MMPI-2 profiles of filicidal, mariticidal, and homicidal women.

The present study compared the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) clinical and content scale profiles of a group of adult women (N = 73) charged with either murder of their child (filicide) (n = 30), their partner (mariticide) (n = 19), or an unrelated adult (homicide) (n = 24). No significant differences were seen among the three groups on either the MMPI-2 clinical or content scales. Clinical inspection of the 53 valid MMPI-2 profiles (F < 110T) revealed a 6-8 mean profile for the filicidal women, a 2-6 mean profile for the mariticidal women, and a 4-8 mean profile for the homicidal women. Application of the data for criminal forensic psychological evaluations is discussed.

Psychological preparation for nasogastric feeding in children.

Psychological preparation of children undergoing enteral nutrition by nasogastric tube was evaluated in a prospective study of 48 children nursed at home. They were randomly allocated to receive either standard informal preparation or detailed psychological preparation and support. The children were divided into two groups according to age: group A comprised toddlers and younger children aged 2-6 years and group B comprised older children and adolescents aged 7-16 years. Detailed questionnaires were administered to all parents and older children by dietetic colleagues who were blinded to the type of preparation received by the children. The results emphasize that detailed psychological preparation of families takes time. Passage of a nasogastric tube was seen as very distressing to both parents and children. Having a nasogastric tube was perceived as a major problem by group A. There was no statistical difference in the effects of enteral nutrition between younger children who received routine preparation and those who received detailed preparation; however, parental assessment of their child's behaviour was the sole means of determining how the younger child felt and reacted. In group B, there were marked differences: scores suggested that those who received detailed preparation had been better prepared for enteral feeding in hospital and at home and that the passage of the nasogastric tube, although unpleasant, was less distressing to them (P < 0.05). Talking to a nurse and play therapist was seen by parents as essential (P < 0.05). The authors conclude that children should be prepared for painful procedures and followed up sensitively, according to their needs.

Insanity and filicide: women who murder their children.

A mother who murders her child challenges the empathic skills of evaluating clinicians. In this chapter, original research, supplemented by detailed case histories, compares women adjudicated criminally responsible for the murders of their children with those adjudicated not guilty by reason of insanity.

Criminal responsibility and solvent exposure.

This case report contains the history of a man's exposure to benzene, trichloroethylene, and toluene. J suffered acutely from classic symptoms of toxic exposure to these compounds, such as fatigue, clumsiness, staggering, and hematopoietic depression. During his medical hospitalization, he was exposed to further organic insults, such as being treated with medications like Cytoxan and medications to treat an abscess in his right parietal lobe. After the acute exposure and after the abscess had resolved, his functioning on neuropsychological testing was still depressed, as he had a Full Scale IQ of 105, whereas at the time of the forensic evaluation he had a Full Scale IQ of 114. It would therefore appear that he did have some mild deficits when originally discharged from the hospital. While he reported having continual mental status changes at the time of the offense and even at the time of the forensic evaluation, it was not felt that these played a significant role in the commission of the offense. Comprehensive forensic evaluation suggested that psychological reactions to his illness and an underlying personality disorder were more direct contributors to the criminal acts. J was therefore recommended and ultimately found to be responsible for his behavior, according to the law.

The nutritional response to home enteral nutrition in childhood.

The nutritional response to home enteral nutrition (HEN) was evaluated in a prospective study of 44 consecutive children (median age 48 months) who received HEN for more than 1 month (median duration 6 months). Three groups were studied: 17 children were stunted, 14 were wasted and 13 were adequately nourished but unlikely to maintain oral intake during anticipated nutritional stress. In the stunted group (median duration of HEN 15 months) there was a significant correlation between improvements in height-for-age z scores and duration of feeds (r = 0.63; p = 0.006). In the wasted group (median duration of HEN 4 months) all anthropometric indices improved significantly (p < 0.05). HEN was also successful in maintaining nutritional status in the third group. Thus, supplementary HEN is an effective method of nutritional support for a variety of indications, provided concurrent advice from a nutritional care team is available.

Intensive enteral feeding in advanced cirrhosis: reversal of malnutrition without precipitation of hepatic encephalopathy.

Ten children with advanced cirrhosis and malnutrition (less than 90% weight for height) were fed for eight weeks with a nasogastric feed comprising whey protein (enriched with branched chain amino acids), fat as 34% medium chain and 66% long chain triglycerides, and glucose polymer. Six of the children were studied for an eight week control period before feeding. Weight, triceps skinfold thickness, mid-arm circumference, mid-arm muscle area, and fasting plasma ammonia and amino acid concentrations were measured before and after the control period and after the consequent feed period. Results showed that despite high energy and protein intakes the children remained malnourished over the control period. All anthropometric indices improved significantly during the feed period, and no child developed clinical encephalopathy. The feed period was associated with a small, and not clinically significant, increase in the plasma ammonia concentration, but no consistent trend in the plasma amino acid concentrations. Thus, in children with advanced hepatobiliary disease awaiting liver transplantation, enteral feeding improved nutritional status without adverse clinical or biochemical effects.

Staff training: a key factor in reducing intravascular catheter sepsis.

A children's hospital nutritional care team prospectively monitored the frequency of sepsis in central venous catheters used for administering parenteral nutrition. During an initial study period of 12 months, 26/58 (45%) of catheters were removed because of proved sepsis. The possible causes of this alarmingly high rate were examined, with catheter care techniques on the wards coming under particular scrutiny. As a result protocols were modified and an intensive staff training programme implemented throughout the hospital, led by the nutritional care sister. Subsequently, the catheter sepsis rate was significantly reduced with only 9/107 (8%) of consecutive catheters becoming infected. These findings emphasise the key role that education of staff plays in controlling central venous catheter sepsis and the importance and cost effectiveness of special nursing staff in implementing such measures.

Home enteral nutrition in paediatric practice.

Nasogastric feeding at home is increasingly being used to provide nutritional support for children with chronic conditions associated with poor growth. The development of specialized feeding products together with accurate and portable enteral feeding pumps has facilitated this process. Parents manage home nasogastric feeding well but require education and continued support. This is probably best offered by a specialized multidisciplinary nutritional care team.

Nasogastric feeding at home: acceptability and safety.

A questionnaire was administered to 70 families with experience of home enteral nutrition. All but one patient received at least some of their feeding overnight. During 11,041 patient days of home enteral nutrition, no serious complications were seen. Sleep disturbance was common, however, and affected 59 parents and 35 children. A nocturnal cough or 'chestiness' were noted in 10 children suggesting occult gastro-oesophageal reflux. Enteral feeding disposables were not prescribable by general practitioners, and funding for the equipment was inadequate in the hospital and community. The mean time to arrange funding for equipment was eight months (range two weeks to two years). Parental views on home enteral nutrition were positive and none felt that its disadvantages outweighed the benefits. Altogether 35 children were described as being more happy and active. Given adequate preparation and continued support at home, parents can manage home enteral nutrition safely and effectively.

Growth and feeding problems after repair of oesophageal atresia.

Of 230 families belonging to a support group for parents of children born with oesophageal atresia, 124 returned a detailed questionnaire on feeding history and growth. Being slow to feed, refusing meals, coughing or choking during eating, and vomiting at meal times were significantly more common than in 50 healthy control children. Anthropometric analysis indicated that almost one third of patients were growth retarded, although those with a primary oesophageal anastomosis were less likely to be stunted or wasted compared with children who had an oesophageal substitution preceded by an oesophagostomy. Feeding problems tended to resolve spontaneously but slowly, with half of all children still reporting some difficulties at 7 years of age. Parents were considerably worried by feed related symptoms and families benefited from mutual support. There is a need for additional help and advice to be provided both by hospital staff interested in nutrition and feeding disorders and those professionals involved with primary care.

The pathology and prevention of Volkmann's ischaemic contracture.

Ischaemia is a rare complication of injury to a limb but must be excluded in every case. Two distinct types occur: Type I, where a proximal arterial injury gives rise to ischaemia distally; and Type II, where a direct injury gives rise to ischaemia at the site of the injury. Whatever the nature of the insult, an ischaemic contracture only develops as a result of swelling of the soft tissues where these soft tissues are contained in un unyielding osteofascial compartment. This secondary ischaemia can only be relieved by a timely fasciotomy. The diagnosis of ischaemia in an injured limb and the indications to operate on it can usually be made on clinical grounds alone.

Cutaneous bullae in coma due to poisoning. An association with deep seated ischaemic lesions of muscle.

A deeply unconscious patient may develop ischaemia in those soft tissues subjected to pressure. Pressure on the skin may give rise to blistering which is reversible. Pressure on the limbs may precipitate irreversible ischaemia of the muscles and nerves unless a fasciotomy is performed.

Compartmental syndromes following trauma.

When an ischemic contracture develops after injury it appears that the ischemia has pursued a middle course between full recovery and gangrene. The mechanism of such a pathology is difficult to understand. There appear to be two distinct types of injury that precipitate such a contracture; one where a major vessel is occluded and the ischemic tissue lies distal to the injury; and a second where the injury is a direct one and the ischemia develops at the site of the injury. The ischemic changes that develop after both types of injury appear to be remarkably similar and they develop, almost exclusively, where the tissues involved lie within unyielding osteofascial compartment. In both types, compartmental syndrome could have been precipitated; on the one hand by the ischemia of arterial interruption and on the other by direct tissue damage. Early fasciotomy is advocated after both types of injury, quite apart from any necessary arterial repair.