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PubMed1999

Munchausen syndrome by proxy and intra-alveolar haemosiderin.

Munchausen syndrome by proxy is characterised by the invention of a false history and/or the deliberate inducement of a factitious illness by parents in their child. First reported as a disorder of mothers, this syndrome is now recognised to have male perpetrators. One of the most common characteristic presentations is with the child allegedly suffering repeated apnoeic attacks. These are in fact deliberately induced episodes of upper airway obstruction. The children of these parents are at great risk of serious harm or death if not recognised. The identification of smothering at autopsy is fraught with difficulty and the presence of intra-alveolar haemosiderin has been claimed to be a marker of previous smothering. A case of Munchausen syndrome by proxy is presented where there were deliberate acts of repeated partial smothering and where the finding of intra-alveolar haemosiderin at autopsy provided additional supportive evidence of smothering.

Airway Obstruction↗
PubMed2004

Validation of the 'Vienna List' as a proxy measure of quality of life for geriatric rehabilitation patients.

The reason for the study was to investigate the discriminative, content- and criterion-related validity of the 'Vienna List', a newly developed proxy-rating measurement for quality of life in very old and severely demented persons. The total population of patients of a geriatric rehabilitation clinic of one year (from November 2001 to October 2002; n = 687) was evaluated at admission and discharge by means of this proxy rating method together with the mini mental state examination, the timed up and go test, the Tinetti measure, the Barthel Index, and the Katz activities of daily living list. Differences, mainly on factors communication, mobility, aggression, and negative affect, appeared between seven diagnostic groups as well between several care-related categories and destination after discharge. The five factors of the measurement explained a significant amount of variance with a high specificity and more than 50% of the Barthel Index scores. The 'Vienna List', originally developed for the assessment of quality of life in severely demented patients, proved to be a useful, differentiating, less time-consuming and practical tool for the documentation of the outcome of geriatric inpatient rehabilitation, as well.

Activities of Daily Living↗
PubMed2006

Commentary on Cox CL, Lensing S, Rai SN et al. Proxy assessment of quality of life in pediatric clinical trials: application of the Health Utilities Index 3. Qual Life Res 2005; 14: 1045-1056.

The paper by Cox et al. offers an important potential for informing designs of future studies. The rates of missing measurements in the study are much greater than those reported by other investigators. This is not surprising because the nurse assessors were restricted explicitly by the study protocol from collecting required information, had little contact with many of the patients, and some had a poor understanding of the measurement system. Standard multi-attribute system questionnaires, such as the one used in the Cox et al. study, have been designed carefully and require assessments of aspects of health that are not always readily observable (e.g. emotional status). There is an abundance of published evidence, from studies conducted around the world, of acceptable measurement properties for these instruments. However, the published evidence also indicates that measurement properties are compromised with the use of proxy assessors who have little day-to-day knowledge of patients. We conclude that the Cox et al. study results provide evidence that multi-attribute system assessments should be elicited from patients themselves or, failing that, from proxy assessors known to be well-informed about the patients' capacity on all relevant attributes.

Clinical Trials as Topic↗
PubMed2004

Diagnostic, expanatory, and detection models of Munchausen by proxy: extrapolations from malingering and deception.

OBJECTIVE: The overriding objective is a critical examination of Munchausen syndrome by proxy (MSBP) and its closely-related alternative, factitious disorder by proxy (FDBP). Beyond issues of diagnostic validity, assessment methods and potential detection strategies are explored. METHODS: A painstaking analysis was conducted of the MSBP and FDBP literature as it relates diagnostic and assessment issues. Given the limitations of this literature, extrapolations were provided from the extensive theory and research on malingering as a related response style. RESULTS: Diagnostic formulations for both MSBP and FDBP de-emphasize the clinical characteristics of the perpetrator. In the case of FDBP, inferential judgments about motivation (e.g., adoption of a sick role) are challenging on conceptual and clinical grounds. When explanatory models from malingering are applied, most research has focused pathogenic models, often allied with psychodynamic thought. Finally, clinical methods for the assessment of MSBP and FDBP are not well developed. CONCLUSIONS: Refinements in the conceptualization of MSBP and FDBP can be provided through prototypical analysis. Drawing from malingering research, explanatory models should be expanded to include adaptational and criminological models. Finally, detection strategies for MSBP and FDBP must be formally operationalized and rigorously validated.

Adult↗
PubMed2005

A case of Munchausen syndrome by proxy with subsequent suicide of the mother.

Munchausen syndrome by proxy is a subtle and difficult to diagnose form of child abuse in which the carer (usually the mother) simulates, manipulates or produces symptoms of illness in the victim. In most cases the detrimental effect is caused by applying foreign substances or by airway obstruction. In the presented case a 20-month-old girl developed a spreading soft-tissue infection resistant to treatment on the left upper arm after vaccination, which required a number of surgical interventions. Repeatedly, microorganisms from the intestinal flora were isolated from the wound secretion. After the girl suffered respiratory and circulatory arrest, which required resuscitation measures, chemical toxicological tests revealed not medically prescribed benzodiazepines in serum and urine. When the mother, a trained nurse, was confronted with the allegation to have manipulated the symptoms of the illness she committed suicide. The forensic autopsy of the suicide produced numerous hints suggesting chronic self-damaging behaviour described as Munchausen syndrome. This case shows a number of manipulation forms with the maintenance of a chronic skin and soft tissue infection belonging to the rarer forms of inflicting damage to the child. It also illustrates that confrontation with the allegation of Munchausen syndrome by proxy creates a very stressful emotional situation that may lead to a suicidal act.

Chronic Disease↗
PubMed2005

Economic valuation of informal care: lessons from the application of the opportunity costs and proxy good methods.

This paper reports the results of the application of the opportunity costs and proxy good methods to determine a monetary value of informal care. We developed a survey in which we asked informal caregivers in The Netherlands to indicate the different types of time forgone (paid work, unpaid work and leisure) in order to be able to provide care. Moreover, we asked informal caregivers how much time they spent on a list of 16 informal care tasks during the week before the interview. Data were obtained from surveys in two different populations: informal caregivers and their care recipients with stroke and with rheumatoid arthritis (RA). A total of 218 care recipients with stroke and their primary informal caregivers completed a survey as well as 147 caregivers and their care recipients with RA. The measurement of care according to both methods is more problematic compared to the valuation. This is especially the case for the opportunity costs method and for the housework part in the proxy good method. More precise guidelines are necessary for the consistent application of both methods in order to ensure comparability of results and of economic evaluations of health care.

Adult↗
PubMed2006

Soy consumption and mortality in Hong Kong: proxy-reported case-control study of all older adult deaths in 1998.

OBJECTIVES: This study investigates the relation between soy consumption and mortality in a population-based case-control study in Hong Kong of all adult deaths in 1998. METHODS: Multivariable logistic regression was used to assess the effect of soy on all-cause and cause-specific mortality in 21,494 deceased cases and 10,968 living controls who were ethnic Chinese aged 60 or above, using proxy reports collected from the person registering the death. Dietary habits were obtained from proxies in both cases and controls, based on a 7-item questionnaire. RESULTS: The adjusted odds ratios for all-cause mortality for soy consumption 4 or more times a week compared with less than once a month were 0.77 (95% CI: 0.62, 0.95) for men and 0.66 (0.54, 0.81) for women. Mortality from lung cancer (males P = 0.02, females P = 0.02), colorectal cancer (males P = 0.07, females P < 0.001), stomach cancer (males P = 0.04, females P = 0.03), female breast cancer (P = 0.02) and ischemic heart disease (males P < 0.001, females P = 0.002) was inversely associated with soy consumption. CONCLUSIONS: Our study suggests that maintaining traditional levels of soy consumption could be protective for some chronic diseases in China.

Case-Control Studies↗
PubMed2003

The deceit continues: an updated literature review of Munchausen Syndrome by Proxy.

OBJECTIVE: This article presents an updated review of the literature of Munchausen Syndrome by Proxy (Factitious Disorder by Proxy, MBP). METHOD: Four hundred fifty-one cases of MBP were analyzed from 154 medical and psychosocial journal articles. RESULTS: Typical victims may be either males or females, usually 4 years of age or under. Victims averaged 21.8 months from onset of symptoms to diagnosis. Six percent of victims were dead, and 7.3% were judged to have suffered long-term or permanent injury. Twenty-five percent of victims' known siblings are dead, and 61.3% of siblings had illnesses similar to those of the victim or which raised suspicions of MBP. Mothers were perpetrators in 76.5% of cases, but as knowledge of MBP grows a wider range of perpetrators is identified. In a small number of cases, MBP was found to co-exist with secondary gain or other inflicted injury. CONCLUSION: Although published cases form a non-random sample, they add to knowledge about MBP and validate claims that it occurs. More knowledge about non-medical aspects of MBP, and more pooling of data, is desirable.

Adult↗
PubMed2003

Recurrent conjunctivitis as a presentation of munchausen syndrome by proxy.

PURPOSE: To report a case of Munchausen syndrome by proxy, which manifested as recurrent bilateral keratoconjunctivitis in an infant. DESIGN: Interventional case report. INTERVENTION: The patient underwent numerous diagnostic studies, including two endoscopies, skin biopsy, conjunctival pH measurement, and a skeletal survey. She underwent daily eye examinations until the corneal and conjunctival epithelial defects resolved. MAIN OUTCOME MEASURE: Resolution of cutaneous, mucosal, corneal, and conjunctival epithelial defects. RESULTS: A punch biopsy of the right postauricular area was performed, and pathology subsequently determined that the findings seemed to be the result of an exogenous injury. The conjunctival pH was 8.0, consistent with exposure to an exogenous, caustic agent. The acute ocular lesions resolved. CONCLUSIONS: Munchausen syndrome by proxy can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough and methodical evaluation.

Conjunctivitis↗
PubMed1998

Two siblings poisoned with diphenhydramine: a case of factitious disorder by proxy.

We report a case of factitious disorder by proxy (FDBP), formerly known as Munchausen syndrome by proxy, in which 2 siblings were poisoned with diphenhydramine. Although diphenhydramine is a readily available medication, no report of its use as the sole agent in an FDBP case was found in a literature search. Although sibling involvement in FDBP is well documented, this is the first case report of 2 siblings hospitalized simultaneously because of intentional poisoning with the same substance. Finally, the use of physostigmine to definitively diagnose anticholinergic poisoning in a case of FDBP has not previously been described.

Antidotes↗
PubMed1995

Fictitious epilepsy in Munchausen syndrome by proxy: family psychodynamics.

This paper presents experience of Munchausen Syndrome by Proxy in four families where symptoms and signs of seizures in children were deliberately fabricated or induced by their own parent. At the time when the condition was suspected, the children (5, 7, 13 and 14 years old) had already been exposed to numerous investigations and antiepileptic drug intake-in one case resulting in drug intoxication. The important data, giving clues about how to uncover the condition, are peculiar to each family. After the condition was confirmed, a multidisciplinary team organized an approach aimed at protecting the abused child and changing the pathological parent-child relationship. Personality disorders were recognized in all illness perpetrators (the father in one and the mother in three families) and various psychopathological manifestations were present in all of the abused children. Psychodynamic factors causing the Manchausen Syndrome by Proxy are described and discussed.

Adolescent↗
PubMed2003

Screening for preexisting cognitive impairment in older intensive care unit patients: use of proxy assessment.

OBJECTIVES: To determine the prevalence of preexisting cognitive impairment (CI) in patients admitted to the medical intensive care unit (ICU) and compare two different proxy measures of preexisting CI in ICU patients. DESIGN: Cross-sectional comparative study. SETTING: Urban university teaching hospital. PARTICIPANTS: One hundred thirty patients aged 65 and older admitted to the medical ICU. MEASUREMENTS: Two previously validated proxy measures of CI: the Modified Blessed Dementia Rating Scale (MBDRS) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). RESULTS: The prevalence of preexisting CI in the ICU, determined using a combination of the measures, was 42%. Agreement between the two CI measures was 86%, with a kappa of 0.69, with discrepancies being related to the different domains measured by each instrument. CONCLUSION: There is a high prevalence of preexisting CI in patients admitted to the medical ICU. Both the MBDRS and IQCODE can be used to screen for preexisting CI in situations where direct patient assessment is not feasible. Future studies are needed to address physician recognition of CI and its effect on patient care decisions and outcomes.

Aged↗
PubMed1998

Recurrent hypoglycaemia in multiple myeloma: a case of Munchausen syndrome by proxy in an elderly patient.

A 73-year-old woman with multiple myeloma experienced four episodes of loss of consciousness, convulsions and profuse sweating whilst she was in the hospital. A thorough investigation in the department of medicine disclosed that with each attack, she had a serum glucose < 1.6 mM L-1, insulin level > 1400 pMol L-1 (N- < 150) and a normal level of serum C-peptide. Since she had no anti-insulin antibodies (which may rarely exist in multiple myeloma), a diagnosis of exogenous injection of insulin was made. A search for a possible perpetrator discovered that the patient had a daughter who was a surgical nurse and who was genuinely concerned whenever she was told that her mother was about to be discharged from the hospital. If she was the perpetrator in the present case, then it is possible that the motive for such an action was to postpone the mother's discharge from hospital. This case is an example of a 'factitious disease by proxy' in an elderly patient. The aim of the present report is to alert the medical personnel to the possibility that Munchausen's syndrome by proxy may also occur in the elderly.

Aged↗
PubMedDate not supplied

Full-spectrum proxy consent for research participation when persons with Alzheimer disease lose decisional capacities: research ethics and the common good.

This article focuses on riskier forms of research in Alzheimer disease (AD). It asks two fundamental questions. First, what is the upper threshold of potential risk that should be allowable in AD Research ("maximal potential risk")? Second, should proxy consent be permitted in higher-risk research even when there is no clear potential therapeutic value to the subject? There has been little discussion of maximal potential risk at a time when studies may be becoming increasingly invasive and risky. Proxy consent under such circumstances merits more thorough defense. This article discusses these questions on the basis of a "common good" ethic and calls for more input from researchers and the AD-affected constituency in resolving them.

Alzheimer Disease↗
PubMed2006

Ethics update: lessons learned from Terri Schiavo: the importance of healthcare proxies in clinical decision-making.

PURPOSE OF REVIEW: In this review, we discuss issues of privacy and personal choice in end-of-life decision-making and existing options for directing end-of-life care, and highlight important differences between living wills, advance directives and other forms of healthcare proxies. RECENT FINDINGS: The events surrounding the death of Terri Schiavo raise many ethical, legal and moral issues that warrant discussion. In that context, we examine the implications associated with family disagreement over end-of-life care, the ramifications for healthcare providers and the role played by politicians, the courts and the media in galvanizing the debate. Groups promoting a variety of causes seized the opportunity to further their own agenda by using the internet and other methods to rapidly disseminate often false information, fueling arguments over misdiagnosis of persistent vegetative state and raising false hopes for neurological recovery. SUMMARY: It is incumbent upon the medical community, political and religious leaders and the media to educate the public appropriately about options regarding end-of-life issues and to foster open discourse and encourage the execution of advance directives or healthcare proxies. Although the content of this article deals with a specific case and legal rulings pertaining to the USA, the issues and questions raised are pertinent to healthcare providers and individuals around the world.

Florida↗
PubMed2006

Munchausen syndrome by proxy caused by ipecac poisoning.

OBJECTIVE: To present a case of Munchausen syndrome by proxy caused by ipecac poisoning to increase the awareness of their warning signs and symptoms so that they may be recognized and diagnosed earlier. CASE: Report of one case of a child who was determined to be a victim of Munchausen syndrome by proxy by ipecac poisoning who was hospitalized multiple times over a 4-year period at 2 different hospitals before an accurate diagnosis was made.

Child↗
PubMed2003

Ethics seminars: health care proxies and suicidal patients.

Advance directives, health care proxies, and living wills are forms of advance planning that permit patients to make decisions regarding their health care and are used when the patient becomes incapacitated. The ethics of allowing these forms of advance planning are questioned when the patient has attempted suicide. The authors present an ethical analysis of a case of an elder patient who overdosed on sustained-release diltiazem and had a health care proxy who wanted all treatments stopped.

Advance Directives↗