The impact of common variables on non-attendance at a radiology centre in Singapore.

INTRODUCTION: With the increasing demand for medical imaging, non-attendance inhibits private and public radiology practices in Singapore from providing timely care and achieving maximal efficiency. Missed radiological appointments adversely affect clinical and economic outcomes and strain the finite healthcare resources. We examined the prevalence and predictors of patient non-attendance for radiological services at a regional public hospital in Singapore and compared them against other medical imaging centres globally. METHODS: Outpatient records of patients who were scheduled for specialised medical imaging obtained from Radiological Information System (RIS) were retrospectively reviewed. Analysed variables include patient demographics, radiology modalities, visit statuses and appointment lead times where Pearson's chi-square test and Fisher's exact test were used for categorical variables, and independent sample t-test was used for continuous variables. The association between each patient characteristic and non-attendance status was assessed using Binary Logistics Regression. Variables that showed statistical significance in univariate analysis were included in the multivariate logistic regression model to identify the independent risk factors associated with non-attendance. RESULTS: Among the 59,748 outpatient appointments with medical imaging requests, 15.5% did not turn up for their appointments. Logistic regression indicated that patient's age, ethnicity, subsidy status, house ownership, living vicinity to regional hospital cluster, appointment wait times, appointment hours and appointment months were significant factors associated with the failure to attend scheduled radiological examinations. CONCLUSION: Even though predictors of non-attendance remained consistent across medical imaging centres worldwide, Singapore reported a higher prevalence of missed appointments calling for future exploratory studies to understand the population's health-seeking behaviours and ordering patterns of clinicians. IMPLICATIONS FOR PRACTICE: Comparison and identification of these predictors will assist in the design of targeted interventions that may improve patient's adherence and utilisation of imaging services.

Bias-Dependent Scanning Tunneling Microscopy Signature of Bridging-Oxygen Vacancies on Rutile TiO2(110).

The rutile TiO2(110) surface has long-served as a well-characterized, prototypical transition-metal oxide surface used in heterogeneous catalysis and photocatalytic water splitting. Naturally occurring defects on this surface, called bridging-oxygen (BO) vacancies, are important as they determine the overall reactivity of the surface. Herein, we report a bias-dependent, scanning tunneling microscopy (STM) signature of the BO vacancies on TiO2(110): for sample bias voltages past a threshold of +3 V, the bright vacancies are flanked on either side (along the oxygen row) by two dark spots approximately shaped like half-moons. The BO vacancies have a bright aspect below the threshold bias also but are not surrounded by half-moon dark depressions. Using generalized gradient approximation calculations with Hubbard correction (GGA + U) for projected density of states (DOS) and simulated STM images, we find that the bias-dependent STM signature originates from (i) local DOS maxima of all BOs (lighter background that occurs above the threshold bias) and (ii) the increased separation between the first and second BO atoms neighboring the vacancy which leads to an apparent dip between these neighboring oxygens. These results offer a new striking example of the STM signature that appears without switching the polarity of the bias. Similar approaches can be employed for seeking distinguishing features on the surfaces of other large band gap semiconductors and insulators.

Palladium Intercalated into the Walls of Mesoporous Silica as Robust and Regenerable Catalysts for Hydrodeoxygenation of Phenolic Compounds.

Nanostructured noble-metal catalysts traditionally suffer from sintering under high operating temperatures, leading to durability issues and process limitations. The encapsulation of nanostructured catalysts to prevent loss of activity through thermal sintering, while maintaining accessibility of active sites, remains a great challenge in the catalysis community. Here, we report a robust and regenerable palladium-based catalyst, wherein palladium particles are intercalated into the three-dimensional framework of SBA-15-type mesoporous silica. The encapsulated Pd active sites remain catalytically active as demonstrated in high-temperature/pressure phenol hydrodeoxygenation reactions. The confinement of Pd particles in the walls of SBA-15 prevents particle sintering at high temperatures. Moreover, a partially deactivated catalyst containing intercalated particles is regenerated almost completely even after several reaction cycles. In contrast, Pd particles, which are not encapsulated within the SBA-15 framework, sinter and do not recover prior activity after a regeneration procedure.

Preleukemia: one name, many meanings.

Definition of preleukemia has evolved. It was first used to describe the myelodysplastic syndrome (MDS) with a propensity to progress to acute myeloid leukemia (AML). Individuals with germline mutations of either RUNX1, CEBPA, or GATA2 can also be called as preleukemic because they have a markedly increased incidence of evolution into AML. Also, alkylating chemotherapy or radiation can cause MDS/preleukemia, which nearly always progress to AML. More recently, investigators noted that AML patients who achieved complete morphological remission after chemotherapy often have clonal hematopoiesis predominantly marked by either DNMT3A, TET2 or IDH1/2 mutations, which were also present at diagnosis of AML. This preleukemic clone represents involvement of an early hematopoietic stem cells, which is resistant to standard therapy. The same clonal hematopoietic mutations have been identified in older 'normal' individuals who have a modest increased risk of developing frank AML. These individuals have occasionally been said, probably inappropriately, to have a preleukemia clone. Our evolving understanding of the term preleukemia has occurred by advancing technology including studies of X chromosome inactivation, cytogenetics and more recently deep nucleotide sequencing.

Parental pre-pregnancy BMI is a dominant early-life risk factor influencing BMI of offspring in adulthood.

OBJECTIVE: We examined parental and early-life variables in order to identify risk factors for adulthood overweight and obesity in offspring. We report here on the longitudinal prevalence of overweight and obesity in Australian children born between 1989 and 1991 and followed from birth to age 22. METHODS: Data were analysed on 1355 participants from the Western Australian Pregnancy Cohort (Raine) Study, with anthropometry collected during pregnancy, at birth, one year and at three yearly intervals thereafter. Multivariate analyses and cross-sectional logistic regression quantified the timing and contribution of early-life risk factors for overweight and obesity in young-adulthood. RESULTS: At five years of age 12.6% of children were overweight and 5.2% were obese. By early adulthood, the prevalence of obesity had increased to 12.8%, whilst overweight remained relatively stable at 14.2% (range from early childhood to adulthood 11-16%). Parental pre-pregnancy body mass index (BMI) was the strongest determinant of adult offspring BMI. Although rapid first year weight gain was associated with increased offspring BMI, the impact of first year weight-gain diminished over childhood, whilst the impact of parental BMI increased over time. CONCLUSIONS: Parental pre-pregnancy BMI and rapid early-life weight gain predispose offspring to obesity in adulthood.

Improving surveillance of sexually transmitted infections using mandatory electronic clinical reporting: the genitourinary medicine clinic activity dataset, England, 2009 to 2013.

A new electronic surveillance system for sexually transmitted infections (STIs) was introduced in England in 2009. The genitourinary medicine clinic activity dataset (GUMCAD) is a mandatory, disaggregated, pseudo-anonymised data return submitted by all STI clinics across England. The dataset includes information on all STI diagnoses made and services provided alongside demographic characteristics for every patient attendance at a clinic. The new system enables the timely analysis and publication of routine STI data, detailed analyses of risk groups and longitudinal analyses of clinic attendees. The system offers flexibility so new codes can be introduced to help monitor outbreaks or unusual STI activity. From January 2009 to December 2013 inclusive, over twenty-five million records from a total of 6,668,648 patients of STI clinics have been submitted. This article describes the successful implementation of this new surveillance system and the types of epidemiological outputs and analyses that GUMCAD enables. The challenges faced are discussed and forthcoming developments in STI surveillance in England are described.

Shape-directional growth of Pt and Pd nanoparticles.

The design and synthesis of shape-directed nanoscale noble metal particles have attracted much attention due to their enhanced catalytic properties and the opportunities to study fundamental aspects of nanoscale systems. As such, numerous methods have been developed to synthesize crystals with tunable shapes, sizes, and facets by adding foreign species that promote or restrict growth on specific sites. Many hypotheses regarding how and why certain species direct growth have been put forward, however there has been no consensus on a unifying mechanism of nanocrystal growth. Herein, we develop and demonstrate the capabilities of a mathematical growth model for predicting metal nanoparticle shapes by studying a well known procedure that employs AgNO3 to produce {111} faceted Pt nanocrystals. The insight gained about the role of auxiliary species is then utilized to predict the shape of Pd nanocrystals and to corroborate other shape-directing syntheses reported in literature. The fundamental understanding obtained herein by combining modeling with experimentation is a step toward computationally guided syntheses and, in principle, applicable to predictive design of the growth of crystalline solids at all length scales (nano to bulk).

Subacute delayed ascending myelopathy: not just a post-traumatic disorder.

STUDY DESIGN: Case report. OBJECTIVES: Subacute delayed ascending myelopathy (SDAM), also known as subacute post-traumatic ascending myelopathy, is a rare early neurological complication of spinal cord injury (SCI), and the aetiology, pathogenesis and optimal management of this condition are poorly understood. The radiological features together with the clinical picture appear to be the most useful. We aim to increase awareness and further characterise SDAM. SETTING: Spinal Cord Injuries Unit, Royal North Shore Hospital, Sydney, Australia. METHODS AND RESULTS: We report two cases with radiological findings consistent with SDAM, and review the literature. Only a small number of cases have been reported and importantly, we report the first case occurring following a non-traumatic SCI. There are several hypotheses regarding pathogenesis, with several factors in our cases implicating a vascular mechanism. CONCLUSION: There is a lack of data characterising SDAM, and ascending myelopathy in a stable SCI should alert the clinician. Importantly, we propose that SDAM is the appropriate terminology.

Determination of ginsenoside content in Panax ginseng C.A. Meyer and Panax quinquefolius L. root materials and finished products by high-performance liquid chromatography with ultraviolet absorbance detection: interlaboratory study.

An interlaboratory study was conducted on an HPLC method with UV absorbance detection, previously validated using AOAC single-laboratory validation guidelines, for the determination of the six major ginsenosides (Rg1, Re, Rb1, Rc, Rb2, and Rd) in Panax ginseng C.A. Meyer and Panax quinquefolius L. root materials, extracts, and finished products. Fourteen participating laboratories analyzed five test materials (P. ginseng whole root, P. ginseng powdered extract, P. quinquefolius whole root, P. quinquefolius powdered extract, and P. ginseng powdered extract spiked in a matrix blank) as blind duplicates, and two test materials (P. ginseng powdered whole root tablet and P. quinquefolius powdered extract hard-filled capsule) as single samples. Due to the variability of the ginsenosides (low level concentration of Rb2 in P. quinquefolius raw materials and in P. ginseng spiked matrix blanks, and the possibility of incomplete hydrolysis of the finished products during processing), it was deemed more applicable to analyze total ginsenosides rather than individual ones. Outliers were evaluated and omitted using the Cochran's test and single and double Grubbs' tests. The reproducibility RSD (RSD(R)) for the blind duplicate samples ranged from 4.38 to 5.39%, with reproducibility Horwitz Ratio (HorRat(R)) values ranging from 1.5 to 1.9. For the single replicate samples, the data sets were evaluated solely by their repeatability HorRat (HorRat(r)), which were 2.9 and 3.5 for the capsule and tablet samples, respectively. Based on these results, the method is recommended for AOAC Official First Action for the determination of total ginsenosides in P. ginseng and P. quinquefolius root materials and powdered extracts.

Life expectancy after spinal cord injury: a 50-year study.

STUDY DESIGN: Cohort of incident cases from 1955 to 2006. OBJECTIVES: To analyse acute and long-term mortality, estimate life expectancy and identify survival patterns of individuals experiencing traumatic spinal cord injury (SCI). SETTING: Specialised SCI unit in Australia. METHODS: Data for patients with traumatic SCI admitted to a spinal unit in Sydney, Australia between January 1955 and June 2006 were collated and deaths confirmed. Cumulative survival probability was estimated using life-table techniques and mortality rates were calculated from the number of deaths and aggregate years of exposure. Standardised mortality ratios (SMRs) were estimated from the ratio of observed to expected number of deaths. Life expectancy was then estimated using adjusted attained age-specific mortality rates. RESULTS: From 2014 persons, 88 persons with tetraplegia (8.2%) and 38 persons with paraplegia (4.1%) died within 12 months of injury, most often with complete C1-4 tetraplegia. Among first-year survivors, overall 40-year survival rates were 47 and 62% for persons with tetraplegia and paraplegia, respectively. The most significant increases in mortality were seen in those with tetraplegia and American Spinal Injury Association Impairment Scale (AIS) grades A-C lesions, with SMRs between 5.4 and 9.0 for people <50 years, reducing with advancing attained age. Estimated life expectancies from 25 to 65 years ranged between 69-64%, 74-65%, 88-91% and 97-96% for C1-4 AIS A-C, C5-8 A-C, T1-S5 A-C and all AIS D lesions, respectively. CONCLUSION: Survival related strongly to extent of neurological impairment. Future research should focus on identifying contextual factors, personal or environmental, that may contribute to the reduced life expectancy after SCI.

Comparing and contrasting knowledge of pressure ulcer assessment, prevention and management in people with spinal cord injury among nursing staff working in two metropolitan spinal units and rehabilitation medicine training specialists in a three-way comparison.

AIM: To assess for differences in knowledge of pressure ulcer (PU) prevention and management among nurses working in two metropolitan spinal cord injury (SCI) units, and between nurses and rehabilitation registrars (doctors). BACKGROUND: There is anecdotal evidence of wide variation in PU management. An understanding of current knowledge is fundamental to evidence-based practice implementation. METHODS: This was a prospective survey, using a multiple choice question format developed with nurse wound specialists. A total of 10 questions assessed PU prevention and 10 assessed management. It was distributed to nurses working at the spinal units and rehabilitation registrars. The results from the groups were analysed for similarities and differences using one- and two-way analysis of variance (ANOVA) tests and tests for significance of specific linear combinations of group means. RESULTS: The response rate was 79% (19/24) and 71% (20/ 28) from the two SCI units, and 46% (13/28) from doctors. Doctors performed better than nurses on prevention questions (P<0.005) but worse on management (P<0.05). There was a significant difference in management knowledge (P<0.001) between nurses working in the two units but not in prevention knowledge (P<0.5) and interestingly years of experience did not correlate with performance (P<0.2 for prevention and P<0.5 for management questions). CONCLUSIONS: Rehabilitation registrars score better in prevention questions, but poorer in management questions, which reflects academic rather than experiential knowledge. There are also differences in management knowledge among nurses, based on work area rather than years of experience. Although knowledge does not necessarily reflect practice, this calls for better standardisation and implementation of wound management pathways.

The Ski proto-oncogene regulates body composition and suppresses lipogenesis.

OBJECTIVE: The Ski gene regulates skeletal muscle differentiation in vitro and and in vivo. In the c-Ski overexpression mouse model there occurs marked skeletal muscle hypertrophy with decreased adipose tissue mass. In this study, we have investigated the underlying molecular mechanisms responsible for the increased skeletal muscle and decreased adipose tissue mass in the c-Ski mouse. APPROACH: Growth and body composition analysis (tissue weights and dual energy X-ray absorptiometry) coupled with skeletal muscle and white adipose gene expression and metabolic phenotyping in c-Ski mice and wild-type (WT) littermate controls was performed. RESULTS: The growth and body composition studies confirmed the early onset of accelerated body growth, with increased lean mass and decreased fat mass in the c-Ski mice. Gene expression analysis in skeletal muscle from c-Ski mice compared with WT mice showed significant differences in myogenic and lipogenic gene expressions that are consistent with the body composition phenotype. Skeletal muscle of c-Ski mice had significantly repressed Smad1, 4, 7 and myostatin gene expression and elevated myogenin, myocyte enhancer factor 2, insulin-like growth factor-1 receptor and insulin-like growth factor-2 expression. Strikingly, expression of the mRNAs encoding the master lipogenic regulators, sterol-regulatory enhancer binding protein 1c (SREBP1c), and the nuclear receptor liver X-receptor-alpha, and their downstream target genes, SCD-1 and FAS, were suppressed in skeletal muscle of c-Ski mice, as were the expressions of other nuclear receptors involved in adipogenesis and metabolism, such as peroxisome proliferator-activated receptor-gamma, glucocorticoid receptor and retinoic acid receptor-related orphan receptor-alpha. Transfection analysis demonstrated Ski repressed the SREBP1c promoter. Moreover, palmitate oxidation and oxidative enzyme activity was increased in skeletal muscle of c-Ski mice. These results suggest that the Ski phenotype involves attenuated lipogenesis, decreased myostatin signalling, coupled to increased myogenesis and fatty acid oxidation. CONCLUSION: Ski regulates several genetic programs and signalling pathways that regulate skeletal muscle and adipose mass to influence body composition development, suggesting that Ski may have a role in risk for obesity and metabolic disease.

Situation of HIV infections and STIs in the United Kingdom in 2007.

In the United Kingdom (UK) in 2007, an estimated 77,400 persons were living with human immunodeficiency virus (HIV) of whom 28% are unaware of their infection. A total of 7,734 persons were newly diagnosed with HIV infection in 2007, of which 31% were diagnosed late. This highlights the need for wider HIV testing, especially in those areas with a high diagnosed prevalence, as recommended in recent national guidelines. Among newly diagnosed cases of HIV in 2007, 41% acquired their infection through sex between men (four in five of whom acquired their infection in the UK) and 55% through heterosexual contact (four in five of whom acquired their infection abroad, mainly in sub-Saharan Africa). Young persons aged 16 to 24 years are disproportionally affected by sexually transmitted diseases (STIs) accounting for 65% of genital chlamydia infections, 50% of cases of genital warts and 50% of cases of gonorrhoea that were diagnosed in 2007.

Rates of surgical site infection after hip replacement as a hospital performance indicator: analysis of data from the English mandatory surveillance system.

OBJECTIVE: To describe rates of surgical site infection (SSI) after hip replacement and to use these data to provide a simple mechanism for identifying poorly performing hospitals that takes into account variations in sample size. DESIGN: Prospective surveillance study. SETTING: A total of 125 acute care hospitals in England that participated in mandatory SSI surveillance from April 1, 2004 through March 31, 2005. PATIENTS: Patients who underwent total hip replacement (THR) or hip hemiarthroplasty (HH). METHODS: A standard data set was collected for all eligible operations at participating hospitals for a minimum of 3 months annually. Defined methods were used to identify SSIs that occurred during the inpatient stay. Data were checked for quality and accuracy, and funnel plots were constructed by plotting the incidence of SSI against the number of operations. RESULTS: Data were collected on 16,765 THRs and 5,395 HHs. The cumulative SSI incidence rates were 1.26% for THR and 4.06% for HH; the incidence densities were 1.38 SSIs per 1,000 postoperative inpatient days for THR and 2.3 SSIs per 1,000 postoperative inpatient days for HH. The risk of infection associated with revision surgery was significantly higher than that associated with primary surgery (2.7% [95% confidence interval, 2.0%-3.5%] vs. 1.1% [95% confidence interval, 1.0%-1.2%]; P=.003). Rates varied considerably among hospitals. Nineteen hospitals had rates above the 90th percentile. However, the use of funnel plots to adjust for the precision of estimated SSI rates identified 7 hospitals that warranted further investigation, including 2 with crude rates below the 90th percentile. CONCLUSIONS: Funnel plots of rates of SSI after hip replacement provide a valuable method of presenting hospital performance data, clearly identifying hospitals with unusually high or low rates while adjusting for the precision of the estimated rate. This information can be used to target and support local interventions to reduce the risk of infection.

Duration of operation as a risk factor for surgical site infection: comparison of English and US data.

T times are used to categorize surgical procedures into long and short durations. They constitute a part of the US National Nosocomial Infection Surveillance (NNIS) risk index that is widely used internationally in surveillance for surgical site infections (SSIs). The objective of this study was to compare the US NNIS T times with data collected in England. The Surgical Site Infection Surveillance Service in England holds data collected by 168 hospitals in 13 categories of surgical procedures between 1997 and 2002. The 75(th) percentile and corresponding T time were calculated from English data and compared with US times. Differences in rates of SSI above and below the T times were compared. Graphical methods were used to assess the cut points that exhibited an association with risk of SSI. The results show that English and US T times were the same for all surgical categories except coronary artery bypass graft and vascular surgery, where the English T time was 4 h. The 75(th) percentile time for hip hemiarthroplasties was 40 min less than for total hip replacements (THR). Although the incidence of SSI in THR was significantly higher in operations lasting for longer than the T time (P<0.05), no association between risk of SSI and T times set at 1, 1.5 or 2 h was observed for hip hemiarthroplasties. In conclusion, operations lasting for longer than the T time were associated with a higher risk of SSI in most categories. In the hip prosthesis category, this association only applied to THR.

Estrogen inhibits GH signaling by suppressing GH-induced JAK2 phosphorylation, an effect mediated by SOCS-2.

Oral estrogen administration attenuates the metabolic action of growth hormone (GH) in humans. To investigate the mechanism involved, we studied the effects of estrogen on GH signaling through Janus kinase (JAK)2 and the signal transducers and activators of transcription (STATs) in HEK293 cells stably expressing the GH receptor (293GHR), HuH7 (hepatoma) and T-47D (breast cancer) cells. 293GHR cells were transiently transfected with an estrogen receptor-alpha expression plasmid and luciferase reporters with binding elements for STAT3 and STAT5 or the beta-casein promoter. GH stimulated the reporter activities by four- to sixfold. Cotreatment with 17beta-estradiol (E(2)) resulted in a dose-dependent reduction in the response of all three reporters to GH to a maximum of 49-66% of control at 100 nM (P < 0.05). No reduction was seen when E(2) was added 1-2 h after GH treatment. Similar inhibitory effects were observed in HuH7 and T-47D cells. E(2) suppressed GH-induced JAK2 phosphorylation, an effect attenuated by actinomycin D, suggesting a requirement for gene expression. Next, we investigated the role of the suppressors of cytokine signaling (SOCS) in E(2) inhibition. E(2) increased the mRNA abundance of SOCS-2 but not SOCS-1 and SOCS-3 in HEK293 cells. The inhibitory effect of E(2) was absent in cells lacking SOCS-2 but not in those lacking SOCS-1 and SOCS-3. In conclusion, estrogen inhibits GH signaling, an action mediated by SOCS-2. This paper provides evidence for regulatory interaction between a sex steroid and the GHJAKSTAT pathway, in which SOCS-2 plays a central mechanistic role.

Glucocorticoid excess during adolescence leads to a major persistent deficit in bone mass and an increase in central body fat.

Endogenous Cushing's syndrome (CS) in children causes growth retardation, decreased bone mass, and increased total body fat. No prospective controlled studies have been performed in children to determine the long-term sequelae of CS on peak bone mass and body composition. A 15-year-old girl with Cushing disease (CD), and her healthy identical co-twin, were followed for 6 years after the CD was cured. At the 6-year follow-up both twins had areal bone mineral density (BMD) and body composition determined by dual-energy X-ray absorptiometry (DXA) and three-dimensional quantitative computed tomography (3DQCT). Z scores for height, weight, and body mass index (BMI) were -2.3, -0.8 and 0.2, and 1.2, 0.2, and -0.6, in the twin with CD and her co-twin, respectively. In the twin with CD, areal BMD and bone mineral apparent density (BMAD) at different sites varied from 0.7 to 3 SD below her co-twin. Volumetric lumbar spine bone density Z score was -0.75 and 1.0, and total body, abdominal visceral, and subcutaneous fat (%) was 42, 10, and 41 versus 26, 4, and 17 in the twin with CD and her co-twin, respectively. The relationship between total body fat and L2-L4 BMAD was inverse in the twin with CD (p < 0.05), which by contrast in her co-twin was opposite and direct (p < 0.001). In the twin with CD, despite cure, there was a persistent deficit in bone mass and increase in total and visceral body fat. These observations suggest that hypercortisolism (exogenous or endogenous) during adolescence may have persistent adverse effects on bone and fat mass.

Potential erosion of psychotherapist-patient privilege beyond California: dangers of "criminalizing" Tarasoff.

The "dangerous patient exception" to psychotherapist-patient privilege, adopted almost a decade before the celebrated case of Tarasoff v. Regents of the University of California (1976), was mentioned in a footnote to that decision in the context of an analogy. Although intended to permit testimony in civil commitment proceedings, this exception has been used to "criminalize" the Tarasoff duty in California. California courts eroded the privilege initially primarily to permit victims to sue psychotherapists and later to require psychotherapists to testify against their patients in criminal proceedings and appear to have confused evidentiary privilege and confidentiality. If consistent, similar reasoning in California in the future should allow therapists to testify against their patients if they were civilly committed in the past for dangerousness and attorneys to testify against their clients in criminal cases if at some earlier time they believed their clients represented a risk of future harm. Although most other jurisdictions may not word their privilege exceptions for civil commitment in the same way as California, most states have some type of privilege exception for civil commitment that could allow for such an interpretation. The United States Supreme Court in Jaffee v. Redmond (1996) found a psychotherapist-patient privilege, but stated in a footnote that an exception to the privilege would exist if a serious threat of harm to the patient could be averted only by means of disclosure by the therapist. Other jurisdictions have begun to consider these issues. Rather than being unique to California, similar reasoning could lead to the "criminalization" of Tarasoff in other jurisdictions and thereby compel therapists outside California to testify against their patients in criminal proceedings.