The person of the therapist

Abstract Reversing the current primacy in outcome studies of therapy comparisons, this study brings the person of the therapist to the fore. The character of the therapist is a vital component in effective psychotherapy, especially ambitious, relationship-focused, long-term work. Although the person-therapist relationship contributes only 10 to 20% to outcome, identifying beneficial and malign characteristics across therapies is a fruitful area for research, training, and service delivery.     

The effect of clonidine on the minimum local analgesic concentration of epidural ropivacaine during labor

On the basis of the determination of minimum local analgesic concentration (MLAC), ropivacaine has been demonstrated to be less potent than bupivacaine during the first stage of labor. In this study we assessed the effect of clonidine on the MLAC of ropivacaine. Seventy-seven parturients of mixed parity requesting epidural analgesia for labor (cervical dilation, 3-7 cm) were included in the study. They received an epidural bolus of either ropivacaine (n = 30), ropivacaine plus clonidine 30 microg (n = 28), or ropivacaine plus clonidine 60 microg (n = 19) in the second part of the study. The concentration of the ropivacaine solution was determined by the response of the previous parturient in that group by using an up-down sequential allocation. A visual analog pain score of < or =10 mm within 30 min after the epidural bolus (20 mL) was considered an effective response. An effective result directed a 0.01% wt/vol decrement for the next patient. An ineffective result directed a 0.01% wt/vol increment. The MLAC of ropivacaine was 0.097% wt/vol (95% confidence interval, 0.085%-0.108%). It was unaffected by a 30-microg dose of epidural clonidine (0.081% [0.045%-0.117%]) but was significantly decreased by a 60-microg clonidine dose (0.035% [0.024%-0.046%]) (P < 0.001). This study documents a decrease in the MLAC of ropivacaine by clonidine, significant for a 60- microg dose. IMPLICATIONS: Epidural ropivacaine potency in labor can be increased by the addition of epidural clonidine. This study demonstrates that 60 microg of epidural clonidine significantly decreases the minimum local analgesic concentration of ropivacaine during the first stage of labor but is associated with sedation.     

Genetic diversity of Mycobacterium africanum clinical isolates based on IS6110-restriction fragment length polymorphism analysis, spoligotyping, and variable number of tandem DNA repeats

A collection of 105 clinical isolates originally identified as Mycobacterium africanum were characterized using both phenotypic and genotyping methods. The phenotypic methods included routine determination of cultural properties and biochemical tests used to discriminate among the members of the M. tuberculosis complex, whereas genotypic characterization was based on IS6110-restriction fragment length polymorphism (IS6110-RFLP) analysis, IS1081-RFLP analysis, direct repeat-based spacer oligonucleotide typing (spoligotyping), variable number of tandem DNA repeats (VNTR), and the polymorphism of the oxyR, pncA, and mtp40 loci. The results obtained showed that a majority of M. africanum isolates were characterized by a specific spoligotyping pattern that was intermediate between those of M. tuberculosis and M. bovis, which do not hybridize with spacers 33 to 36 and spacers 39 to 43, respectively. A tentative M. africanum-specific spoligotyping signature appeared to be absence of spacers 8, 9, and 39. Based on spoligotyping, as well as the polymorphism of oxyR and pncA, a total of 24 isolates were excluded from the final study (19 were identified as M. tuberculosis, 2 were identified as M. canetti, and 3 were identified as M. bovis). The remaining 81 M. africanum isolates were efficiently subtyped in three distinct subtypes (A1 to A3) by IS6110-RFLP analysis and spoligotyping. The A1 and A2 subgroups were relatively more homogeneous upon spoligotyping than A3. Further analysis of the three subtypes by VNTR corroborated the highly homogeneous nature of the A2 subtype but showed significant variations for subtypes A1 and A3. A phylogenetic tree based on a selection of isolates representing the three subtypes using VNTR and spoligotyping alone or in combination confirmed the subtypes described as well as the heterogeneity of subtype A3.     

Tuberculosis in the Caribbean: using spacer oligonucleotide typing to understand strain origin and transmission.

We used direct repeat (DR)-based spacer oligonucleotide typing (spoligotyping) (in association with double-repetitive element polymerase chain reaction, IS6110-restriction fragment length polymorphism [RFLP], and sometimes DR-RFLP and polymorphic GC-rich sequence-RFLP) to detect epidemiologic links and transmission patterns of Mycobacterium tuberculosis on Martinique, Guadeloupe, and French Guiana. In more than a third of the 218 strains we typed from this region, clusters and isolates shared genetic identity, which suggests epidemiologic links. However, because of limited epidemiologic information, only 14.2% of the strains could be directly linked. When spoligotyping patterns shared by two or more isolates were pooled with 392 spoligotypes from other parts of the world, new matches were detected, which suggests imported transmission. Persisting foci of endemic disease and increased active transmission due to high population flux and HIV-coinfection may be linked to the recent reemergence of tuberculosis in the Caribbean. We also found that several distinct families of spoligotypes are overrepresented in this region.     

Immunosuppression by delta-opioid antagonist naltrindole: delta- and triple mu/delta/kappa-opioid receptor knockout mice reveal a nonopioid activity

The delta-opioid antagonist naltrindole has been shown to inhibit graft rejection in vivo and suppress allogeneic mixed lymphocyte reaction (MLR) in vitro, similarly to cyclosporin A. We investigated whether this action is mediated by delta-opioid receptors using both genetic and pharmacological tools. Naltrindole and two related compounds, 7-benzylidene-7-dehydronaltrexone and naltriben, inhibited MLR performed with lymphocytes from wild-type and delta-opioid receptor knockout mice, with comparable potency. Furthermore, these compounds suppressed the proliferation of spleen cells from triple delta/mu/kappa-opioid receptor-deficient animals as well. Finally, the highly delta-selective, but structurally distinct, antagonist N,N-dimethyl-Dmt-Tic-OH and the general opioid antagonist naltrexone were inactive in the MLR assay. In conclusion, we demonstrate for the first time that the immunosuppressive activity of naltrindole and close derivatives is not mediated by any of the three cloned opioid receptors. Therefore, the postulated inhibitory activity of naltrindole in the graft rejection process is mediated by a target, which remains to be discovered.     

坦桑尼亚一家三级医院耳鼻喉科咽喉反流性疾病的患病率与临床特征

目的咽喉反流性疾病(LPRD)是一种非特异性疾病.晚期可导致恶性肿瘤。在坦桑尼亚耳鼻喉科的患者中,LPRD的患病率和临床特征尚未明确。方法本研究是一项基于医院的描述性横断面研究,在坦桑尼亚莫西比利国立医院耳鼻喉科的病房和门诊进行。将有咽喉反流性疾病症状的患者纳入本研究。通过问卷和临床检查表收集数据,使用SPSS软件处理和分析数据。结果研究纳人256例患者,其中男性131例(51.2%)。年龄41.38+13.94岁。咽喉反流性疾病的患病率为18.4%.男女无明显差异。常见症状是咽异物感(95.79%6)、声嘶(88.1%)和过度清嗓(83.0%),见的体征是喉内黏液附着(9.9%),声带水肿(88.6%)和部分喉室消失(72.7%)。饭后2 h内平卧和辛辣食物是该病的危险因素。高血压和2型糖尿病是与咽喉反流性疾病相关的最常见合并症。结论LPRD在坦桑尼亚莫西比利国立医院耳鼻喉科就诊者中患病率高。所有具有LPRD相关症状的患者应尽早诊断和治疗。     

Postoperative analgesia and early rehabilitation after total knee replacement: A comparison of continuous low‐dose intravenous ketamine versus nefopam

The effects of nefopam and ketamine on pain control and rehabilitation after total knee replacement were compared in a prospective, double blinded study.Seventy-five patients were randomly assigned to receive a 0.2 mg kg^?1 bolus of nefopam or ketamine, followed by a 120 μg kg^?1 h^?1 continuous infusion until the end of surgery, and 60 μg kg^?1 h^?1 until the second postoperative day, or an equal volume of saline considered as placebo. Pain scores measured on a visual analog scale at rest and on mobilization, and patient-controlled intravenous morphine consumption, were assessed during 48 h. We measured the maximal knee flexion on the third postoperative day, and the delay to obtain a 90° flexion.Ketamine and nefopam reduced morphine consumption (p < 0.0001). Pain scores, were lower at rest and on mobilization in the ketamine group compared to the two other groups at all times of measurement. Pain score were lower in patients receiving nefopam compared to placebo, on arrival in the recovery room and at 2 h. Ketamine improved knee flexion on post operative day 3 (59° [33–63] vs. 50° [47–55] and 50° [44–55] in ketamine, placebo and nefopam groups, respectively, p < 0.0002) and decreased the delay to flex the knee at 90° (9.1 ± 4.2 vs. 12.3 ± 4.0 days, in ketamine and placebo groups, respectively, p = 0.01).Ketamine produces opioid-sparing, decreases pain intensity, and improves mobilization after total knee replacement. Nefopam achieves less significant results in that circumstances.