Arterial–Pulse Oximetry Loops: A New Method of Monitoring Vascular Tone

Objective. We report the off-line calculation of the vascular complianceof the finger and suggest the continuous on-line use of this methodology asan aid to monitoring the peripheral vascular resistance. This method consistsof the simultaneous analysis of the waveform signals from the pulse oximetermonitors and the arterial pressure as indicators of volume andpressure respectively to continuously calculate the vascularcompliance (volume change per unit pressure change). This shouldbe seen as a relative compliance as the pulse plethysmographsignal is not calibrated. This new methodology allows for continuousmonitoring of peripheral vascular compliance as a beat-to-beat indicator ofperipheral vascular resistance. The vaso-constrictors, phenylephrine andephedrine, were shown to decrease the compliance as predicted. Methods. Thearterial pressure and pulse oximeter waveforms were obtained during routineanesthetic care. The waveforms were collected with a computer data-acquisitionsystem and then analyzed off-line as an indirect indicator oftotal vascular tone. Demographic and clinical information including drugadministration were recorded. Results. A case report is presented using thisnew form of analysis. Vascular compliance changes induced by phenylephrine andephedrine were studied. A dose response curve of peripheral vascularcompliance to phenylephrine was generated from these data. Conclusions. Byplotting the pulse oximeter waveforms versus the arterial waveforms, multiplevolume versus pressure (relative compliance) loops were obtained. Analysis ofthese loops may assist in the monitoring of vascular compliance.     

“Effectance” and representation of causality in quadraplegic cerebral palsied children

This paper reports on the results of a study regarding effectance and representation of causality in noninstitutionalized children with severe physical handicaps affecting all limbs. Forty-five quadraplegic cerebral palsied children, enrolled in a day program, were presented with a series of toys which could be activated to produce interesting effects. Factor analysis of their responses to this situation yielded seven factors. The most commonly observed, effectance, referred to intentional efforts to make the interesting spectacles last through the child's own activity directed toward and immediately affecting the toys. Next most frequently observed was nonaction—indicating an absenceof engagement in the experimental situation. Appearing with less frequency were nonverbal communication, verbal communication, preeffectance responses, and evidence of mental representation of causality. There was marked variability in factor scores. Differences in severity (within the severity range studied) accounted for less than 5% of this variance. Test-based MA and IQ accounted for only about 10% on average. Most of these children had notbeen in infant programs designed to foster active engagement with objects and people. The results suggest that nevertheless, an effectance orientation and early mentation could survive drastic deprivation or distortion of normal sensorimotor experience in infancy, at least in some children. The potential of the experimental procedures for eliciting effectance behavior is discussed.     

The Role of Control in Childhood Anxiety Disorders

This study investigated the role of control beliefs in childhood anxiety disorders. The sample comprised 117 youth aged 9–17 years (86 met diagnostic criteria for an anxiety disorder and the remaining 31 were nonreferred comparison participants). Participants' anxiety levels and their perceptions of control over anxiety-related events (e.g., things that might be harmful, feeling shaky or nervous) were assessed. Findings indicated that perceived control over anxiety-related events was significantly negatively correlated with self-reported anxiety levels. Moreover, youth with anxiety disorders reported significantly lower perceived control about anxiety than the nonreferred participants. Findings were consistent with theory and suggest that anxiety disorders in youth are associated with beliefs that anxiety is uncontrollable.     

Automated ST-segment trending: What does it mean?

This article is the first segment of what we hope will become a regular feature in theJournal of Clinical Monitoring. The Monitoring Dilemmas series is designed for clinicians who are struggling with the information presented by new monitoring. The past decade has seen an explosion in the number and type of clinical monitors in daily use. Health-care providers are increasingly faced with a plethora of monitoring data, often without guidance on how to interpret it.Each Monitoring Dilemma consists of a case report that describes a clinical dilemma brought on by information from a monitor—a dilemma that would not even have been considered had the monitor not been in place or existence. The case reports are sent to experts in the particular fields concerned. To prevent Monday morning quarterbacking, each reviewer is sent several envelopes, each containing information that progressively reveals more and more about the case. The case is presented as it actually evolved, and the experts comment as the case unfolds. Thus, the reader can share the dilemma with the reviewers, as well as with the original clinicians. We welcome your comments on this new section. We also welcome your own Monitoring Dilemmas. Please contact the Section Editor, Dr Partridge, for more details.     

Similarities between cognitive and humanistic approaches to psychotherapy

It is suggested that humanistic and cognitive therapies share some similar goals. Both see the employment of rigid absolutistic shoulds as generative of dysfunctional behavior. Both value self-acceptance, in the form of discouraging the client from forming negative overgeneralized trait-like self-judgements. Both value viewing one's failures and mistakes as part of a process of exploration and coping. Hypothesis-testing and holding constructs tentatively is also valued. At the level of practice some of Beck's cognitive strategies appear to help the client learn to stick to his/her moment to moment experiencing, and to be more phenomenological. Similarly Rogers' client-centered interventions appear to lay bare the client's negative self-statement process, and to counter and correct overgeneralized negative cognitions.     

Causal Thinking About Somatic Symptoms—How Is It Related to the Experience of Symptoms and Negative Affect?

The relation between causal thinking about somatic symptoms (psychological, somatic, and external symptom attribution) and the experience of somatic complaints and negative affect was studied in a community sample of 208 individuals. Although cluster analysis identified groups of individuals with psychological, somatic, and external attribution styles, the analysis also revealed groups of individuals with combinations of high or low scores on two or three attribution dimensions. Consistent with previous research, psychological attribution of symptoms was associated with a higher degree of somatic complaints and negative affect; this effect, however, was primarily due to a group of psychologizers/externalizers, and not to the pure psychologizers. Also in replication of earlier studies, all three attribution subscales were intercorrelated. The findings are discussed in terms of rumination processes. It is argued that the findings concerning psychological symptom attribution have received too little attention in the literature so far, probably because they go against dominant theoretical paradigms in psychosomatic medicine.     

Das Critical Incident Reporting System (CIRS) als Mittel zur Qualit?tsverbesserung in der Medizin

Es mag als bedauerlich bezeichnet werden, dass eine Maßnahme, die ganz eindeutig dazu geeignet ist, die medizinische Qualität zu verbessern, erst im Zusammenhang mit Bemühungen zur Abwehr von Risiken bekannt wird und eine breite Diskussion auslöst.Dem System der Erfassung von Beinahezwischenfällen mit dem international gebräuchlichen Fachterminus Critical Incident Reporting System (CIRS) liegt die Erkenntnis zugrunde, dass zwischen schweren und folgenreichen Zwischenfällen, leichten Zwischenfällen und Beinahezwischenfällen ein zahlenmäßiger Zusammenhang besteht. Über die Vermeidung von Beinahezwischenfällen soll die Häufigkeit folgenschwerer Komplikationen und Zwischenfälle verringert werden. Beim CIRS spielt im Gegensatz zur klassischen Fehleranalyse der tatsächliche Schadenseintritt also eine ganz untergeordnete Rolle. Fehler werden in Deutschland bisher ganz überwiegend unter dem Aspekt der persönlichen Verantwortung betrachtet und sind daher häufig sanktionsbedroht (Fehlerkultur vom Typ A). Aber erst wenn Fehler nicht mehr unter dem Aspekt persönlicher Schuld und drohender Sanktionen betrachtet werden, wenn allgemein akzeptiert wird, dass Fehler überall und bei jedem Menschen vorkommen und vorwiegend unter dem Aspekt zu betrachten sind, wie Wiederholungen zu vermeiden sind (Fehlerkultur vom Typ B), kann die notwendige Transparenz erzielt werden und ein offener Umgang mit Beinahezwischenfällen entstehen. Dies ermöglicht Fehleranalysen mit dem Ziel einer Qualitätsverbesserung durch Fehlervermeidung.     

Effects of two inotropic drugs,dopamine and dobutamine,on pulmonary gas exchange in artificially ventilated patients

The inotropic agents, dopamine (DP) and dobutamine (DB), both decrease PaO₂, probably by a resistribution of the ratio. The aim of this study was to assess the effect of both drugs on the ratio, using the multiple inert gas elimination method. Ten artificially ventilated patients (eight males), aged 45–74 years were investigated. Blood gases, cardiac output and concentrations of inert gases were measured before and 30 min after infusion of DB or DP. DP and DB were administered alternatively at a rate of 5 g·k^-1 min^-1. The decrease in PaO₂ was significantly greater with DP (12±9 torr) than with DB (7±9 torr) (P< 0.01) Both drugs similarly increased cardiac ouput: +2.6l·min^-1±1.4 for DP and 2.2l·min^-1±1.5 for DB. Both DP and DB significantly (P< 0.01) increased the perfusion of alveoli with (+4±7% for DP and +3±7% for DB) and (+11±8.5% for DP and +5.5±10.5% for DB) (no significant difference between the drugs). When shunt and shunt-like effect are considered together, there was a significantly greater increase in the amout of blood going to alveoli with a low ratio with DP compared to DB. Both drugs decreased the perfusion of alveoli with , but the decrease was significantly less for DB than for DP (-15±6.5% for DP and-8.5±7% for DB,p< 0.01). We conclude that dopamine induces a greater degree of hypoxaemia compared to dobutamine due to a larger increase in shunt and/or maldistribution of the ratio.     

Genetic Etiologies of Mental Retardation: Issues for Interventions and Interventionists

This paper outlines some practical implications of new work on the behavioral effects of genetic mental retardation disorders. After describing historical and definitional issues concerning so-called behavioral phenotypes, we use Down syndrome and Williams syndrome to illustrate how specific genetic disorders might differentially predispose individuals to particular, etiology-related behaviors. We then explore educational and other intervention implications of such etiology-related behaviors, before ending with a discussion of the area's critical unresolved issues.     

Self-esteem and causal attributions for success and failure in children

In a comparison of causal attributions following success and failure in hypothetical social, athletic, and academic situations, high self-esteem grade school children were more likely than low self-esteem children to attribute their success to ability and their failure to either lack of effort or bad luck. Low self-esteem children, on the other hand, attributed their success more often than high self-esteem children to good luck (and in social situations to effort and task ease as well) and their failure to lack of ability. Whereas prior studies that focused only on the internal-external dimension found that low and high self-esteem children differed in their attributional style to success but not to failure, the present study found that when distinctions between behavioral and characterological attributions (stability and globality dimensions) were included, the two groups differed significantly in response to both success and failure. Although perhaps not generalizable beyond the present attribution measure, the most pronounced attribution differences between low and high self-esteem children were observed in the social domain, the least in the academic domain, with athletics falling in between. Finally, it was found that sex and age (within the limited fourth- to sixth-grade range examined in the present study) did not alter the overriding difference in attributional style between low and high self-esteem children.This study is based on a doctoral dissertation submitted by the first author under the supervision of the last author in partial fulfillment of the requirements for the Ph.D. degree at the University of Vermont.     

Knowledge-based approach to intelligent alarms

The goal of intelligent alarms is not only to recognize potentially dangerous situations, but to discriminate whether the condition is truly threatening or has resulted from nonthreatening causes, such as artifacts. The authors describe a knowledge-based approach in the development of intelligent alarms, using complex guidelines that simulate human reasoning and follow if, then rules of problem solving.     

Komplexitätstheorie und Manualmedizin

Zusammenfassung  Ausgehend von Fallbeobachtungen wird dargestellt, dass die teils sehr unterschiedlichen Effekte manueller Therapie (MT) am besten verständlich sind, wenn man 2 unterschiedliche Wirkungsweisen unterscheidet. Diese Differenzierung in robuste und subtile MT ermöglicht es, beide Behandlungstypen effizienter einzusetzen. Komplexitätstheoretische Konzepte und die Theorie des intelligenten Organismus werden zur Erklärung dieser Effekte erläutert und diskutiert.

The Validation of the Transition-to-Work Inventory: A Job Placement System for Workers with Severe Disabilities

The reliability and validity of the Transition-to-Work Inventory (TWI; Friedman et al., 1996), which is designed to diagnose worker/job fit problems for individuals with severe disabilities, was assessed. Worker/job analyses were conducted using the TWI for 64 workers with severe disabilities, in 35 jobs at 11 different organizations. These analyses were performed by supported employment staff members and other job-content experts. Worker's capabilities (as determined by the worker analysis) and the job's requirements (as determined by the job analysis) were directly compared to each other to determine potential target item problems for the worker (i.e., items designating activities that the worker may have difficulties performing). Once target items had been determined, their importance to task performance was rated, and correlations between the items' importance to tasks and actual performance were computed. Results indicated that TWI ratings of both worker capabilities and job requirements were reliable. In addition, the TWI was determined to have predictive validity. The more important the worker's target items were rated for task performance, the greater were the decreases in the worker's performance appraisal ratings. Results indicate that specific problems for worker performance can be assessed using this instrumentation.     

The concept of “baby lung”

Background The baby lung concept originated as an offspring of computed tomography examinations which showed in most patients with acute lung injury/acute respiratory distress syndrome that the normally aerated tissue has the dimensions of the lung of a 5- to 6-year-old child (300–500 g aerated tissue).Discussion The respiratory system compliance is linearly related to the baby lung dimensions, suggesting that the acute respiratory distress syndrome lung is not stiff but instead small, with nearly normal intrinsic elasticity. Initially we taught that the baby lung is a distinct anatomical structure, in the nondependent lung regions. However, the density redistribution in prone position shows that the baby lung is a functional and not an anatomical concept. This provides a rational for gentle lung treatment and a background to explain concepts such as baro- and volutrauma.Conclusions From a physiological perspective the baby lung helps to understand ventilator-induced lung injury. In this context, what appears dangerous is not the V_T/kg ratio but instead the V_T/baby lung ratio. The practical message is straightforward: the smaller the baby lung, the greater is the potential for unsafe mechanical ventilation.     

Drug smuggling by ingested cocaine-filled packages: conventional x-ray and ultrasound

Purpose To evaluate the imaging characteristics and the diagnostic value of both abdominal ultrasound and conventional abdominal x-ray in identifying ingested drug packages in body packers.Materials and Methods Twelve individuals were studied prospectively by abdominal ultrasound and by abdominal x-ray to rule out incorporated drug containers.Results Both abdominal ultrasound and abdominal x-ray correctly identified the 7 of 12 individuals who had ingested multiple drug packages. In 5 of the 12 individuals, ultrasound as well as abdominal x-ray were correctly unremarkable with regard to abdominal foreign bodies.Conclusions Abdominal ultrasound and abdominal x-ray both represent valuable diagnostic tools in the assessment of ingested drug packages. Abdominal x-ray is superior to ultrasound in differentiating ingested drug-filled condoms from pseudocondoms.An editorial commentary on this article follows on p. 339.     

Bronchodilatatoren in der Dauertherapie der chronisch-obstruktiven Lungenerkrankung (COPD)

Bronchodilatativ wirksame Substanzen bilden die pharmakologische Basistherapie der chronisch-obstruktiven Lungenerkrankung (COPD). Die Fülle publizierter Studien, die Vielzahl der verschiedenen Wirkansätze und die inhalativen bronchodilatativen/antiinflammatorischen Kombinationspräparate erschweren die Entscheidung des primär auszuwählenden Präparats. In dieser Übersicht wird eine Bewertung der Anticholinergika, der lang und kurz wirksamen ₂-Mimetika, der Methylxanthine, deren verschiedener Applikationsformen und Kombinationsmöglichkeiten vorgenommen. Die klinische Effektivität dieser Substanzgruppen wird anhand der Verbesserung der Lungenfunktionsparameter, aber auch, sofern klinisch-wissenschaftlich evaluiert, der physischen Parameter, wie dem 6-min-Gehtest, des klinischen Verlaufs einschließlich der Reduktion der Exazerbationsrate und Verbesserung der Lebensqualität sowie des Dyspnoe-Scores bewertet. Danach sind in der Basistherapie inhalativ zu applizierende lang wirksame Bronchodilatatoren wie Tiotropiumbromid oder lang wirksame ₂-Mimetika primär zu bevorzugen. Die Kombination eines Anticholinergikums mit einem ₂-Mimetikum führt zu einem additiven bronchodilatativen Effekt. Erst ab dem COPD-Schweregrad III sind als Kombinationspartner auch inhalative Kortikosteroide indiziert. Die Pharmakotherapie muss durch präventive und ggf. supportive Therapiemaßnahmen flankiert werden.     

Studies on the ultrastructure of blood cells and the microaggregate fraction in stored human blood

Electron microscopy of citrate-phosphatedextrose (CPD) buffered bank blood performed over 21 days shows that the normal architecture of erythrocytes, platelets and leucocytes disappears and that deformed organelles, leucocyte ghosts, cell fragments and microaggregates accumulate. Leucocytes and platelets emerge as the most sensitive indicators of blood deterioration showing profound morphological changes from the first day. Microaggregates which passed through a 20-m high capacity transfusion filter were identified as platelet conglomerates, leucocyte ghost and platelet-leucocyte ghost coaggregates with diameters of 6–20, 20–30 and 30–40 m respectively. of these aggregates present in the filtrate, 62% fell into the size range of 20–40 m. The composition of microaggregates varies with storage time, the platelet conglomerates appear first during or after Day 1, leucocyte ghosts after Day 5 followed by platelet-leucocyte ghost coaggregate formation. At this stage the number of intact leucocytes and platelets is reduced and the filtrate shows an abundance of leucocyte debris. Microfiltration would thus appear to reduce but not eliminate the danger of microembolism and damage to capillary endothelium.     

Postoperative education concerning the use of the upper limb,and exercise and treatment of the upper limb: cross-sectional survey of 105 breast cancer patients

In this retrospective survey we investigated the recall of breast cancer patients (n=105) 6 months after the operation concerning postoperative instructions on exercises for shoulder mobility, and instructions for oedema prevention and treatment, upper limb strength training and the use of the upper limb in daily activities. Patients also described the content in their own words and ranked the instructors who had mostly given this education. Operation type and length of hospital stay did not have any effect on the education recalled, but the age of the respondent had some effect (r=–0.23, p<0.05). The Wilcoxon signed ranks test showed that the most commonly reported item was instructions on shoulder movements (P<0.001). Patients reported that they had more instructions for using the upper limb in daily activities than instructions for strength training (P=0.002) and oedema prevention and treatment (P=0.001). Patients own comments were sometimes conflicting: Use the upper limb as before and you can even lift weights and You cannot drive a car or lift a weight over 3 kg for 6 weeks. Over half of the respondents named the physiotherapist or physiotherapy assistant as the person who had given them most of the instructions. A medical doctor was ranked in first place by 19% of the patients. Only half of the patients reported that they had some education after hospitalization. This study suggests that postoperative education of breast cancer patients is inconsistent and insufficient to provide knowledge for independent rehabilitation for future.