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Administering involuntary medications to minors to restore competence to stand trial is a decision highlighting the ambiguities of current legal standards and evolving clinical practice. Overriding the objections of incompetent youth requires the application of case law associated with the state’s interests in prosecuting adults, which may not address how the potential side effects of antipsychotic medications impact adolescent development. Parents’ investment in their children’s wellbeing is not formally recognized in such situations; however, parental consent may be given weight by the juvenile court. The two cases presented here describe how conflicts arising from legal and clinical contingencies were resolved.

For people with insulin-dependent diabetes mellitus (IDDM) renal disease represents a life-threatening and costly complication. The EURODIAB IDDM Complications Study, a cross-sectional, clinic-based study, was designed to determine the prevalence of renal complications and putative risk factors in stratified samples of European individuals with IDDM. The present study examined the relationship between dietary protein intake and urinary albumin excretion rate (AER). Food intake was assessed centrally by a standardized 3-day dietary record. Urinary AER was determined in a central laboratory from a timed 24-h urine collection. Complete data were available from 2696 persons with IDDM from 30 centres in 16 European countries. In individuals who reported protein consumption less than 20 % of total food energy intake, mean AER was below 20 μg/min. In those in whom protein intake constituted more than 20 %, mean AER increased, a trend particularly pronounced in individuals with hypertension and/or poor metabolic control. Trends reached statistical significance for intakes of total protein (% of energy, p = 0.01) and animal protein (% of energy, p = 0.02), while no association was seen for vegetable protein (p = 0.83). These findings support the current recommendation for people with diabetes not to exceed a protein intake of 20 % of total energy. Monitoring and adjustment of dietary protein appears particularly desirable for individuals with AER exceeding 20 μg/min (approximately 30 mg/24 h), especially when arterial pressure is raised and/or diabetic control is poor. [Diabetologia (1997) 40: 1219–1226]

Objectives: Repeatability of a dietary method is important in determining the quality of nutritional data. It should be assessed in the population of interest. This study evaluated the repeatability of nutritional data from standardized three-day dietary records, from the clinic-based, cross-sectional multi-centre EURODIAB IDDM Complications Study. Design and Subjects: 15% of the total EURODIAB cohort was randomly selected to test the repeatability of nutritional intake data. Two three-day records, completed three weeks apart, were available for 216 diabetic patients (7.5%) representative of the total cohort. All records were analysed centrally, for intakes of protein (animal and vegetable), fat (saturated fat and cholesterol), carbohydrate, fibre, alcohol and energy. Repeatability was measured comparing mean intakes, determining the proportion of patients classified into the same/opposite quartile by the two three-day records and assessing mean differences with standard deviations (s.d.d). Results: There were no significant differences in mean energy and nutrient intakes between the first and second records. Classification of individuals into the opposite quartile occurred only in 0–4% of patients and overall about 50% (range 44–74%) of the subjects were classified into the same quartiles of intakes. Only small mean differences were found for energy intake (−156 (1633) kJ; 95% confidence limits −375, 63 kJ) and nutrients with s.d.ds comparable to intra-individual variations in the general population. The differences in energy intake were randomly distributed over the range of intakes. Conclusions: The present study demonstrates that standardized three day dietary records show a high degree of repeatability within a short period of time in a sample of European IDDM patients. The good repeatability strengthens the conclusions drawn from the nutritional data in the EURODIAB IDDM Complications Study. Sponsorship: Nutrition Co-ordinating Centre research funds, Diabetes Research Institute at Heinrich-Heine University, Dusseldorf. The EURODIAB IDDM Complications Study was supported by the European Community.

The simulated effects of anthropogenic global warming have become important in many fields and most models agree that significant impacts are becoming unavoidable in the face of slow action. Improvements to model accuracy rely primarily on the refinement of parameter sensitivities and on plausible future carbon emissions trajectories. Carbon emissions are the leading cause of global warming, yet current considerations of future emissions do not consider structural limits to fossil fuel supply, invoking a wide range of uncertainty. Moreover, outdated assumptions regarding the future abundance of fossil energy could contribute to misleading projections of both economic growth and climate change vulnerability. Here we present an easily replicable mathematical model that considers fundamental supply-side constraints and demonstrate its use in a stochastic analysis to produce a theoretical upper limit to future emissions. The results show a significant reduction in prior uncertainty around projected long term emissions, and even assuming high estimates of all fossil fuel resources and high growth of unconventional production, cumulative emissions tend to align to the current medium emissions scenarios in the second half of this century. This significant finding provides much-needed guidance on developing relevant emissions scenarios for long term climate change impact studies. © 2012 Elsevier Ltd.

The care of the patient begins at the moment of injury, and thus, prehospital care is crucial in the overall treatment of the patient. This article discusses the basic principals involved in prehospital care, including the importance of timing, emergency medical training, and resuscitation at the scene. It discusses how the patient is evaluated, the types of transportation available, and the appropriate destination for the patient depending on his or her injuries.

Diabetic nerve damage leads to a wide variety of unpleasant problems: painful sensations, muscle weakness, numb feet predisposing to ulcers, impotence, and a series of distressing effects due to autonomic dysfunction. At present, there is no single effective treatment for the many clinical syndromes--each of which may well have a different cause. Improved blood glucose control must remain the first line of treatment, hopefully to improve nerve structure and function but also to raise the pain threshold. A variety of sedatives and analgesics may also help some patients. Inhibition of the enzyme aldose reductase with resultant interference with neural sorbitol and myo-inositol metabolism would seem to have a good theoretical basis in therapy, and detailed results of long term clinical trials of aldose reductase inhibitors such as sorbinil and tolrestat are awaited with interest. Their role in the future could be more important in prevention of nerve damage than in attempting to reverse gross end-stage nerve destruction. In diabetic subjects with loss of pain sensation in the foot due to neuropathy or in the more advanced state of foot ulceration, intensive educational and clinical efforts should be exerted to prevent this distressing and common problem. In the future, a more detailed understanding of the biochemical abnormalities occurring in nerves and their effect on nerve function, structure and vasculature may lead to more satisfactory and logical treatments for this the commonest single complication of diabetes.

Publisher Summary The changes found in the diabetic nerve have been well documented, the characteristic finding being segmental demyelination, indicating disease of the Schwann cell. Segmental demyelination results in a decrease in nerve fiber diameter that interferes with the saltatory conduction of nerve impulses. The chapter presents a study in which values for mean MCV in nondiabetic and diabetic groups were measured at various times during treatment. There was a striking difference between the diabetic and nondiabetic groups. Upon diagnosis of the disease, MCV was already reduced, the values being comparable to those quoted in the literature for established cases. A significant change had already occurred in the nerves of such diabetics. The mean MCV improved slightly during the first six weeks of treatment, but the improvement was more marked after six months of adequate diabetic control. It was found that the mean values after six months of treatment were well below those of the nondiabetic group. All nondiabetic subjects had an easily recordable sensory action potential, but this was absent in eight diabetic patients.