: The legal regulations relevant for forensic psychiatry in EU-member states are outlined. Definitions of mental disorders given within these acts are introduced and compared with ICD-10 diagnoses. Finally the application of the concept of criminal responsibility by the law and in routine practice is presented. CONCLUSION: Legal frameworks for the processing and placement of mentally disordered offenders varied markedly across EU-member states. Since May 2004 the European Union has expanded to 25 member states and in January 2007 it will reach 27. With increasing mobility across Europe, the need for increasing trans-national co-operation is becoming apparent in which great variation in legal tradition pertains.

Ethical dilemmas in forensic psychiatry: two illustrative cases.

One approach to the analysis of ethical dilemmas in medical practice uses the "four principles plus scope" approach. These principles are: respect for autonomy, beneficence, non-maleficence and justice, along with concern for their scope of application. However, conflicts between the different principles are commonplace in psychiatric practice, especially in forensic psychiatry, where duties to patients often conflict with duties to third parties such as the public. This article seeks to highlight some of the specific ethical dilemmas encountered in forensic psychiatry: the excessive use of segregation for the protection of others, the ethics of using mechanical restraint when clinically beneficial and the use of physical treatment without consent. We argue that justice, as a principle, should be paramount in forensic psychiatry, and that there is a need for a more specific code of ethics to cover specialised areas of medicine like forensic psychiatry. This code should specify that in cases of conflict between different principles, justice should gain precedence over the other principles.

Psychiatry and the Palestinian population.

Some key issues pertaining to Palestinian psychiatry are described. Bearing in mind the geographical location and history of the Palestinian population, the development of psychiatry needs to be seen in the context of the Arab world, on the one hand, and of Israel, on the other. In the Middle Ages, Arab culture and medicine were more developed than in Europe. Aspects of general and forensic psychiatry on the West Bank and Gaza are outlined. Issues pertaining to the death penalty, suicide and suicide bombers are also discussed. The biblically-described relationship between the Arab and Jewish peoples has its resonance today with regard to cohabitation and conflict.

Name change among offender patients: an English high security hospital sample.

BACKGROUND: There is scant literature on change of name among psychiatric patients but a more substantial amount on the use of aliases among offenders. No one to our knowledge has explored name changes among offender patients. AIM: This study was undertaken to establish the prevalence of name change among high security hospital patients and to compare those who changed name with those who did not. HYPOTHESIS: It was hypothesized that name change would be associated with male gender, repeated offending and a diagnosis of personality disorder. METHOD: The clinical records of all patients resident in one high security hospital on 31 January 2000 were searched. As all such patients are compulsorily detained, all name changes must be recorded. Any change prior to that date was also noted, together with basic demographic and diagnostic information; supplementary data were obtained from the special hospitals' case register. RESULTS: Seventy-one patients (17%) of the resident population changed names (exclusive of a woman changing her surname on marriage). Name changing was associated with disrupted upbringing. Patients with personality disorder were more likely to change names than those with psychosis, regardless of sex, age or ethnic group. Those with psychosis were more likely to select unusual or symbolic names. CONCLUSIONS: On the evidence of previous literature, people from this serious offender patient population were more likely to change names than other psychiatric patients but less likely than non-mentally-disordered offenders. Changes by people with psychosis seemed related to their illness, whereas changes by those with personality disorder might reflect childhood disruptions in rearing patterns.