Mental health law and the EU: the next new regulatory frontier?

Over the last decade the EU's engagement with health law and policy has rapidly increased and there is now a growing body of literature highlighting this evolution and the impact of legal and regulatory structures in this area. In contrast the specific impact of EU law and policy in relation to the area of mental health remains the subject of comparatively little engagement. The aim of this paper is to examine whether mental health law and policy will become a major site for EU policy and law in the future. It examines the development of EU policy in this area. It sets this in the context of related legal developments such as the Charter of Fundamental Rights and the new EU Patients Rights Directives. It suggests that while it might be at present premature to envisage that a single body of EU mental health law itself may be unlikely that nonetheless the EU presents what is a potentially very influential site for regulation, law and policy in this area in the years to come.

[Presentation of the french adaptation of McHale's coparenting scale for families with young children.] / Présentation de l'adaptation française de << l'échelle de coparentage >> de McHale pour familles avec jeunes enfants.

The aim of this paper is to present McHale's coparenting scale,a self-administered questionnaire enabling assessment of the quality of coparenting, and first steps in structural and construct validation of the French version. A total of 41 French speaking Swiss families and 84 US families completed this questionnaire and the Dyadic Adjustment Scale, a measure of marital satisfaction. The results of the Swiss families correspond to those of US families: first, items distributed into four factors (family integrity, conflict, affection and disparagement) and second, a partial link was found between quality of coparenting and marital adjustment. This finding supports the construct validity of the questionnaire, reflecting the established link between these two family sub-systems. Given that coparenting quality has a major influence on children's socio-affective development, the questionnaire will find great use in assessing not just negative features of coparenting, such as conflicts and disparagement, but also positive components such as warmth and support. This will be an important asset for research as well as clinical purposes.

Successful perioperative utilisation of inhaled nitric oxide in mitral valve surgery.

Pulmonary hypertension associated with mitral valve disease can significantly complicate mitral valve replacement. Nitric oxide (NO) has an established role in congenital heart surgery and in cardiac transplantation. However the evidence to date suggests that iNO does not provide a clinical advantage in pulmonary hypertension associated with valvular heart disease. We discuss a 56-year-old male with acute mitral incompetence who underwent emergency surgery. Following mitral valve replacement he was weaned off cardiopulmonary bypass with an intra-aortic balloon pump and high doses of inotropic support but continued to be hypotensive. Inspection of the heart showed right-sided dysfunction and evidence of pulmonary hypertension. Following the introduction of iNO he rapidly improved. He was successfully separated from the cardiopulmonary bypass support and subsequently made a full recovery and was discharged. We believe that this case demonstrates the utility of iNO in the management of pulmonary hypertension secondary to valvular disease in the acute setting. This is in contrast to the evidence against its utility in established pulmonary hypertension in chronic valvular heart disease. Further confirmation of this observation may lead to the therapeutic use of NO in this subpopulation of cardiac surgery patients.

Resynchronization of ovulation and timed insemination in lactating dairy cows I: use of the Ovsynch and Heatsynch protocols after non-pregnancy diagnosis by ultrasonography.

The objective was to compare pregnancy rates and pregnancy losses in lactating dairy cows that were diagnosed not pregnant and re-inseminated following either the Ovsynch or Heatsynch protocols. Also evaluated were the effects of stages of the estrous cycle, ovarian cysts and anestrus on pregnancy rates for both treatments. Non-pregnant cows (n = 332) as determined by ultrasonography on day 27 post-AI (study day 0) were divided into two groups. Cows in the Ovsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, GnRH on day 9, and timed AI (TAI) 16 h later (day 10). Cows in the Heatsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, estradiol cypionate (ECP) on day 8, and TAI 48 h later (day 10). Cows detected in estrus on days 8 and 9 were inseminated and included in the study. On day 0, cows were classified according to different stages of the estrous cycle, or presence of ovarian cysts or anestrus. Pregnancy rates were evaluated 27, 45 and 90 days after resynchronized AI. Overall, there was no difference in pregnancy rates on days 27, 45 and 90 between cows in the Ovsynch (25.2, 17.5, and 13.9%) and Heatsynch (25.8, 19.9, and 16.1%) groups. There was no difference in pregnancy losses from days 27 to 45 and days 45 to 90 for cows in the Ovsynch (25.0 and 17.9%) and Heatsynch (14.7 and 10.3%) groups. However, pregnancy rates were increased when cows in metestrus were subjected to the Heatsynch protocol and cows with ovarian cysts were subjected to the Ovsynch protocol.

Resynchronization of ovulation and timed insemination in lactating dairy cows, II: assigning protocols according to stages of the estrous cycle, or presence of ovarian cysts or anestrus.

Pregnancy rates were compared in lactating dairy cows (n = 1083) assigned to protocols for resynchronization of ovulation based on stages of the estrous cycle, or presence of ovarian cysts or anestrus. Cows were detected not pregnant by ultrasonography 30 d after a previous AI (study day 0) and classified as diestrus, metestrus, proestrus, with ovarian cysts or anestrus. Cows in diestrus (January-May) were assigned to either Ovsynch (GnRH day 0, PGF2alpha day 7, GnRH day 9, and timed-AI [TAI] 16 h later; n = 96), or Quicksynch (PGF2alpha day 0, estradiol cypionate [ECP] day 1, AI at detected estrus [AIDE] on day 2, or TAI on day 3; n = 96). Cows in diestrus (June-December) were assigned to either Ovsynch (n = 156) or Modified Quicksynch (PGF2alpha day 0, ECP day 1, AIDE days 2 and 3, and to Ovsynch on day 4 if not detected in estrus; n = 142). Cows in metestrus were assigned either to Ovsynch (n = 68), Heatsynch (GnRH day 0, PGF2alpha day 7, ECP day 8, AIDE day 9, or TAI day 10; n = 62), or GnRH + Ovsynch (GnRH on day 0, followed by Ovsynch on day 8; n = 64). Cows in proestrus, with ovarian cysts, or anestrus were assigned to either Ovsynch (proestrus n = 89, ovarian cysts n = 97, anestrus n = 8) or GnRH + Ovsynch (proestrus n = 87, ovarian cysts n = 109, anestrus n = 9). Pregnancy rate was evaluated 30, 55 and 90 d after resynchronized AI. For cows in diestrus (January-May), pregnancy rates were higher for Ovsynch (35.9, 29.2 and 26.0%) than for Quicksynch (21.7, 16.7 and 15.6%). For cows in diestrus (June-December), pregnancy rates were similar for Ovsynch (34.4, 24.0 and 23.6%) and Modified Quicksynch (27.1, 26.2 and 21.6%). For cows in metestrus, pregnancy rates were higher for GnRH + Ovsynch (33.3, 24.5 and 20.3%) than for Heatsynch (20.3, 12.9 and 9.8%). For cows with ovarian cysts, pregnancy rates were higher for GnRH + Ovsynch (30.3, 26.6 and 22.9%) than for Ovsynch (20.2, 18.5 and 14.7%). Assignment to resynchronization protocols based on the stages of the estrous cycle, or presence of ovarian cysts improved pregnancy rates.

Resynchronization of ovulation and timed insemination in lactating dairy cows III. Administration of GnRH 23 days post AI and ultrasonography for nonpregnancy diagnosis on day 30.

The objective was to compare pregnancy rates to resynchronization and timed AI (TAI) protocols in lactating dairy cows that received GnRH at 23 d and were diagnosed not pregnant at 30 d after the pre-enrollment AI. Nonpregnant cows (624) at ultrasonography on day 30 (study day 0) were classified as diestrus (74.8%), metestrus (5.6%) and without a CL (19.5%). Cows in diestrus were assigned either to the GnRH group (PGF2alpha on day 0, GnRH on day 2 and TAI 16 h later, n = 238) or the estradiol cypionate (ECP) group (PGF2alpha on day 0, ECP on day 1, and TAI 36 h later, n = 229). Cows in metestrus were assigned to the Modified Heatsynch Group (GnRH on day 0, PGF(2alpha) on day 7, ECP on day 8 and TAI on day 9, n = 35). Cows without a CL (n = 122) were classified either as proestrus (10.6%), ovarian cysts (7.5%) or anestrus (1.4%), and assigned to factorial treatments (i.e., use of GnRH versus CIDR) to either the GnRH group (GnRH on day 0, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28), the CIDR group (CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 34), the GnRH + CIDR group (GnRH on day 0, CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16h later, n = 32), and the control group (PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28). For cows without a CL, plasma P4 concentrations were determined on days 0, 7, 10 and 17 and ovarian structures determined on days 0, 7 and 17. Pregnancy rates were evaluated at 30, 55 and 90 d after the resynchronized AI. For cows in diestrus, there were no differences in pregnancy rates on days 30, 55 and 90 for cows in the GnRH (27.5, 26.5 and 24.2%) or ECP (29.1, 25.5 and 24.1%) groups. In addition, there were no differences in pregnancy losses between days 30 and 55 and 55 and 90 between the GnRH (7.0 and 8.6%) and ECP (9.8 and 5.4%) groups. For cows without a CL, GnRH on day 0 increased the proportion of cows with a CL on days 7 and 17 and plasma P4 concentration on day 17 in cows with ovarian cysts but not for cows in proestrus. The CIDR insert increased pregnancy rate in cows with ovarian cysts but reduced pregnancy rate for cows in proestrus.

Strategic use of gonadotrophin-releasing hormone (GnRH) to increase pregnancy rate and reduce pregnancy loss in lactating dairy cows subjected to synchronization of ovulation and timed insemination.

The objective of this study was to determine the effect of GnRH (100 microg i.m.) treatment 5 and 15 days after timed insemination (TAI) on pregnancy rate and pregnancy loss in lactating dairy cows subjected to synchronization of ovulation. The study included 831 lactating dairy cows subjected to a Presynch-Ovsynch protocol for first service. On the day of TAI (Day 0), cows were randomly assigned to one of four experimental groups. Cows in Group 1 (n = 214) were treated with GnRH on Day 5; cows in Group 2 (n = 209) were treated with GnRH on Day 15; cows in Group 3 (n = 212) were treated with GnRH on both Day 5 and Day 15; cows in Group 4 (n = 196) were not treated. Pregnancy rate was evaluated at Day 27 and Day 45 after TAI. The interestrus interval and the proportion of cows diagnosed not pregnant based on expression of estrus and insemination before pregnancy diagnosis on Day 27 were determined. The results of this study are: (1) GnRH treatment on Day 5 or Day 15 did not increase pregnancy rate, or reduce pregnancy loss between Day 27 and Day 55 after TAI; (2) cows treated with GnRH on both Day 5 and Day 15 had a lower (P < 0.01) proportion of cows diagnosed not pregnant based on expression of estrus before ultrasonography on Day 27 (26.5%) compared to control cows (52.9%), and these cows had an extended (P = 0.05) interestrus interval (23.4 days vs. 21.5 days); and (3) GnRH treatment on both Day 5 and Day 15 after TAI reduced pregnancy rate on Day 27 (36.8% vs. 44.4% for control cows; P < 0.03) and Day 55 (28.3% vs. 36.2% for control cows; P < 0.01). Therefore, strategies to stimulate CL function using multiple doses of GnRH during the luteal phase need to consider potential negative effects.

In situ hybridization of parathyroid hormone-related protein in normal skin, skin tumors, and gynecological cancers using digoxigenin-labeled probes and antibody enhancement.

We describe a novel procedure for in situ hybridization that combines the use of digoxigenin-labeled oligonucleotide probes with an antibody enhancement step that can be performed on formalin-fixed, paraffin-embedded tissues. Addition of a second antibody enhances the visibility of parathyroid hormone-related protein (PTHrP) mRNA expression from barely to highly discernible and interpretable, with virtually no nonspecific background expression. This technique has allowed visualization of PTHrP mRNA in normal human skin and epithelium-derived tumors. PTHrP mRNA expression was confined to the basal and spinous keratinocyte layers of skin. There was strong hybridization in the spinous keratinocyte layer and a low level of hybridization in the basal layer. An extensive panel of positive and negative controls included poly d(T) probe to indicate total mRNA present in the sections. Squamous cell carcinomas and basal cell carcinomas of the skin, from pathology archives, were examined for the presence of PTHrP mRNA. The results reflected previous immunohistochemical studies, with every squamous cell carcinoma hybridizing strongly with the PTHrP probes. The basal cell carcinomas showed no expression of PTHrP mRNA, although the total mRNA signal was very strong. The localization of PTHrP mRNA in the tumors of the gynecological tract also reflected the immunohistochemical findings, with expression found in the squamous cell carcinomas but not in the adenocarcinomas. In situ hybridization with digoxigenin-labeled oligonucleotide probes and antibody enhancement has provided a sensitive, highly specific procedure for detection of PTHrP mRNA in tumors and normal tissue.

CORD9 a new locus for arCRD: mapping to 8p11, estimation of frequency, evaluation of a candidate gene.

PURPOSE: To determine the locus of the mutant gene causing autosomal recessive cone-rod dystrophy (arCRD) in a consanguineous pedigree, to evaluate a candidate gene expressed in retina that maps to this locus, and to estimate the percentage of arCRD cases caused by mutations in this gene. METHODS: DNAs from family members were genotyped for markers covering the entire genome at an average spacing of approximately 9 centimorgans (cM). The data were input into a pedigree computer program to produce output files used to calculate lod scores. Significant linkage was revealed at 8cen, prompting the genotyping of a number of additional markers. Exons of a candidate gene were sequenced directly by standard fluorescent dideoxy methods. Haplotype analysis was performed with markers in this locus in 13 multiplex and 2 simplex CRD families in which neither parent had disease. RESULTS: Four-point linkage analysis gave a maximum lod score of approximately 7.6 at both D8S1769 and GATA101H09 in the large consanguineous family. Recombination events defined an interval of 8.7 cM between D8S1820 and D8S532 within which the gene must lie. This 8p11 locus (CORD9) is immediately distal to but distinct from the RP1 autosomal dominant RP (adRP) locus. Two islands of homozygosity were found in this locus: The alleles of 6 of 10 markers in one of the islands and 2 of 4 in the other were homozygous. The UniGene cluster Hs.8719 (UniGene System, provided by the National Center for Biotechnology Information and available at http://www.ncbi.nlm.nih.gov/UniGene), which tags a gene with significant homology to Dual Specificity Phosphatase 3, maps within the CORD9 interval and is highly expressed in the retina. To evaluate this gene as a potential disease candidate, intron-exon structure was determined, and exons were screened in the consanguineous family. No variants were found that could be related to disease. Haplotype analysis of 15 other families with CRD, using markers at CORD9, excluded this locus in 9 of 15. CONCLUSIONS: A new arCRD locus (CORD9) has been identified corresponding to a yet unidentified gene in the 8.7-cM interval D8S1820-D8S532. No mutations were found in one candidate gene in affected members of the primary study family. Haplotype analysis of a cohort of 13 multiplex and 2 simplex families with CRD ruled out the CORD9 gene in 9 of 15 of the families. To date, a total of 126 loci carrying gene mutations causing various forms of retinal degeneration have been mapped, and the mutant gene has been identified in 64 of them. However, only 2 loci for arCRD have been documented. This is the report of a third.

Quality in health care: a role for the law?

This paper considers the way in which English law can and does play a part in ensuring quality standards in healthcare practice. It examines the enhanced scope for judicial scrutiny of standards of care and the role played by law in the form of statutory regulation. There is an increasing degree of legal involvement in healthcare decision making. The law may provide some effective checks and balances to quality but, at the same time, the limits of the law as an effective regulator of quality have to be recognised because of the multifaceted nature of clinical judgment.

Buerger's disease and protein S deficiency: successful treatment with prostacyclin.

In this report we describe a female patient who presented with peripheral circulatory impairment. She had previously been thought to have a systemic vasculitis, but had failed to respond to corticosteroid and immunosuppressive therapy. Serologic investigations were negative. The patient was a very heavy smoker, and it became clear that her condition had many of the clinical features of Buerger's disease (thrombangiitis obliterans). The diagnosis was confirmed by angiography, and a coagulation screen showed her to have associated protein S deficiency. Her symptoms responded rapidly to cessation of smoking, warfarin therapy, and a series of intravenous prostacyclin infusions. We discuss in detail the possible pathologic mechanisms which might explain the association of protein S deficiency and thrombangiitis obliterans.

Effects of MHz ultrasound on electrical pain threshold perception in humans.

An electrode system was developed consisting of two 8 mm long 0.2 mm diameter silver-coated copper wires arranged parallel to each other 8 mm apart and held in contact with the skin by means of an acoustically transparent plastic adhesive tape. This system was attached to the upper arms of young adult volunteers who increased the voltage of the rectangular electrical pulses supplied to the electrodes until a reproducible sharp prickling pain sensation was perceived. A one inch diameter physiotherapy transducer was positioned over the electrode site so that ultrasound could be administered throughout the measurement period. The experiments were performed single blind to eliminate any subjective bias on the part of the volunteers. Preliminary experiments established that highly reproducible (+/- 3 to 4%) pain threshold perception values could be obtained, and that these values were not affected by changes in (a) the duration of the "on" time of the electrical pulses between 1.5 and 48 ms, (b) the contact pressure between the transducer and the electrode site, (c) the time interval between successive threshold measurements (providing that an unacceptable level of oedema was not produced around the electrodes), and (d) whether or not a test measurement was preceded by a control. Ultrasound exposure via a direct contact technique consistently produced a statistically significant (p less than 0.05) decrease in the perception threshold for electrical pain. This effect usually developed within 30-60 s and its magnitude increased both with increasing intensity (rising to 20.7 +/- 0.57% at an SATA intensity of 0.43 W/cm2 at 1.1 MHz) and with increasing frequency at the same ultrasonic intensity. Delivering the same amount of ultrasonic energy in the form of 2 ms bursts at several different peak intensities produced exactly the same reduction in pain threshold perception. These results indicate a thermal interaction mechanism, and similar threshold changes could be obtained by heating or cooling the electrode site by nonacoustic means. The inclusion of a thermocouple junction between the electrode wires showed that temperature increases of up to 10 degrees C could be produced when the transducer was in direct contact with the tape over the electrodes. The volunteers were not aware of these temperature increases which were primarily caused by heating of the transducer face. If the temperature of the skin surface is kept constant by interposing a thermostatted water path between the transducer and the electrode system, then similar ultrasound exposures had no detectable effects upon the electrical pain perception threshold.(ABSTRACT TRUNCATED AT 400 WORDS)

Correlates of marital behavior at 6 months postpartum.

The birth of a baby may adversely affect spouses' adaptation, as indexed by self-reported marital satisfaction and psychological well-being. However, less is known about the interpersonal dynamics of marital behavior during the months after a child is born. This research examined correlates of marital behavior in 2 contexts for 104 couples with 6-month-old infants. Spouses completed measures of their relationship history, personality, self-esteem, and marital adjustment and were videotaped in their homes during couple discussion and family play. Spouses reporting greater marital adjustment exhibited more positive and less negative engagement during couple discussion and greater harmony during family play. Older spouses, however, displayed less positive engagement during couple discussion than younger spouses. During family play, greater hostility was observed when wives reported less positive relationship histories and greater negative affectivity. These findings suggest that marital behavior after the birth of a baby is multiply determined and that its correlates vary across contexts.

Understanding triadic and family group interactions during infancy and toddlerhood.

This paper outlines recent conceptual and methodological developments in the assessment of triadic and family group process during infancy and toddlerhood. Foundations of the emerging family group process are identified, and conditions specific to the assessment of the family during the early phases of family formation are summarized. Both microanalytic and global approaches to evaluating mother-father-child interactions are discussed. We highlight both similarities and differences in the strategies and methods employed by several different investigators who have been studying the group dynamics of families with infant and toddler children, and underscore several important family patterns and emerging themes that appear to be cutting across these different methods and measurement strategies. Preliminary evidence for the validity and clinical significance of family-level assessments is summarized, and directions currently being pursued by researchers engaged in studies of the family triad are outlined. We close by identifying several conceptual and clinical issues that remain to be addressed by subsequent work.

Marital behavior and the security of preschooler-parent attachment relationships.

Longitudinal and concurrent relations among positive and negative marital behaviors in 2 contexts and preschoolers' security of attachment were examined for 53 families. At 6 months postpartum, couples were observed in their homes during couple discussion and family play. At 3 years, parents completed the Attachment Q-Set (E. Waters, 1987); marital and parenting behavior was also observed. Interparental hostility during family play at 6 months predicted less secure preschooler-mother attachment. Greater marital conflict at 3 years was associated with less security with mother and father, whereas positive marital engagement at 3 years was associated with more secure child-father attachment. Mothers' parenting partially explained the linkages between marital behavior and child-mother attachment. These results highlight the impact of positive and negative marital behaviors on children's abilities to use their parents as a secure base.

Parental reports of coparenting and observed coparenting behavior during the toddler period.

Fifty-two married partners played with their 30-month-olds in both dyadic (parent-child) and whole family contexts and reported on their own coparenting activities (family integrity-promoting behavior, conflict, disparagement, and reprimand). Coparenting behavior observed in the whole family context was evaluated for antagonism, warmth and cooperation, child-adult centeredness, balance of positive involvement, and management of toddler behavior. Parallel balance and management scores were also formed using dyadic session data. Men's reported family integrity-promoting activities and women's reported conflict and reprimand activities were reliable correlates of family group process in both bivariate and discriminant analyses, with links enduring even after controlling for marital quality. Whole family- and dyad-based estimates of coparenting were altogether unrelated, and reported coparenting was tied only to behavior in family context, not to family measures created from dyad-based data.

Testing the Uniform Needs Assessment Instrument for hospital discharge planning with older adults.

The Uniform Needs Assessment Instrument (UNAI) was developed to systematically assess the continuing care needs of high-risk older adults in response to the 1986 Omnibus Budget Reconciliation Act. Based on previous studies, a revised UNAI was tested with 103 hospitalized older adults, comparing usual discharge planning with the UNAI. High interrater reliability was obtained. The UNAI had high (> or = 85%) sensitivity and specificity when comparing needs identification on the UNAI with subjects' reported needs at 10 to 14 days after discharge. Overall, the UNAI was more effective (sensitive and specific).

Down by law.

Will legal challenges to health authorities be more successful than before the reforms? Jean McHale and David Hughes report on the case of Rhys Daniels.

Self-harm: what's the problem? A literature review of the factors affecting attitudes towards self-harm.

People who have experienced self-harm report dissatisfaction with the care provided by statutory services. This review provides a critical exploration of the evidence examining the attitudes of healthcare professionals across both mental health and medical settings towards people who self-harm. It also explored in detail service users perceptions of care. A literature search conducted via electronic databases and cross-matching reference lists produced 19 papers that met the inclusion criteria. A thematic analysis of the literature indicated six key areas which contributed to the development of attitudes defined as positive or negative towards people who self-harm. Negative attitudes and experiences of care were associated with lack of education and training, the impact of differences in perceptions of health professionals' role and the influence of clinical culture as well as how self-harm was perceived as a health need. More positive attitudes were associated with a greater understanding of experiences of self-harm and improved training. However, the nature of care reported by service users indicates that there are still significant improvements needed to the attitudes in health settings to ensure they receive a high-quality service.