Does Guilt Mediate the Association Between Tonic Immobility and Posttraumatic Stress Disorder Symptoms in Female Trauma Survivors?

Tonic immobility (TI) is an involuntary freezing response that can occur during a traumatic event. TI has been identified as a risk factor for posttraumatic stress disorder (PTSD), although the mechanism for this relationship remains unclear. This study evaluated a particular possible mechanism for the relationship between TI and PTSD symptoms: posttraumatic guilt. To examine this possibility, we assessed 63 female trauma survivors for TI, posttraumatic guilt, and PTSD symptom severity. As expected, the role of guilt in the association between TI and PTSD symptom severity was consistent with mediation (B = 0.35; p < .05). Thus, guilt may be an important mechanism by which trauma survivors who experience TI later develop PTSD symptoms. We discuss the clinical implications, including the importance of educating those who experienced TI during their trauma about the involuntary nature of this experience.     

Intra‐aortic Balloon Pumping: Does Posture Matter?

BACKGROUND: The effect of the posture of semirecumbent patients on the hemodynamics and performance of intra-aortic balloon (IAB) were studied in vivo and in vitro. METHODS: An IAB was inserted into a glass tube filled with saline, fully inflated and deflated using an intra-aortic balloon pump (IABP). Three successive cycles were filmed at 125 frames/s with the tube positioned at various angles between 0 degrees (horizontal) and 90 degrees (vertical). Pressure and flow were measured distal to both ends of the balloon. In parallel, coronary left anterior descending (LAD) flow velocity and aortic pressure were recorded in 6 patients using IABP, postcardiac surgery in the intensive care unit. Recordings were made when the patient was lying horizontally (recumbent) and when the patient's torso was inclined at 30 degrees to the horizontal (semirecumbent). RESULTS: With the tube horizontal, the inflation was effectively uniform along the length of the balloon. At all other angles, the higher end of the balloon inflated first, and mean pressure and flow measured distal to the higher end of the balloon were less than those measured at 0 degrees . Mean aortic pressure and LAD flow decreased by 10 +/- 2% (P = 0.001) and 15 +/- 3% (P = 0.001), respectively, when the patient was semirecumbent compared to when the patient was recumbent. CONCLUSION: The decreased mean aortic pressure and LAD flow velocity suggests that unless patients using IABP are required to be semirecumbent, it may be best to position them horizontally to gain the full benefits of balloon counter pulsation to the coronary circulation.     

The Ischial Spine Sign: Does Pelvic Tilt and Rotation Matter?

Although the ischial spine sign (ISS) has been advocated to detect acetabular retroversion, it is unknown whether the sign is valid on anteroposterior (AP) pelvic radiographs with tilted or rotated pelves. We therefore evaluated reliability of the ISS as a tool for diagnosing acetabular retroversion in the presence of considerable pelvic tilt and/or malrotation. We obtained radiographs of 20 cadaver pelves in 19 different malorientations resulting in 380 pelvis images (760 hips) for evaluation. In addition, 129 clinical radiographs of patients’ hips that had varying pelvis orientations were reviewed. We found an overall sensitivity of 81% (90%), specificity of 70% (71%), positive predictive value of 77% (80.7%), and negative predictive value of 75% (85%) in the cadaver (patient) hips. Our data suggest the ISS is a valid tool for diagnosing acetabular retroversion on plain radiographs taken using a standardized technique regardless of the degree of pelvic tilt and rotation.     

The Challenging Estrogen Receptor‐Negative/ Progesterone Receptor‐Negative/HER‐2‐Negative Patient: A Promising Candidate for Epidermal Growth Factor Receptor‐Targeted Therapy?

While epidermal growth factor receptor (EGFR)-targeted therapy has been very promising in a number of human malignancies, to date these targeted biologic agents have not proven effective in breast cancer. However, the EGFR tyrosinase inhibitors have been used indiscriminately against all types of breast tumors, perhaps missing a subpopulation of patients who may be prime candidates for EGFR-targeted therapy. In this communication we propose that patients with estrogen receptor (ER)-negative/progesterone receptor (PR)-negative/HER-2-negative tumors, which currently present a therapeutic challenge for the oncologist, may be the subgroup of breast cancer patients that might benefit from specific EGFR-targeted therapies.     

Perceived Reciprocity and Well‐Being at Work in Non‐Professional Employees: Fairness or Self‐Interest?

This article assesses the links between non‐professional employees' perceptions of reciprocity in their relationships with their supervisors and the positive and negative sides of employees' well‐being at work: burnout and engagement. Two hypotheses were explored. First, the fairness hypothesis assumes a curvilinear relationship where balanced reciprocity (when the person perceives that there is equilibrium between his/her efforts and the benefits he/she receives) presents the highest level of well‐being. Second, the self‐interest hypothesis proposes a linear pattern where over‐benefitted situations for employees (when the person perceives that he/she is receiving more than he/she deserves) increase well‐being. One study with two independent samples was conducted. The participants were 349 employees in 59 hotels (sample 1) and 690 employees in 89 centres providing attention to people with mental disabilities (sample 2). Linear and curvilinear regression models supported the self‐interest hypothesis for the links from reciprocity to burnout and engagement. We conclude with theoretical implications and opportunities for future research. Copyright © 2012 John Wiley & Sons, Ltd.     

Trade‐offs Between Efficacy and Cardiac Toxicity of Adjuvant Chemotherapy in Early‐Stage Breast Cancer Patients: Do Competing Risks Matter?

Evidence about treatment efficacy and long‐term toxicities for adjuvant chemotherapy in patients with early‐stage breast cancer is often presented in different formats and studies. This leads to challenges for patients and their physicians to adequately weigh the trade‐offs between effectiveness and long‐term cardiac toxicity when making decisions about adjuvant chemotherapy. We used a decision‐analytic framework to quantify these trade‐offs by combining the available evidence into a single, comparable metric. We developed a Markov model to simulate a hypothetical cohort of newly diagnosed breast cancer patients under three scenarios: no treatment, anthracycline (AC)‐based adjuvant chemotherapy (more effective but also more cardiotoxic), and non‐AC‐based adjuvant chemotherapy. We derived the model parameters from medical literature (e.g., clinical trials). Our primary outcome is 10‐year mortality, and other metrics such as cause of death; life years (LYs) and quality‐adjusted LYs over 10 years were evaluated in sensitivity analysis. For 55‐year‐old women with a 10‐year risk of metastatic recurrence <12.5% no chemotherapy resulted in the preferred strategy. In general, non‐AC‐based adjuvant chemotherapy resulted in lower 10‐year mortality than AC‐based chemotherapy. Patients with low risk of metastatic recurrence are better off without adjuvant chemotherapy regardless of the outcome considered (i.e., the risks of cardiac toxicity from chemotherapy outweighed the benefits). Trade‐offs between effectiveness and induced cardiac toxicity impact health outcomes. The choice of adjuvant treatment must consider the patient's risk of distant recurrence and the quality of life associated with different health outcomes.     

The Impact of Hazardous Drinking Among Active Duty Military With Posttraumatic Stress Disorder: Does Cognitive Processing Therapy Format Matter?

This study was a secondary data analysis of clinical trial data collected from 268 active duty U.S. military service members seeking cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) at Fort Hood, Texas, related to combat operations following September 11, 2001. Our primary aim was to evaluate changes in PTSD symptom severity and alcohol misuse as a function of baseline hazardous drinking and treatment format (i.e., group or individual). At baseline and posttreatment, PTSD was assessed using the PTSD Symptom Scale–Interview Version and PTSD Checklist for DSM‐5. Hazardous drinking was categorically defined as an Alcohol Use Disorder Identification Test total score of 8 or higher. Employing intent‐to‐treat, mixed‐effects regression analysis, all groups reported reduced PTSD symptom severity, Hedges’ gs = ?0.33 to ?1.01, except, unexpectedly, nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.12. Hazardous drinkers who were randomized to individual therapy had larger reductions in PTSD symptoms than nonhazardous drinkers who were randomized to group CPT, Hedges’ g = ?0.25. Hazardous drinkers also reported significant reductions in alcohol misuse, regardless of treatment format, Hedges’ gs = ?0.78 to ?0.86. This study builds upon an emerging literature suggesting that individuals with PTSD and co‐occurring alcohol use disorder can engage successfully in CPT, which appears to be an appropriate treatment for these individuals whether it is delivered individually or in a group format. However, as a portion of participants remained classified as hazardous drinkers at posttreatment, some individuals may benefit from integrated treatment.     

The Role of Anxiety in Simulation-Based Dexterity and Overall Performance: Does It Really Matter?

Background: Essential Skills in the Management of Surgical Cases (ESMSC) is an international undergraduate surgical masterclass which combines ex vivo, dry lab and high fidelity in vivo simulation-based learning (SBL). It consists of 32 stations of skills-based learning, including open reduction internal fixation (ORIF) of fractures. Current literature suggests early involvement in skills-based learning at the undergraduate level is vital. Aims: To compare students' dexterity and skills-based performance with demographic and educational background parameters. Methods: 112 medical students from European Union countries including the United Kingdom, Germany, Greece, Cyprus, Germany, and Bulgaria were selected from a competitive pool of candidates to attend the course. Students undertook ORIF in an ex vivo swine model, and in a simulated fracture on a bamboo rod. Skills-based performance was assessed by two consultant surgeons with validated direct observation of procedural skills (DOPS) forms. Anxiety was self-assessed using the Westside Anxiety Scale prior to the ORIF stations. Dexterity was measured with the O'Connor tweezer dexterity test. Results: Female students had significantly higher dexterity scores (median difference 7, p =.003). Right-handed students achieved higher dexterity than left-handed students (median difference 7, p =.043). There was no difference in students' performance across different medical schools, and across year groups (p <.05 for any correlation). Self-reported anxiety was not correlated with high fidelity skills-based performance (r = 0.032, p =.74). Conclusion: Anxiety does not seem to play a significant role in Simulation Skills-Based learning. Undergraduate surgical curricula should incorporate SBL-based modules to enhance practical skills learning and motivate future orthopedic surgeons.     

A Functional Near‐Infrared Spectroscopy Study of Trauma‐Related Auditory and Olfactory Cues: Posttraumatic Stress Disorder or Combat Experience?

The prevalence of posttraumatic stress disorder (PTSD) among U.S. veterans deployed to Iraq or Afghanistan necessitates the need for comprehensive assessment and treatment strategies. This study investigated the utility of a combat‐related PTSD symptom provocation paradigm to elicit unique neurological responses across three groups: combat veterans with PTSD, combat veterans without PTSD, and nonmilitary participants without PTSD. Using functional near‐infrared spectroscopy (fNIRS) the results indicated that combat veterans with PTSD demonstrated significant activation to a trauma‐related sound compared with nonmilitary personnel, channel 14: d = 1.03, 95% confidence interval (CI) [0.28, 1.76]; channel 15: d = 1.30, 95% CI [0.53, 2.06]; and combat veterans without PTSD, channel 14: d = 0.87, 95% CI [0.14, 1.59]. Specifically, this increased neural activation was approximately located in the right medial superior prefrontal cortex (Brodmann areas 9/10), an area associated with experiencing negative or threatening stimuli and emotional detachment. There were no differences across the groups for nontrauma‐related sounds. Results were less clear with respect to a combat‐related odor. These results suggest a specific neurophysiological response to trauma‐related cues and, if replicated, may offer a biomarker for combat‐related PTSD. Such a response could provide incremental validity over diagnostic assessments alone and assist in planning and monitoring of treatment outcome.     

The Seventh Prototype of the Mini‐Spindle‐Pump: Does It Fulfill the Expectations of a Short‐Term Pump?

According to recent trends to develop implantable nonpulsatile blood pumps for different function modes and times, our intention was and still is to build a Mini-Spindle-Pump for a pumping duration of about 14 days. Initial conception for this plan was the premise that the device in a mock circuit should move 4 L of water/min at a speed of 12,000 to 15,000 rpm against a pressure difference of 90 mm Hg between pump inlet and outlet. Despite the development of 6 different prototypes, this project was not realized. Under the above-mentioned conditions, the main problem of this type of blood pump, the blood trauma, could not be reduced to an adequate level, i.e., the Mini-Spindle-Pump is not a high speed pump. Therefore, a revision of the conception was necessary. The device in a mock circuit should transport 5 L of water/min at a speed of about 9,000 rpm against a pressure difference of 90 mm Hg between its inlet and outlet. Considering the implantability of the blood pump, the following measurements for its components were arrived at. The U-shaped blockformed plexiglas housing was enlarged to 120 x 40 x 40 mm (length of blood chamber 86 mm, inner diameter 27 mm), and the rotor with 5 windings was redesigned at a length of 64 mm (outer diameter 25 mm, inner diameter 6.7 mm). In a mock circuit, this 7th prototype transported with a speed of 9,000 rpm about 10 L of water/min at an afterload of 80 mm Hg. In acute animal experiments with calves up to 15 h of pumping duration, the device showed the expected efficiency. Experiments with a longer pumping duration are necessary to confirm that this prototype will fulfill the criteria of a short-term pump according to Dr. Y. Nosé's advice.     

The assessment of patient life‐expectancy: how accurate are urologists and oncologists?

OBJECTIVE: To assess the degree of accuracy, precision and consistency with which consultant urologists, oncologists and junior doctors predict a patient's 10-year life-expectancy. SUBJECTS AND METHODS: Eighteen doctors of varying seniority independently examined 70 patient case scenarios containing detailed medical histories; 13 of these cases were duplicate scenarios. Bland-Altman analyses were used to compare doctors' estimates of the probability of each hypothetical patient surviving 10 years with that calculated using actuarial methods. Intra- and interdoctor reliability were also assessed. RESULTS: Compared with actuarial estimates, doctors underestimated the 10-year survival probability by an overall mean of 10.8% (95% confidence interval, 10.1-11.5%). The 18 individual doctors ranged from a mean underestimation of 33.2% to a mean overestimation of 3.9%. Variation around these means was considerable for each doctor, the standard deviations being 14.5-20.9%. Inter-doctor reliability was 0.58, while overall intra-doctor reliability was 0.74, but for individual doctors was 0.31-0.94. Junior doctors were less accurate in their predictions than the senior doctors. Five doctors tended to overestimate where life-expectancy was poor and underestimate where it was good. CONCLUSIONS: Doctors were poor at predicting 10-year survival, tending to underestimate when compared with actuarial estimates. There was also substantial variability both within and between doctors. The inaccuracy, imprecision and inconsistency amongst the doctors in assessing patient life-expectancy is an important finding and has significant implications for managing patients. Many patients may be denied treatment after a pessimistic assessment of life-expectancy and (less commonly) some may inappropriately be offered treatment after an optimistic assessment. The particular inaccuracy in junior doctors compared with their senior colleagues also highlights the need for training. The development of a tool to assist in both training and clinical practice has the potential to improve doctors' decision-making and patient care.