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People with borderline personality disorder (BPD) are typically excluded from assertive community treatment (ACT) teams, the intensive model that typically serves people with serious psychotic and mood disorders. Nevertheless, many people with BPD are on ACT teams for clinical comorbidity or other reasons. Suitability and ability of ACT to provide their care is understudied. Our scoping literature review shows a limited body of research, with strong but mixed opinions on this dilemma, but notable incorporation of training and skills (e.g., dialectical behavioral therapy) into ACT may improve care for this population whose presence on ACT teams is a clinical reality.

Assertive Community Treatment (ACT) teams provide the most intensive care for patients with serious mental illness. This online study surveyed the 88 ACT and Flexible ACT (FACT) teams in Ontario, Canada (144/232 surveys, 62.1%) during the height of Covid-19 in 2021, and qualitative thematic analysis on impact of team function and patient outcome showed challenges of teams switching to virtual care, reduced psychosocial services, division to smaller groups, staff redeployment, having unequal compensations, and exacerbated regional differences; there were also increased patient stress, loneliness, hospital and ER visits, substance use and related deaths, and police/crisis team involvement. There was limited morbidity related to actual Covid-19; and positive adaptations included observed independence and resilience, increased interdependence with community partners, and new communication formats.

Assessment of a patient’s capacity to make treatment decisions and working with the wishes of a patient with mental illness against the best medically indicated plan is a complex and dynamic task. It is particularly challenging when the course of deterioration of the illness is meandering and slow, and the time horizon for recovery is uncertain, providing no clear point of entry for definitive crisis intervention. High-impact decisions concerning body integrity, such as the amputation of a leg, further complicate the task. To highlight these challenges and complexities, we present the case of a man who suffered from schizophrenia, with a worsening diabetic foot ulcer and suboptimal acceptance of proper wound care. The patient died as a result of his refusal of a proposed amputation to address his life-threatening infection. Medical system and cultural issues are also considered.

Recognizing futility is a challenging aspect of clinical medicine, particularly in psychiatry. We present a case of a man who suffered from clozapine-resistant schizophrenia. His illness was characterized by prominent religious delusions and severe self-starvation. Neither the intensity of his symptoms nor his quality of life improved with available psychiatric interventions, and he experienced significant iatrogenic harms from enforced treatments. Recognizing clinical futility, in collaboration with a diverse multidisciplinary team, and making a clear shift to a patient-centered palliative approach allowed the patient’s treatment team to prioritize his autonomy and subjective meaning in his final months. Such approaches are understudied in psychiatry and warrant greater attention.

Psychiatry as a field and undergraduate psychiatry education (UPE) specifically have historically been in the periphery of medicine in China, unlike the relatively central role they occupy in the West. During the current economic reform, Chinese undergraduate medical education (UME) is undergoing significant changes and standardization under the auspices of the national accreditation body. A comparative study, using Bereday’s comparative education methodology and Feldmann’s evaluative criteria as theoretical frameworks, to gain understanding of the differences and similarities between China and the West in terms of UPE can contribute to the UME reform, and specifically UPE development in China, and promote cross-cultural understanding. The authors employed multi-sourced information to perform a comparative study of UPE, using the University of Toronto as a representative of the western model and Guangxi Medical University, a typical program in China, as the Chinese counterpart. Key contrasts are numerous; highlights include the difference in age and level of education of the entrants to medical school, centrally vs. locally developed UPE curriculum, level of integration with the rest of medical education, visibility within the medical school, adequacy of teaching resources, amount of clinical learning experience, opportunity for supervision and mentoring, and methods of student assessment. Examination of the existing, multi-sourced information reveals some fundamental differences in the current UPE between the representative Chinese and western programs, reflecting historical, political, cultural, and socioeconomic circumstances of the respective settings. The current analyses show some areas worthy of further exploration to inform Chinese UPE reform. The current research is a practical beginning to the development of a deeper collaborative dialogue about psychiatry and its educational underpinnings between China and the West.

This study examined the clinical and social characteristics of clients (N= 110) in a retrospective chart review from a 1-year continuous psychiatric consultation series in the Inuit community of Iqaluit, Nunavut. Interpersonal and socio-environmental stressors were found to be unusually extensive and the primary precipitators of psychiatric crises such as suicide attempts. Negative health determinants such as unemployment, overcrowding, domestic violence, substance abuse, and legal charges were also prevalent. Psychiatric issues in the Arctic appear deeply interwoven with interpersonal, socioeconomic, and societal changes; effective community mental health services must address a broad spectrum of psychosocial issues beyond the medical model.

Summary A "picture book" of surface potentials, Laplacians, and magnetic fields due to distributed, neocortical sources is presented. The mathematically simulated data is based on 4200 current sources at the macrocolumn scale. Estimated scalp surface maps are based on the three-concentic spheres model of the head. Emphasis is placed on the effects of sampling with a limited number of electrodes, the choice of reference electrode, and the use of the spline Laplacian to improve spatial resolution. The spline Laplacian is applied to median and ulnar nerve somatosensory evoked potentials and to auditory evoked potentials including P300. Substantial improvement in spatial resolution over conventional methods is obtained. The implementation of practical high resolution EEG systems based on the spline Laplacian is considered.

Summary A three dimensional digitizer was used to locate 62 positions on an electrode cap placed on the heads of nine subjects. Nonlinear regression methods were used to obtain the best fit sphere, ellipsoid, and perturbed ellipsoid. RMS errors varied from approximately 1 cm to 2 mm, depending on subject and surface chosen. The spherical coordinates of the standard 10/20 electrodes on best fit spheres were obtained. A method to estimate ellipsoid axes using only three standard EEG head dimensions with an ordinary tape measure is derived from the data. The results have at least two potential applications: the forward/inverse problem in EEG and MEG, and the estimation of surface Laplacians from EEG data.

Summary A study of skull thickness and resistivity variations over the upper surface was made for an adult human skull. Physical measurements of thickness and qualitative analysis of photographs and CT scans of the skull were performed to determine internal and external features of the skull. Resistivity measurements were made using the four-electrode method and ranged from 1360 to 21400 Ohm-cm with an overall mean of 7560±4130 Ohm-cm. The presence of sutures was found to decrease resistivity substantially. The absence of cancellous bone was found to increase resistivity, particularly for samples from the temporal bone. An inverse relationship between skull thickness and resistivity was determined for trilayer bone (n=12, p<0.001). The results suggest that the skull cannot be considered a uniform layer and that local resistivity variations should be incorporated into realistic geometric and resistive head models to improve resolution in EEC Influences of these variations on head models, methods for determining these variations, and incorporation into realistic head models, are discussed.

Fractures of the proximal tibial epiphysis are rare, representing less than 3% of all epiphyseal and 1% of all physeal injuries in adolescents. Bilateral injuries are extremely rare. The specific anatomical and histological features of the proximal tibial epiphysis make it vulnerable to a specific fracture pattern that occurs when the tensile force of the quadriceps is greater than the fibrocartilaginous tissue underlying the tibial tuberosity. We report the first case to our knowledge of a 12-year-old boy who sustained simultaneous bilateral tibial avulsion fractures on the background of a previous conservatively managed unilateral tibial tuberosity avulsion fracture. We report this case for its uniqueness and as an educational review of the anatomy, the mechanism of injury, and the development of classifying these fractures and discussion of the stages of the growing physis that determine the treatment approach.

Accurate diagnosis and subclassification of lymphoma is essential as it directly dictates therapy and underpins translational research. We audited all cases of lymphoma diagnosed histologically at Royal North Shore Hospital during the calendar year 2010. 191 cases were definitively diagnostic of lymphoma and 28 cases were reported as non-diagnostic but lymphoid or atypical lymphoid proliferations. There were 67 (35%) diffuse large B-cell lymphoma, 40 (21%) follicular centre cell lymphoma, 21 (11%) marginal, seven (4%) T-cell and five (3%) mantle. There were 27 (14%) cases of Hodgkin’s lymphoma. One hundred and five lymphomas were diagnosed in nodal tissue with the most common site being the neck nodes (29%). We encountered 11 cases of CNS lymphoma representing 6% of all lymphoma diagnoses. Core biopsy was performed in only 92 (43%) of cases but was definitively diagnostic of lymphoma in 82 (89%). This high rate of positive core biopsy confirms its role in diagnosis.