It is ethical to diagnose a public figure one has not personally examined

Should psychiatrists be able to speculate in the press or social media about their theories? John Gartner argues the risk to warn the public of concerns about public figures overrides the duty of confidentiality; whereas Alex Langford suggests this is beyond the ethical remit of psychiatric practice.Declaration of interestA.O'B is joint debates and analysis Editor of the British Journal of Psychiatry. J.G. is the founder of Duty To Warn, an association of mental health professionals who advocate the president's removal under the 25th Amendment on the grounds that he is psychologically unfit and dangerous.

Intermittent catatonia and complex automatisms caused by frontal lobe epilepsy in dementia

An 82-year-old man was admitted to the emergency department following bizarre behaviour. Police had noticed him driving erratically through his village. He did not stop when instructed, drove slowly home and appeared 'vacant' on questioning. While in hospital, he had approximately 15 episodes of catatonia, involving rigidity, negativism, mutism except echolalia and perseveration, automatic obedience and utilisation phenomena, lasting 2-20 min each. Between episodes, he was amnestic but otherwise well. Electroencephalography demonstrated bifrontal slowing with left-sided emphasis, and captured two focal onset partial seizures with the clinical correlate of the syndrome described above. He improved rapidly on levetiracetam and lorazepam, was discharged and received a diagnosis of dementia by his community mental health team shortly afterwards, based on chronic short-term memory loss, functional decline and MRI changes. This case has implications for our understanding of the neural correlate of catatonia, specifically frontal lobe pathway dysfunction.

Electrocution-induced atrial fibrillation: a novel cause of a familiar arrhythmia

A previously fit and well 40-year-old man presented to the emergency department with palpitations after suffering an 11 000 volt electrical shock from overhead power cables through a mobile crane which he was operating. His ECG demonstrated the presence of new atrial fibrillation at a rate of 80 beats per min. He was haemodynamically stable, and had otherwise only sustained a small exit burn to his left great toe. Routine blood tests including creatine kinase and troponin T were normal. A bolus of intravenous flecainide failed to restore sinus rhythm, but an amiodarone infusion was successful. An electrical shock is a rare cause of atrial fibrillation. There is no consensus over optimal medical management. Numerous treatment plans have been previously employed with varying degrees of success.

Immunohistochemical assessment of the tumour-associated epitopes CD44v6 and E48 in tumour-free lymph nodes from patients with squamous cell carcinoma in the head-neck region

We examined immunohistochemically 370 tumour-free lymph nodes from 41 patients with a head and neck squamous cell carcinoma (HNSCC) to clarify whether the tumour-associated epitopes CD44v6 and E48 are suitable for adjuvant postoperative immunotherapy. All the positively immunostained cells found were single cells. CD44v6+ cells were found in 55% of the lymph nodes, with their numbers increasing in pN>0-patients (62%). Only pN>0-patients had abundant to massive CD44v6+ cells. A comparison with mononuclear cells in lymphatic tissue from control patients suggested a similarity with activated T-cells. In the 41 cancer patients there were significantly fewer lymph nodes with E48+ cells (11%), but the number of E48+ cells increased in pN> 1-patients (29%) with predominantly abundant E48+ cells. We conclude from the comparison with the epithelial marker EMA that the E48+ single cells are epithelial in origin. Only a specific E48 peptide sequence appears suitable for adjuvant immunotherapy in patients with head-neck tumours.

Treatment of squamous cell carcinomas of the floor of the mouth and tongue by interstitial high-dose-rate irradiation using iridium-192

The results are presented of afterloading high-dose-rate-radiation with iridium-192 in 34 patients with squamous cell carcinomas of the floor of the mouth and tongue. Some patients were also treated surgically or given percutaneous radio- or chemotherapy. At the time of diagnosis, 28.0% had a T2 tumour, 41.9% a T3 tumour and 30.1% a T4 tumour, 41.2% had positive lymph nodes and 2.9% distant metastases. The response rate was 64.7%, 26.5% of which were complete remissions and 38.2% partial remissions. In 61.8% of cases, the tumour was recurrent and responded with a rate as high as 57.2%, 23.9% of which were complete remissions and 33.3% partial remissions. Survival times were dependent upon therapy results. The mean survival of patients with complete remission was 40.3 months, with partial remission 16.1 months as opposed to 7.2 and 3.5 months respectively in patients showing no change or progressive disease. It can be concluded that afterloading therapy using high-dose-rate-radiation with iridium-192 achieves good palliative results and should be looked at as a supplementary treatment modality for squamous cell carcinomas of the floor of the mouth and tongue.

Otoplasty: a combined approach to different structures of the auricle

A technique for otoplasty is presented, which combines the advantages of different methods. The procedure includes a dorsal skin excision, a cartilage incision at the border between the concha and scapha, scoring of the crus superior on the anterior side, and if necessary a reduction of the conchal height and modification of the position of the cauda helicis by cartilage excision. The results of the treatment of 526 ears in 312 patients are retrospectively analysed by a patient questionnaire and a chart review.

[Improving the facial profile by implant supported dentures]

Forty toothless patients were examined over a period of 3 years for the purpose of improving the face profile after integration of implant-supported, removable full dentures. The data before the treatment were related to the corresponding normal values. The same parameters were measured 3 months after the prosthetic treatment was finished and were compared to the preoperative data. In all parameters we saw an significant increase in the normal value rate.

The infrahyoid flap. A technique for defect closure in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall

The surgical technique, indications, and results of the infrahyoid muscle flap are presented. This flap is fed by the superior thyroid vessels and innervated by the ansa cervicalis. The flap is indicated in case of medium-sized defects in the floor of the mouth, the tongue, the buccal mucosa, and the lateral pharyngeal wall. The advantages of the technique presented include the rapid flap elevation close to the original operating field, the ability to use the motor capability of the flap, and the ability to combine it with other local flaps--for example, the platysma flap. This technique appeared to render excellent function for swallowing and speech. Safe flap grafting is possible only if the internal jugular vein is preserved.

3D-computed tomography: a new method for the evaluation of fetal cranial morphology

This study is the first presentation of three-dimensional computed tomography (3D-CT) for the in vitro evaluation of the prenatal human cranium. The study was based on CT examinations from 26 aborted normal fetuses between 10 and 25 weeks gestational age. Incremental coronal and transverse CT slices of 1 mm thickness and a threshold segmentation algorithm were used to generate 3D-CT reconstructions (surface-shaded display, SSD) of the cranial bones similar to their anatomical appearance. The threshold of the segmentation algorithm was selected after comparison of the 3D-CT images generated with varying thresholds and graphically reconstructed histological serial sections of particular sutures in five specimens. The variation of the segmentation threshold resulted in alterations of the bone sizes and suture widths. However, 3D-CT images allowed sensitive identification of the cranial ossification centers and accurate evaluation of the bone topography. Cutting and rotating procedures made it possible to evaluate all imaged bones in arbitrary views without disturbing superpositions, thus making isolated examinations of particular macroscopic sections of the specimens unnecessary. In conclusion, 3D-CT of the fetal cranium promises to be of considerable help in the evaluation of prenatal cranial development.

Abdominal aortic aneurysm pathway: outcome analysis

The current and future health care environment demands that health care providers place increased emphasis on the achievement of acceptable patient outcomes within an effective timeline and with more efficient use of resources. Clinical pathways provide a tool that defines the processes and activities that must occur to meet these goals. The purpose of this study is to describe a process for analysis of clinical and fiscal outcomes of a clinical pathway initiated at an academic medical center for elective abdominal aortic aneurysm repair. Patients were monitored throughout their preoperative and postoperative course to identify and trend variances, assess opportunities for improved resource use, and determine patient/family satisfaction. Data were collected by use of multiple electronic databases available within the university information systems network and analyzed to determine impact on patient charges, treatment course, and length of stay. Outliers were profiled as a means to identify prognostic indicators or establish a high preoperative risk. Results of a sample of 42 patients revealed a reduction in gross charges by 33% per case in comparison to the baseline data obtained before pathway implementation. This study will describe the rationale and process for instituting changes in resource use, such as diagnostic testing and blood use. Clinical outcomes and related nursing implications will also be discussed, including preoperative management, a streamlined same-day admission process, and factors associated with prolonged stay in the intensive care unit. Finally, strategies designed to enlist the support and participation of nurses, physicians, and other health team members will be discussed.

Human immunodeficiency virus-associated squamous cell carcinomas of the head and neck presenting as oral and primary intraosseous squamous cell carcinomas

Six cases of squamous cell carcinoma arising in the head and neck of patients infected with the human immunodeficiency virus are described. This article reports the first two cases of primary intraosseous squamous cell carcinoma associated with infection with human immunodeficiency virus. Clinical presentation, results of imaging studies, histologic characteristics, therapies applied, and the clinical follow-up are described in detail for each of the six cases. These data are evaluated through a review of the current literature.

Gingival and periodontal alterations associated with infection with human immunodeficiency virus

Various changes may occur in the gingiva and/or the periodontium as an expression of existing infection with human immunodeficiency virus. Thus, periodontal disease, characterized by unusual course, progress, and resistance to treatment, may occur with increased frequency. Clinically, pseudomembranous or erythematous (atrophic) forms of candidiasis or so-called papillary hyperplasia may be caused by ubiquitous fungi. Although Candida albicans infections arise frequently on the cheek, the palate, the dorsum of the tongue, and the corner of the mouth (angular cheilitis), gingivo-periodontal manifestation is more unusual. Because of the existing immune defect, infection with or reactivation of various viruses may occur. Recurrent, progressive destructive ulcerations may be caused by herpes simplex virus 1 or 2, but apparently limited ulcerations may be an expression of a disseminated cytomegalovirus infection. Oral Kaposi's sarcoma appears initially as bluish or reddish spots; these may transform during the course of the disease into blue, occasionally lymphoma-like or lymphangioma-like, exophytic tumors.

Distribution of immunocompetent cells in oral Kaposi's sarcoma (AIDS)

Fifteen biopsy specimens of oral AIDS-associated Kaposi's sarcoma (KS), 19 biopsy specimens of uninvolved oral mucosa of HIV-seropositive patients (HIV+) and 22 biopsy specimens of oral mucosa of HIV-seronegative persons (HIV-) were analysed for the distribution of CD4+ and CD8+ lymphocytes and HLA-DR+ cells. The results were statistically evaluated. According to their clinical appearance KS were classified as flat lesions (n = 10) or exophytic tumours (n = 5). KS lesions of both clinical groups as well as uninvolved mucosa of HIV+ patients revealed infiltration with CD4+ cells. In flat, patch-like KS there was a marked increase of CD8+ cells compared to HIV- mucosa, while their numbers decreased in later tumour stages. In both, flat and exophytic KS the number of HLA-DR+ cells was significantly higher than in uninvolved mucosa of HIV+ and HIV- persons. These findings may reflect the local influence of KS growth factors on the inflammatory reaction in the setting of systemic immunosuppression.

Immunocytochemical detection of herpes viruses in oral smears of HIV-infected patients

Cytologic smears (CS) were taken from the lateral border of the tongue of HIV-seropositive patients (HIV+) (n = 39) and of seronegative controls (HIV-) (n = 19) and examined by immunocytochemistry (APAAP) and in situ hybridization (ISH) (biotinylated DNA probes) for the presence of viral antigens/DNA of EBV and CMV. While none of the HIV controls showed positive results for EBV antigen, 61% (APAAP) resp. 79% (ISH) of oral epithelial cells in the group of HIV+ patients were EBV-positive. While all CS taken from areas with the clinical diagnosis of hairy leukoplakia (HL) were EBV positive (APAAP and/or ISH), the detection of EBV in CS from uninvolved oral mucosa seemed to be associated with the later development of HL. In the group of HIV+ patients the detection rate for CMV was about five times (APAAP) resp. three times (ISH) higher than in HIV- persons. This non-invasive technique seems to be a valuable tool to screen for viral antigens/genomes.

Distribution of cytokeratins in oral cytological smears of HIV-infected patients

Cytological smears (CS), taken from the lateral border of the tongue of HIV-seropositive patients (HIV+) (n = 34) and of seronegative controls (HIV-) (n = 16), were examined by means of immunocytochemistry (APAAP) for the distribution patterns of different cytokeratins and MHC class II antigens. Compared with HIV- patients in CS of HIV-infected patients cornification associated cytokeratins 10/11 were increased, while the number of keratinocytes positive for cytokeratins 13/16 was comparable in both groups. Expression of simple epithelial cytokeratins 19, rarely observed in CS of HIV- patients, was a frequent findings in CS of HIV+ patients. Keratinocytes positive for MHC class II antigens were observed in CS of 12/34 HIV+, while all control CS were negative. In the group of HIV+ patients no correlation was found between the clinical presence of HL and the expression of cytokeratins or class II antigens. The altered distribution of cytokeratins may reflect local responses to proliferative stimuli or local inflammation due to the presence of microbial antigens or may occur as a general unspecific reaction in the setting of systemic viral infection. This non-invasive technique seems to be a valuable tool to determine the proliferation rate of oral epithelial cells.

Primary intraosseous AIDS-associated Kaposi's sarcoma. Report of two cases with initial jaw involvement

AIDS-associated Kaposi's sarcoma (KS), which in 80% of cases occurs in the oral cavity, usually presents with characteristic clinical features such as brown-bluish pigmented macules or tumorous lesions. In later stages the tumor, most probably originating from the vascular endothelium, may secondarily induce erosion of the underlying bone. The primary, intraosseous occurrence of KS has prompted the present 2 case reports. The tumor presented as extensive, diffuse osteolysis within the mandible without causing clinical symptoms. Although rare, intraosseous KS must be included in the differential diagnosis of isolated bone defects in HIV-infected patients.

Dental care of HIV positive patients at Berlin clinic

During an exchange programme at the "Freie Universität Berlin" the authors worked on the department of Oral Surgery. Their work consisted of treating HIV positive patients. A report on their experiences is given.

Malignant lymphomas in HIV-seropositive patients. Frequency, features, and prognosis. Report on 31 cases

In a random HIV-seropositive population, malignant lymphomas were diagnosed in 31 patients, of whom 24 (77%) had non-Hodgkin lymphoma (NHL) and 7 (23%) Hodgkin lymphoma (HL). The prevalence of NHL among AIDS patients was 8% (23/279 cases), with a prevalence of 17% among autopsied patients (16/96 cases). No patient with HL had AIDS at the time of diagnosis. In 7 of 23 AIDS patients with NHL (30%) the diagnosis was made only post mortem; among these were all 5 patients with primary CNS NHL. Median survival from the time of diagnosis was 1 month for patients with NHL and 3 months for those with HL. In individual patients, survival for several years may be possible with chemotherapy. Certain patients with NHL appear to benefit from intensive chemotherapy with a combination of methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOPB protocol). Appropriate, therapeutic strategies taking into account the patients' individual conditions, including the overall prognosis, urgently requires development. Metastatic CNS involvement, which was the primary cause of death in 5 of 11 patients with NHL (45%) receiving chemotherapy, represents a serious limitation to successful treatment.

Expression of proteins encoded by Epstein-Barr virus trans-activator genes depends on the differentiation of epithelial cells in oral hairy leukoplakia

The Epstein-Barr virus (EBV) immediate early gene product BZLF1 was localized by indirect immunofluorescence to the cytoplasm of the basal epithelial layer at the lateral border and dorsum of tongue in human immunodeficiency virus-infected and -seronegative patients. Two biopsies of oral hairy leukoplakia revealed a sporadic cytoplasmic staining of the BHRF1 and BRLF1 gene products in the basal epithelial layer. The widespread presence of BZLF1 in the basal epithelial layer indicated that this cell layer contained EBV DNA and was probably directly infected by EBV. Nuclear localization of the immediate early and early gene products BZLF1, BHRF1, BRLF1, and BMLF1 was limited to oral hairy leukoplakia in human immunodeficiency virus-seropositive patients and revealed a codistribution with the virus capsid antigen. Our results indicate that the epithelium of the tongue is a potential reservoir for EBV and that in heavily immunocompromised patients EBV may move from the cytoplasm to the nucleus with increasing differentiation and be coactivated there during the terminal differentiation of epithelial cells at the lateral border and dorsum of tongue.

Oral manifestations of AIDS-associated non-Hodgkin's lymphomas

While B-cell lymphomas are frequently found in AIDS patients, reports on oral manifestations are rare. Among a group of 465 HIV-infected patients 5 presented with primary oral manifestations of a malignant B-cell lymphoma. The primary site of manifestation was the maxilla in 3 cases and the mandible in 2 cases. Based on the histological and immunohistochemical examination the tumors were differentiated as Burkitt's lymphoma (n = 1), as anaplastic large cell (ALC) lymphoma of the B-cell type (n = 1), as high-grade non-Hodgkin's lymphoma not classifiable according to the Kiel classification (n = 1), as immunoblastic-plasmoblastic lymphoma (n = 1), and as centroblastic lymphoma (n = 1). Serum samples were negative for HTLV-I antibodies in 5/5 cases.

[Guided bone tissue regeneration--a clinical and histological pilot study]

The aim of the present investigation was to study whether a technique based on the principle of guided tissue regeneration is able to generate new osseous tissue around osseointegrated implants in humans. 14 titanium implants (IMZ) were inserted in 4 patients. The fixtures were modified by hydroxyapatite (HA) or titanium discs measuring 3 mm in height, which were screwed onto the implants. The modified implants were inserted in such way, that the discs were above the level of the alveolar bone. 3 modalities of treatment were performed. In group I HA granules were placed on the bone around the disc-implant-constructions and completely covered by an ePTFE membrane in order to create a space for ingrowth of bone-derived cells. In group II the membrane alone was placed and in the control group HA granules alone were used. After complete closure of the flap and 2-4 months of healing, the membranes including the generated tissue and the discs were removed and processed for histological examination. Clinical results demonstrated that in group I hard tissue had formed underneath the membrane, which strongly adhered to alveolar bone. Histological examination revealed new formation of trabecular bone. When the membrane alone was used, the created space was almost completely reduced during healing and no significant tissue formation had occurred. The greatest clinical problem was flap dehiscence over the membrane. In the control group the HA granules and discs were encapsulated in connective tissue. Limited by the small number of sites, the study indicates that a membrane technique according to the principle of guided tissue regeneration promotes new bone formation around osseointegrated implants in humans.

[HIV-associated periodontal lesions]

During HIV infection different lesions may occur in the area of the gingiva and/or the periodontium. An increased frequency and severity of periodontal diseases has been observed. Different forms of Candida albicans infection have been clinically characterized as pseudomembranous, erythematous (atrophic) or hyperplastic form or as papillary variant. While infection with Candida albicans may occur frequently in other areas of the oral mucosa, candidiasis of the gingiva seems to be quite rare. Due to the underlying immunodeficiency, HIV-infected patients are prone to infection with and/or reactivation of different viruses, which may cause oral lesions as well. Recurrent progressive ulcerations may occur due to herpes simplex virus 1/2, while ulcerations with a punched-out appearance may result from disseminated CMV infection. Oral Kaposi's sarcoma may clinically present as bluish or red spots, which may increase into exophytic tumors during the progress of the disease.

Cytomegalovirus associated oral ulcerations in HIV-infected patients

Oral ulcerations associated with disseminated cytomegalovirus (CMV) infection were observed in four patients with AIDS manifestations showing low CD4 counts. Virus cultures of urine and saliva samples were positive for CMV in all cases. The lesions were characterized by a punched-out appearance, non-indurated borders, low bleeding tendency and lack of inflammatory wall. Light microscopy revealed granulation tissue containing "owl's eye" like cells in all specimens. Presence of CMV was confirmed by immunohistochemistry and in situ hybridization. The ulcerations were infiltrated with T-lymphocytes of the helper, suppressor and cytotoxic subset, most were positive for HLA DR. Despite the local invasion with immunocytes and high serum titers of serum antibodies the patients experienced progressive CMV disease.

Do nurses consistently document incontinence?

1. Urinary incontinence is inconsistently documented on medical records of nursing home residents. 2. Documentation of urinary incontinence by professional nurses may be improved by changes in organizational factors such as staffing, policy implementation, and staff education. 3. Forms that employ cue words for eliminative status show more documentation of continence status than forms that have an open format. 4. Evaluation of changes in nursing practice in the nursing home setting can benefit from nursing studies that employ an organizational perspective.

Ultrastructural findings in oral hyperpigmentation of HIV-infected patients

Oral hyperpigmentation has been observed in six HIV-infected patients, in two of whom systemic medication (ketokonazole, clofazimine) was supposed to be etiologically involved. Histologically, pigment was found in epithelial basal cells and particularly in subepithelial connective tissue. Ultrastructurally, the presence of premature melanosomes in subepithelial keratinocytes was of interest. Stimulation of melanocytes during HIV infection may occur in association with immunopathologic changes in the oral mucosa.

Oral hairy leukoplakia: observations in 95 cases and review of the literature

Oral hairy leukoplakia (HL) was observed in 25.4% of 373 HIV-seropositive patients (n = 95). 87 were men of an average age of 37.1 yr, 8 were women (30.3 yr). 71.6% of the patients were male homosexuals. At initial diagnosis of HL the majority of cases was classified as CDC IVc1 (45.3%) and CDC II (22.1%). Average CD4/CD8 ratio (n = 19) was 0.24 with a range of 0.04-1.0. Thirty biopsies of HL revealed some of the histologic features thought to be characteristic. In only 20 of 30 biopsies EB-virus-specific-capsid antigen was detected. The problems of clinical and histological diagnosis of HL are discussed. Further strict criteria are necessary in order to define HL more distinctly.

Regression of oral Kaposi's sarcoma in a case of AIDS on zidovudine (AZT)

A case with oral Kaposi's sarcoma (KS) is reported that regressed during therapy with Zidovudine (AZT) which was started 5 months after the first dermal and oral tumours were noted. After 6 months of treatment the absolute number of T-helper cells had increased from 54/microliters to 232/microliters and the ratio of T-helper to T-suppressor cells from 0.15 to 0.3. During the same time the lesions of KS on the gingiva, uvula and the body as well as the face disappeared. The lesion of KS on the hard palate regressed.

Oral hyperpigmentation in HIV-infected patients

Six cases of oral hyperpigmentation in HIV-infected patients are reported. While in two patients the lesions could be related to systemic clofazimine or ketoconazole therapy, in the other patients the cause remained unknown. Clinically, the pigmentations were characterized by a sudden onset and the appearance of well-defined, brown-black macules in the buccal mucosa, the gingiva, the hard palate, or the lateral borders of the tongue. In one patient, longitudinal hyperpigmented striae were observed on all fingernails and toenails. Histologically, hyperpigmentations associated with systemic medication revealed accumulation of melanin in phagocytes and extracellularly within the connective tissue. In those lesions with unknown cause, melanin was restricted to keratinocytes of the basal cell layer or to extracellular foci in the lamina propria. The clinical and histologic findings, as well as differential diagnosis, are discussed.

Ultrastructural findings in clinically uninvolved oral mucosa of patients with HIV infection

Twelve biopsies of clinically normal oral mucosa taken from HIV seropositive patients have been investigated by means of light- and electron microscopy. Vascular abnormalities were found in all biopsies, regardless of the clinical stage of the HIV infection. In particular slit-like vascular channels, sparseness of intercellular junctions and swollen, protruded endothelial cells with an increased quantity of Weibel-Palade bodies were noticed. These findings were similar to those described in lesions of early stage Kaposi's sarcoma.

Immunohistochemical detection of HIV structural proteins and distribution of T-lymphocytes and Langerhans cells in the oral mucosa of HIV infected patients

Seventeen biopsies taken from oral mucosa of HIV infected patients were analysed for the distribution of CD4+/CD8+ T-lymphocytes and Langerhans cells. The results were evaluated statistically. An increase in the absolute number of CD4+ and CD8+ cells in HIV infected patients without clinical symptoms, ARC or AIDS was seen in the connective tissue stroma when compared with normal oral mucosa from sero-negative patients. However, the ratio between CD4+/CD8+ cells was decreased due to the disproportionate increase of CD8+ cells. These findings did not show statistical correlation with the clinical status of the infection. In contrast to the increase in absolute number of CD4+/CD8+ cells the number of Langerhans cells was unchanged when compared with the control group. Using four different monoclonal antibodies against virus structural proteins (2 X anti p24, gp41, gp120) two of 26 patients showed labelled cells in consecutive sections in the same connective tissue areas. It was assumed that latently infected mononuclear cells invaded the oral mucosa together with uninfected cells of the cellular immune system.

Ultrastructural and immunohistochemical findings in oral hairy leukoplakia

Three cases of HL from the lateral border of the tongue of male homosexual AIDS patients were investigated by thin section electron microscopy. Keratinocytes contained condensed chromatin in their pyknotic nuclei and a few organelles in the oedematous cytoplasm. Chromatin was in close association to the nuclear membrane and showed a punched-out appearance. Particles typical of the herpes virus group were abundant in the upper two thirds of the epithelium in all three cases. Virus particles were seen frequently in the nuclei of the ballooned keratinocytes, but rarely in cells containing Candida albicans. Viral nucleocapsids were observed budding at the inner nuclear membrane, thereby acquiring the prospective viral envelope. Complete, enveloped virions were found in the endoplasmic reticulum and in the extracellular space. These virions were identified immunohistochemically as Epstein-Barr virus (EBV) using two monoclonal antibodies directed against EBV capsid and membrane antigen, respectively. Candida albicans was observed in the stratum corneum and in the upper layer of the stratum spinosum. Special cytoplasmic tubular structures arranged in parallel bundles were found in koilocytotic cells in addition to characteristic membrane structures composed of undulating convoluted membranes. Epithelial basement membranes were always intact.

Forensic psychiatric assessments in the Northwest territories

This paper is an analysis of the psychosocial and forensic factors leading to legal referrals to a northern mental health service. It was found, not surprisingly, that most criminal acts were associated with alcoholism, personality disorders, and low socioeconomic status. Young native males figured prominently in both violent and property crimes. Rape offenses and major psychopathology appeared to be more common among Inuit referrals. The influence of rapid culture change and psychosocial and biologic predisposition to the deleterious effects of alcohol were considered relevant criminogenic factors. It was also felt that the high Inuit referral rate might have been related to their willingness to accept consultation and discuss symptoms of mental illness.