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.     

Effect of rational and irrational beliefs on intensity and “inappropriateness” of feelings: A test of rational—emotive theory

This study tested the central rational-emotive hypothesis that greater inappropriate emotional distress is caused by irrational rather than rational beliefs about undesirable situations. Ellis and Harper (1975) have suggested that inappropriate emotions (such as anger) differ qualitatively from appropriate emotions (such as annoyance). Previous research, however, indicates that irrational beliefs are associated with greater appropriate as well as inappropriate negative emotions. In this study, a 3 ×2 pretest—posttest factorial design was used, in which 10 undergraduates of either sex were randomly assigned to one of three treatments, which involved imagining being in a situation. The control condition comprised an emotionally neutral scene, while the two experimental treatments contained rational and irrational statements about being left alone by one's partner at a party. The experimental manipulation was successful, and both inappropriate and appropriate negative emotions were found to be greater in the irrational condition as compared to the neutral or rational condition. Thus irrational beliefs were shown to have an effect on emotions, but the emotions associated with irrational beliefs differed from those associated with rational beliefs in quantity rather than in quality.     

Early evaluation of coagulase negative staphylococcus in blood samples of intensive care unit patients

Of 2160 intensive care unit patients, 36 patients with positive blood cultures had coagulasenegative staphylococcus in one blood bottle, whereas the organism was present in two or more bottles in 38 cases. The groups were not significantly different in 27 clinical variables, obtained at the time of their first positive blood culture. There was also no significant difference in the antimicrobial sensitivities. No initial clinical data supported the classification of coagulase-negative staphylococcus as either pathogen or contaminant.When the 74 patients with blood culture positive coagulase-negative staphylococcus were compared with three control groups (absent septicemia, probable septicemia and proven septicemia) they were not different from those with probable septicemia. A discriminant analysis was performed comparing patients with absent septicemia and with proven septicemia in an attempt to classify patients with isolates of coagulase-negative staphylococcus in one of these groups at an early stage. Patients with two or more positive blood cultures were not statistically classified more frequently as septicemic than patients with one blood bottle positive for this organism. However, patients categorized as septicemic had a significantly higher mortality (59%) than those classified as non-septicemic (35%) (p<0.05).     

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.     

Imaging features of splenic epidermoid cyst with pathologic correlation

The spleen can be involved in a variety of cystic lesions ranging from cystic neoplasms and parasitic cysts to true and false cysts. Epidermoid splenic cyst is a rare true cyst that is developmental in origin. We present two young patients with such a cyst and illustrate their features on ultrasound, CT, and MRI with pathologic correlation.     

Cognitive Mechanisms in the Avoidance of Painful and Dangerous Thoughts: Elaborating the Assimilation Model

The emotional processing of problematicexperiences is a central feature of psychotherapy.Stiles et al. (1990) propose an Assimilation model as ageneric account of such processes. This paper focuses on two aspects of this model: the concepts ofwarding off and unwantedthoughts showing how a cognitive scienceperspective can enrich our understanding of them. Wefocus on the ways in which cognitive processes (particularly different sorts ofmemory) mediate between experience and psychopathology.Two classes of problematic experiences that can beavoided or barred from full awareness to varying degrees are distinguished. We refer to this distinctionas the pain paradigm, in which experiencesare inaccessible to memory retrieval using verbalmnemonics,versus the panic paradigm, inwhich experiences fail to be retrieved or reported because theperson anticipates catastrophic consequences. We discusshow understanding the cognitive origins of thesephenomena promises to allow researchers and therapists to generate new approaches to overcome blocksin therapy.     

The effects of PEEP on arterial oxygenation

The effect of positive end expiratory pressure (PEEP) on arterial oxygenation depends on many factors. Two of the most important are the quality and the quantity of the physiological shunt. The quality depends on the mixed venous oxygen tension, and the quantity on the shunt fraction. Each of these factors may rise or fall with PEEP, depending on the pulmonary and circulatory state of the patient. Their ultimate balance influences the change in arterial oxygen tension.     

A Prospective Study of the Impact of Polygraphy on High-Risk Behaviors in Adult Sex Offenders

This study examined whether polygraph testing would result in sex offenders engaging in fewer high-risk behaviors. Fifty adult male sex offenders taking part in community treatment programs were allocated into 2 groups: Polygraph Aware subjects were told they would receive a polygraph examination in 3 months regarding their high-risk behaviors, while Polygraph Unaware subjects were told their behavior would be reviewed in 3 months. Relevant behaviors for each subject were established at baseline interviews, following which both groups were polygraphed at 3 months. All subjects were polygraphed again at 6 months. The hypothesis was that subjects in the Polygraph Aware group would have engaged in fewer high-risk behaviors, based on their self-report during the examination. Thirty-two subjects (64%) attended the first polygraph examination, with 31 (97%) disclosing an average of 2.45 high-risk behaviors each previously unknown to supervising probation officers. There was no significant difference between the two groups. Because of the high failure rate, all subjects were told to expect a second polygraph. Twenty-one subjects (42%) completed the second polygraph test, with 71% disclosing an average of 1.57 behaviors, a significant decrease compared with the first test. Disclosures to treatment providers and probation officers also increased. It was concluded that polygraph testing resulted in offenders engaging in less high-risk behavior, although the possibility that offenders fabricated reports of high-risk behaviours to satisfy examiners is also considered; similarly, offenders seemed to be more honest with their supervisors, but this only occurred after experience of the test itself. Feedback from offenders who completed the study, taken together with the high drop out rate, suggested that those motivated not to reoffend found polygraphy useful, while those less motivated sought to avoid it.     

Shock and the kidney: Pathophysiology and pharmacological support

This article reviews current knowledge as to the physiological mechanisms that control renal vascular resistence. The contribution of both extrinsic and intrinsic neuro-humoral regulation of both blood flow and glomerular filtration rate are described. The changes that occur both to the renal blood flow and glomerular filtration rate in the pathophysiological situation of pre-renal uraemia as well as acute tubular necrosis are described. Within this setting pharmacological manoeuvres that may improve both renal blood flow and glomerular filtration rate are discussed. In addition, the indications for and general principles of haemo- and peritoneal dialysis are described.     

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.     

A new method for the diagnosis of acute hemorrhagic-necrotizing pancreatitis using contrast-enhanced CT

Twenty-eight consecutive patients with a first attack of alcohol-induced pancreatitis were studied using contrast-enhanced CT. The findings on CT were then related to the course of the disease. The patients with acute hemorrhagic-necrotizing pancreatitis showed significantly lower enhancement values of the pancreatic parenchyma than those with milder forms of the disease.The next 20 patients with severe pancreatitis were scanned using a slightly modified procedure. The enhancement values were calculated and plotted on the graphs for the 2 former groups.Two categories of pancreatic enhancement were found: low enhancement and high enhancement. In all 10 patients with low-enhancement values surgery revealed hemorrhagic-necrotizing pancreatitis. In the 10 patients with highenhancement values conservative treatment was continued, and the clinical course was nonfulminant in all of them.     

The “lung pulse”: an early ultrasound sign of complete atelectasis

Objective Complete atelectasis can be immediately generated by selective intubation. A dynamic lung ultrasound sign can be described as the association of absent lung sliding with the perception of heart activity at the pleural line, a sign which was called lung pulse. We examined whether this sign be used promptly to confirm complete atelectasis due to selective intubation.Design and setting Prospective study in the medical intensive care unit of a university-affiliated teaching hospital.Patients Consecutive patients with no history of respiratory disorders and needing intubation were enrolled. Fifteen patients with selective intubation of the right lung were compared with 30 patients with nonselective intubation and 15 healthy volunteers.Interventions The lung pulse was sought at the left anterolateral chest wall in intubated patients. Healthy subjects were studied during breathing and apnea.Results A left lung pulse was immediately present in 14 of 15 patients with right selective intubation, and absent, with normal lung sliding, in all 30 correctly intubated patients and in all 15 healthy subjects during breathing. All healthy subjects exhibited a lung pulse in apnea. The lung pulse had a sensitivity of 93% and a specificity of 100% for the diagnosis of complete atelectasis following selective intubation in patients without previous respiratory disorders.Conclusions The lung pulse is a sign of complete atelectasis which is observable immediately before radiological changes. Its absence which is correlated with the absence of selective intubation and of conserved lung inflation can eliminate the need for confirmation radiography.Electronic Supplementary Supplementary material is available in the online version of this article at .     

Non-invasive ventilation for cancer patients with life-support techniques limitation

Goals of work The study was conducted to determine the usefulness and efficacy of non-invasive ventilation (NIV) in cancer patients with life-support techniques limitation admitted for an acute respiratory distress, in terms of intensive care unit (ICU) and hospital discharges.Patients and methods A total of 18 consecutive cancer patients (17 with solid tumours and one with haematological malignancy) with life-support techniques limitation in acute respiratory failure and who benefited from NIV were included. NIV was provided with a standard face mask by the BiPAP Vision ventilator (Respironics Inc.). Variables related to the demographic parameters, SAPS II score, cancer characteristics, intensive care data and hospital discharge were recorded.Main results Complications leading to NIV were hypoxemic respiratory failure in 11 patients and hypercapnic respiratory failure in seven. Total median duration of NIV was 29 h. NIV was applied during a median of 2.5 days with a median of 16 h per day. Total median ICU stay was 7 days (range 1–21). Fourteen and ten patients were discharged from ICU and from hospital, respectively.Conclusion NIV appears to be an effective ventilation support for cancer patients with life-support techniques limitation.     

The roles of historical experience and construct accessibility in judgments about alcoholism

A preliminary survey study (1) screened potential subjects and (2) identified characteristics associated with alcoholic and social drinker labels. Subjects at three experience levels (parent alcoholic, friend alcoholic, and no experience) then participated in a perception experiment in which a construct (alcoholic/social drinker) was experimentally primed, followed by an interpersonal understanding experiment in which subjects rated the drinking habits either of hypothetical others or of the self in hypothetical situations. Results indicated that primes significantly interacted with level of prior experience (only subjects with no historical experience tended to make drinking judgments that were more in the direction of alcoholism following an alcoholic prime). Results are discussed in terms of the notion that increased historical exposure to a construct may lead to the development of clearer construct boundaries, thereby reducing the tendency toward indiscriminate construct use under conditions of heightened accessibility.The present research was supported in part by the National Institute on Alcohol Abuse and Alcoholism Research Grant No. AA-06319 to the first author. Parts of this study were presented at the annual meeting of the American Psychological Association, Anaheim, California, August 1983.     

Chronic daily headache: recent insights from functional imaging

Abstract New imaging technology allows us to study neurologic disorders that have had no previous structural basis. There have been recent reports on the involvement of nociceptive pathways in daily headache. A systematic review was performed using key words chronic daily headache and imaging. This paper reviews the literature on imaging studies performed on daily headache with emphasis on the new imaging technology.     

New aspects of pulmonary mechanics: ‘slowly” distensible compartments of the respiratory system,identified by a PEEP step maneuver

Objective The aims of the present study were 1) to evaluate a method for identification of slowly distensible compartments of the respiratory system (rs), which are characterized by long mechanical time constants (RC) and 2) to identify slowly distensible rs-compartments in mechanically ventilated patients.Design Prospective studyon a physical lung model.Setting Intensive Care Unit, University Hospital, Tübingen.Patients and participants 19 patients with severe lung injury (acute respiratory distress syndrome, ARDS) and on 10 patients with mild lung injury.Measurements and results Positive end-expiratory pressure (PEEP)-increasing and-decreasing steps of about 5 cmH₂O were applied and the breath-by-breath differences of inspiratory and expiratory volumes (V) were measured. The sequence of Vs were analyzed in terms of volume change in the fast compartment (V_fast), the slow compartment (V_slow), total change in lung volume (VL) and mechanical time constant of the slow compartment (RC_slow). Thirty-eight measurements in a lung model revealed a good correlation between the preset V_slow/VL and V_slow/VL measured: r²=0.91 The V_slow/VL measured amounted to 0.94±0.15 of V_slow/VL in the lung model. RC_slow measured was 0.92±0.43 of the RC_slow reference. Starting from a PEEP level of 11 cmH₂O PEEP-increasing and PEEP-decreasing steps were applied to the mechanically ventilated patients. Three out of ten patients with mild lung injury (30%) and 7/19 patients with ARDS (36.8%) revealed slowly distensible rscompartments in a PEEP-increasing step, whereas 15/19 ARDS patients and 1/10 patients with mild lung injury showed slowly distensible rs-compartments in a PEEP-decreasing step (78.9% vs 10%,P<0.002, chi-square test).Conclusions The gas distribution properties of the respiratory system can be easily studied by a PEEP-step maneuver. The relative contribution of the slow units to the total increase of lung volume following a PEEP step could be adequately assessed. Slowly distensible rs-compartments could be detected in patients with severe and mild lung injury, however significantly more ARDS patients revealed slow rs-compartments in PEEP-decreasing steps. The influence of slowly distensible rs-compartments on pulmonary gas exchange is unknown and has yet to be studied.The work was performed at the Klinik für Anaesthesiologie und Transfusionsmedizin der Universität Tübingen     

Action control as a vulnerability factor in dysphoria

Kuhl (1984) recently has advanced a theoretical account of metacognitive processes which allow one to exert a measure of voluntary control over one's emotions and cognitions and which assist in the translation of intentions into actions. Central to the theory is the idea that individual differences have an important impact on the ability to exert such controls. It also has been hypothesized (Kuhl, 1984) that persons who are lower in control resources (state-oriented persons) are more vulnerable to depression. The present research tested this hypothesis and provides support for it. The results show that state-oriented persons are more likely to be dysphoric and that stressful life events have a more adverse impact on state-oriented persons. The results also show that future levels of dysphoria can be predicted by current level of state orientation.     

History of psychotherapeutic intervention in cancer patients

Several important aspects of the history of psychotherapeutic interventions in cancer patients, such as the historical role of the cancer personality, the change in the conceptualization of the mind-body relationship and the influence of medical progress and social developments, are discussed.Presented at the Symposium Psychotherapeutic Interventions in Cancer Patients, Flims, Switzerland, 12–14 January 1995     

Mnemonic distortion following behavior observation: Interactions of negative versus positive behavior valence,diagnostic label,and relative behavior frequency

To study how diagnostic labels, positive or negative behavior valence, and high versus low behavior frequencies affect distortion of memory for behavior, 72 undergraduates used an observation system to record occurrences of 10 negative and 10 positive behaviors shown on one of two videotapes of a child. Pilot testing had verified that one tape showed many negative but few positive behaviors, and that the other tape showed few negative but many positive behaviors. Just before viewing the tape, subjects were told either that the child was behaviorally disturbed or normal, or had been given no label. Exaggeration of observed frequencies at a 1-week recall was shown by significant and separate interactions of behavior valence and frequency, and of behavior valence and label. Specifically, negative behavior frequencies were exaggerated significantly at recall when the behaviorally disturbed or no label was present for both high and low frequencies of the negative behaviors. However, recalled frequencies of negative behaviors were exaggerated for the normal label only when they were low in frequency relative to positive behaviors. Positive behavior frequencies were exaggerated significantly in memory only if the normal label was used and then only if the positive behaviors had occurred at low frequencies relative to negative behaviors. No significant underestimation of previously observed behavior frequencies was found for either positive or negative behaviors. Implications of these findings for cognitive theories of memory and behavior, and for minimization of mnemonic stigma, are noted.We thank Laurie Kaslove for composing the videotapes used in this study, and Chris Beebe, Gail Morganstein, and Eric Pedersen for serving as experimenters.     

Two Bankrobbers With “Antisocial” and “Schizoid/Avoidant” Personality Disorders, Comorbid With Partial Seizures: Temporal Lobe Epilepsy and Limbic Psychotic Trigger Reaction, Respectively

Diagnostic overshadowing is illustrated by two cases of unplanned, motiveless bank robbery, initially merely attributed to antisocoial or schizoid/avoidant (loner) personality disorder, respectively. Both disorders, however, were comorbid with their potentially unobservable counterparts, with brief partial seizures, supported by both men's abnormal scalp-EEG's, their symptomatology with psychosis, and their histories of closed head injury in childhood. Such injuries are known to render particularly the temporo-limbic brain system susceptible to later partial seizure: Mr. A. had temporal lobe epilepsy (TLE) with stereotypic auditory command hallucinations and clouding of consciousness. (His past antisocial aggressive behavior might also have reflected TLE-related inter-ictal events.) Mr. B. had the symptomatology proposed as limbic psychotic trigger reaction (LPTR). Mr. B., a social loner, typically ruminated on past intermittent moderate stresses, a specific precondition of seizure kindling, ultimately elicited by a specific stimulus, resembling his past hurts. As is typical for LPTR, Mr. B. had no clouding of consciousness and no amnesia for his atavistically regressive acts, committed with flat affect, nausea, and fleeting delusions of grandeur (being gifted, like Rembrandt).