The use of distraction and imagery with children during painful procedures

The effectiveness of a paediatric pain management programme was examined using a multiple case study design. This study examined both the children's pain experience during cancer treatment, as well as their parents'anxiety and behavioural stress. Fourteen people were videotaped while receiving lumbar punctures during an 8–12 month period. Baseline data were obtained at the first of three visits prior to the introduction of relaxation, imagery and distraction exercises. Self-ratings of child fear and parent anxiety, videotaped observations of child and parent behaviour and child pain ratings were obtained at all three visits. The children's behavioural responses to the procedure varied considerably, but their fear scores were stable and their reports of pain decreased over time. Parents reported high-trait, low-state anxiety scores that were stable over time. They were observed to be very supportive during the procedures. Implications for further research in this area and recommendations for practice are presented.     

Cephalometric evaluation of maxillary advancement with an internal distractor in an adult boxer dog

Objective – The aim of the study was to evaluate cephalometrically the effects of distraction of the maxilla over a 1‐year period by means of an internal distractor applied in a boxer dog. Design – Internal distractors were placed bilaterally in the internal cavity of the maxillary sinus of a 2‐year‐old boxer dog after a Le Fort I osteotomy. Distraction was started 5 days after surgery and activations were continued for 14 days at a rate of 1 mm/day. Standardized lateral cephalograms were taken with an external source of 90 kV, 60 mS immediately pre‐surgery, at day 1 after the start of the distraction (dp) and at day 5 dp, day 7 dp, day 10 dp, day 14 dp (end of distraction), at 14 days of consolidation period (cp), at 28 days cp and at 56 days cp (removal of the distractors). One year after the removal of the distractor, a final lateral cephalogram was taken. Cephalometric analysis was performed and superimpositions were used for the evaluation of the sagittal position of the maxilla. Results – The linear measurements, as well as the superimposition showed evidence for a significantly advanced position of the maxilla, which was stable 1 year after removal of the distractor. Conclusion – The application of the internal maxillary distractor in a boxer dog resulted in a sagittal advancement of the midface that was still present after 1 year.     

Difficult tracheal intubation induced by maxillary distraction devices in craniosynostosis syndromes

BACKGROUND: Difficult intubation occurred during anaesthesia for removal of maxillary distraction devices in five of seven children with syndromal craniosynostoses (four with Apert, two with Pfeiffer and one with Crouzon syndrome). METHODS: Intubation was assessed in terms of laryngeal view and an established intubation difficulty score and had been straightforward before device insertion. Difficulty was induced by trismus due to device insertion and by increased maxillary prominence. This was compounded by preexisting mandibular hypoplasia. Cephalometric analysis, with each child acting as their own control, demonstrated anterior displacement of the maxilla and increased maxillary vertical height, as well as increased protuberance of the maxillary incisors. RESULTS: All five difficult tracheal intubations were associated with preoperative Mallampati scores of 3 or 4 and the nine straightforward intubations with scores of 1 or 2. Maximal interincisor distance was less than the lower 95% confidence limit for age in all five children who were difficult to intubate at the time of device removal. No child had a failed intubation, but all had significantly increased intubation difficulty. CONCLUSIONS: In view of the risks of trauma, hypoxia and aspiration associated with difficult direct laryngoscopy, we recommend elective fibreoptic intubation at anaesthesia for removal of maxillary distraction osteogenesis devices in these children.     

A mechanism of lateral flexion distraction injury of the spine

Flexion distraction fractures or Chance fractures are well described in the literature. We present an unusual pattern of injury of a pure lateral flexion distraction fracture of the T12 vertebra with no posterior element disruption following a blow to the right torso to a passenger in a road traffic accident. The diagnosis was made intra-operatively as the potential for this injury pattern following the described mechanism was not initially recognised. We suggest that this type of injury be suspected in any patient where a fulcrum has acted at any point around the torso.     

Articulated distraction of the hip joint in the treatment of benign aggressive tumors located around the hip joint

Introduction The proximal femur and acetabulum are frequent sites for benign active and aggressive lesions. The risk of pathologic fracture is great when a bone-destroying pathology involves an anatomic location such as the hip joint that undergoes profound mechanical loading. If the destruction involves a large area around the joint, secure fixation cannot be achieved with internal fixation implants. The study investigates use of articulated hip distraction to protect reconstructions performed for the treatment of benign active or aggressive tumors presenting with pathologic fracture.Patients and methods Five patients with a pathologic fracture of the proximal, intracapsular femur or the acetabulum were operated on at the authors' institution between 1997 and 1999. Following histopathologic approval of a benign tumor, all lesions were curetted, chemocauterized, and grafted and osteosynthesis was performed. The reconstruction was protected with an articulated hip distraction external fixator. All patients were mobilized in the immediate postoperative period.Results The patients were kept in external fixators for an average of 19.8 weeks (range: 16–24). The fixator was removed when bony consolidation was observed in anteroposterior and lateral x-rays of the lesion. The patients were followed for an average of 47 months (range: 38–56) after frame removal. None of the lesions recurred. At the last follow-up examination, all patients displayed an excellent function according to the Musculoskeletal Tumor Society Rating Scale. Conclusion According to the authors' knowledge, this investigation is the first in the literature describing the use of articulated joint distraction in the treatment of benign active and aggressive lesions around the hip joint. The procedure adopts principles of joint distraction into bone tumor surgery.     

Functional outcome with special attention to the DASH questionnaire following callus distraction and phalangization of the thumb after traumatic amputation in the middle one-third

Introduction Aim of this retrospective study was to obtain a functional outcome following callus distraction and phalangization of the thumb after traumatic amputation in the middle one-third.Materials and methods From January 1998 to June 2001, 12 patients were treated in a staged procedure starting with corticotomy and continuous distraction (1 mm/day) of the first metacarpal bone using a unilateral external fixator device. After distraction until day 31 (range 25–35 days), the first metacarpal bone was stabilized with a plate, and phalangization was performed.Results At follow-up 1 year after surgery, the thumb was lengthened to 25–35 mm (average 28 mm) in all but 1 patient. In 1 patient a bone graft from the iliac crest had to be interposed. Pinch grip improved by 45%; grip strength improved by 55%. The function/symptom score from the DASH questionnaire was 25 points (range 16–38 points). In a 'pick-up test' all patients were able to pick up a pencil, they were able to write and could hold a full cup of water. Nine patients were able to pick up a paper clip, and 8 patients could hold a 1-liter bottle of water.Conclusion Callus distraction can be considered a suitable procedure to reconstruct an amputated thumb levelled at the middle one-third. Additional phalangization proved essential as it deepened the first web space, enabling good motion and grasp. Callus formation was delayed in elderly patients, but adequate lengthening and bone healing also occurred in this age group. The procedure will not be as beneficial in cases of osteoarthritis of the trapezometacarpal joint or when coverage of the stump is insufficient. The DASH questionnaire is very helpful in evaluating the effect of thumb reconstruction on the entire upper limb.     

Selective attention in anxiety: distraction and enhancement in visual search

According to cognitive models of anxiety, anxiety patients exhibit an attentional bias towards threat, manifested as greater distractibility by threat stimuli and enhanced detection of them. Both phenomena were studied in two experiments, using a modified visual search task, in which participants were asked to find single target words (GAD-related, speech-related, neutral, or positive) hidden in matrices made up of distractor words (also GAD-related, speech-related, neutral, or positive). Generalized anxiety disorder (GAD) patients, social phobia (SP) patients afraid of giving speeches, and healthy controls participated in the visual search task. GAD patients were slowed by GAD-related distractor words but did not show statistically reliable evidence of enhanced detection of GAD-related target words. SP patients showed neither distraction nor enhancement effects. These results extend previous findings of attentional biases observed with other experimental paradigms.     

Patient anxiety and modern elective surgery: a literature review

Medical advances have led to a considerable rise in the level of elective surgery undertaken as day-case surgery and with minimal hospital stay. However, amid such advances, preoperative psychological care has remained relatively static. A considerable number of patients are very anxious prior to elective surgery and little formal care is undertaken to address this major issue. A review of the literature from 1990 to 2002 was therefore undertaken in order to assess the present level of knowledge and interventions concerning patient anxiety when undergoing modern, intermediate surgical intervention. Thirty-four studies embracing data from 3754 patients undergoing both inpatient and day-case procedures were reviewed. Three main themes emerged - causes of anxiety, clinical concerns and measurement, and anxiety management. Each theme is discussed alongside details extracted from the relevant studies. Finally, the main issues arising are summarized and future research challenges identified.     

犬面中份缝牵引成骨过程中骨形成蛋白-2的表达

目的:研究骨形成蛋白(bone morphogenetic protein,BMP)-2在犬面中份缝牵引成骨过程中的表达,探讨缝牵引成骨的机制.方法:18只12周龄杂种犬随机分为牵引成骨组12只和正常对照组6只,在牵引5、10、15 d,固定10、20 d,去固定1个月分别处死实验犬2只和对照犬1只,免疫组化法观察BMP-2在各骨缝的表达情况.结果:牵引期和固定期,BMP-2在实验犬各骨缝边缘大量增殖的未成熟成骨细胞、间充质细胞以及新生骨基质中呈阳性表达,对照犬也有少量表达.随着机械应力牵引, BMP-2在各骨缝表达量逐渐上升,在牵引15 d阳性表达最强,以后逐渐下降,到去固定1个月时表达水平接近正常.结论:机械牵张力刺激可以导致内源性BMP-2产生,BMP-2可能在缝牵引新骨生成过程中扮演重要的角色.