Consent to treatment: loophole in the Ontario Mental Health Act.

The issue of using substitute consent to obtain treatment for patients who are not competent to consent to treatment is complex. The authors present a case which illustrates that patients may delay treatment for extended periods of time by repeatedly challenging their incompetency status. The authors present proposals to change the present system.

Sizing bands on autoradiograms: a study of precision for scoring DNA fingerprints.

We replicated DNA fingerprints of snapping turtles (Chelydra serpentina) and hypervariable restriction fragments of red-winged blackbirds (Agelaius phoeniceus) to estimate the between-blot and between-lane components of variance in molecular weights of restriction fragments. Molecular weight standards were included in every lane, and bands were sized using a sonic digitizer. In both studies, a strong positive correlation was found between band size and coefficient of variation (CV; mean = 0.7%). In the DNA fingerprint study, 26% of the variance in estimates of band size was due to differences between blots, 10% due to differences between lanes on the same blot, and 64% due to error in the digitizing process. In the restriction fragment length polymorphism (RFLP) study, 16% of the variance was due to difference between lanes, and 84% to digitizing. Statistical models were developed to measure the effect of sizing error on identifying identical fragments in different lanes or on different blots, in categorizing distinct alleles, and in determining the size of bins in operational allele definitions. We suggest that the distance between bands be at least 2.8 standard deviations (SD) before they are declared different at alpha = 0.05, and 3.7 SD for alpha = 0.01. A variation in CVs strongly indicates that empirical relationships between SD and band size must be used to decide if two bands represent the same allele. Alleles must be at least 3.9 SD apart before the chance of assigning new observations in error falls below 0.05. We suggest that a minimum bin width of 16 SD is necessary before the chances of assigning a band to the wrong bin falls below 0.05.

Metachromatic leukodystrophy (MLD) in hospitalized adult schizophrenic patients resistant to drug treatment.

Metachromatic leukodystrophy (MLD) is a rare inherited neurodegenerative disease associated with a defect in the catabolism of sulphatide (galactocerebroside-sulphate) which accumulates in the nervous system. MLD can be diagnosed biochemically by demonstrating deficiency in the activity of the enzyme arylsulphatase A (ASA) and an excess of sulphatide in urine and tissues. Clinically adult MLD may present as a schizophrenic-like psychosis, which typically develops years before the onset of neurologial signs which are not inevitable. Urinary ASA was investigated in 99 chronic hospitalized psychiatric patients (including 77 schizophrenics). Thirteen showed reduced ASA activity. Of the nine who were available for further study, only one evinced reduced ASA activity in other tissues (for example, leukocytes and cultured fibroblasts). However, there was no evidence of sulphatidurea with impaired sulphatide hydrolysis in his intact cultured fibroblasts. Therefore, he tested negative for MLD. This biochemical profile is known as pseudosulphatase deficiency. The possible relationship of pseudosulphatase deficiency to schizophrenic-like conditions is discussed.

Consent to treat: clinical and legal implications.

Procedural requirements under the provisions of the Mental Health Act can delay the implementation of treatment for an involuntary psychiatric patient refusing treatment. The authors present such a case where treatment could not be given for nearly two months during which the patient's condition sharply deteriorated. With treatment, the patient improved within two weeks and was allowed to go home. Considerable time and money was spent in the Regional Review Board hearings. The implications of the case are discussed and it is recommended that steps be taken to prevent the interference of a bureaucratic legal system in the day to day practice of psychiatry.

Human erythrocyte acetylcholinesterase in relation to cell age.

Acetylcholinesterase was studied in human red cells that had been fractionated on Ficoll/Triosil density gradients into classes representing different ages in vivo. Reticulocytes have negligible acetylcholinesterase activity; this is rapidly acquired on maturation to the erythrocyte. The activity per cell reaches a maximum and then, after a constant period, declines again towards the end of cell life. The maximum activity and the rates of activity gain and loss per cell are quantitatively different in adults and children. Kinetic studies showed that Vmax. follows the same age/activity profile but Km is unaffected by cell age. The acetylcholinesterase protein content, determined by quantitative crossed immunoelectrophoresis, also shows a profile of increase and then decrease with cell age but the specific activity calculated from the protein estimate shows a reverse picture in which there is a slight decrease from young to mid-age cells followed by an increase again in older cells. These results are interpreted to indicate a complex developmental picture in which the overall cell age against enzyme activity profile is determined partly by the amount of enzyme protein present and partly from the modifying effect on the enzyme activity, of interactions with an aging cell membrane.

Changes in some cytoplasmic enzymes from red cells fractionated into age groups by centrifugation in Ficoll/Triosil gradients. Comparison of normal humans and patients with Duchenne muscular dystrophy.

1. A procedure is described for the fractionation into age classes of human red cells on a Ficoll/Triosil discontinuous density gradient. The fractionated cells appear minimally affected by the procedure. 2. Individual blood samples show a normal cell distribution, but the mean cell density may vary slightly. To allow for this in comparing samples, cell ages are expressed in terms of the mean and standard deviations from the mean. 3. Reticulocyte number decays exponentially in the gradient. By back extrapolation, a standard deviation can be computed corresponding to the theoretical age at which the sample contains 100% reticulocytes. This value can be used to calculate the theoretical activity of an enzyme in the reticulocytes and the enzyme half-life. 4. Glucose 6-phosphate dehydrogenase, 6-phosphogluconate dehydrogenase and glutathione reductase activities in unfractionated and age-fractionated cells were investigated in adults, children and patients with Duchenne muscular dystrophy. 5. The half-life for adult glucose 6-phosphate dehydrogenase (48 days) compares with that found by other workers. In children the half-life is 24 days, although the initial activity is essentially unaltered. 6. The half-life of 6-phosphogluconate dehydrogenase was found to be 117 days; the activity of glutathione reductase did not alter throughout the life of the cell. There was no difference between adults and children for these enzymes. The same results were obtained with dystrophic patients as for control children for all three enzymes.

Split-thickness skin graft for treatment of oral benign mucous membrane pemphigoid. Report of a case.

The painful oral lesions of benign mucous membrane pemphigoid often make the wearing of complete dentures difficult or impossible. A mandibular split-thickness skin graft vestibuloplasty was performed on a patient with benign mucous membrane pemphigoid. This procedure may be indicated in those cases which do not respond to meticulous denture construction and steroid therapy.