Ovarian carcinoma: Management of stress in patients and physicians

A discussion of the management of ovarian cancer invariably involves the problems of death and dying faced by the patient, her family, and her physician. This paper attempts to deal with the general fears, anxieties, and problems of terminality, and also places attention on specific issues involved in living with the ongoing disease and its treatments. Focus is on the effects of the disease on the woman's self-image, on her family and relationships, on life outside the hospital, and on her relationship with her attending physician. Specific problems relating to the periods of (1) diagnosis, (2) operative management and treatment, and (3) terminality are discussed. Understanding the psychosocial realities of the patient provides the physician with added insights into methods to assist the patient in adaptation and coping with this ultimately fatal disease.     

Learned responses to movement in neonates

Numerous previous reports have pointed to the importance of movement (vestibular) stimulation in early infancy. Nevertheless, we have currently no clear understanding of these effects. The present paper looks at the role of movement stimulation in the modification of inborn organized patterns of response. Two laboratory experiments are reported in which newborn infants were presented with a cue (movement stimulus) which was either paired with dextrose presentation (experimental group) or not paired (control group). The experimental and control groups differed on the pattern of sucking in extinction, indicating an effect due to the contiguous presentation of movement and dextrose. Those experiments provide an analog for some naturally occurring conditions in early infancy and support some Soviet observations on the development of the earliest conditioned responses.     

Hyperbaric oxygen for carbon monoxide poisoning : a systematic review and critical analysis of the evidence

Poisoning with carbon monoxide (CO) is an important cause of unintentional and intentional injury worldwide. Hyperbaric oxygen (HBO) enhances CO elimination and has been postulated to reduce the incidence of neurological sequelae. These observations have led some clinicians to use HBO for selected patients with CO poisoning, although there is considerable variability in clinical practice. This article assesses the effectiveness of HBO compared with normobaric oxygen (NBO) for the prevention of neurological sequelae in patients with acute CO poisoning. The following databases were searched: MEDLINE (1966 to present), EMBASE (1980 to present), and the Controlled Trials Register of the Cochrane Collaboration, supplemented by a manual review of bibliographies of identified articles and discussion with recognised content experts. All randomised controlled trials involving people acutely poisoned with CO, regardless of severity, were examined. The primary analysis included all trials from which data could be extracted. Sensitivity analysis examined trials with better validity (defined using the validated instrument of Jadad) and those enrolling more severely poisoned patients. Two reviewers independently extracted from each trial, including information on the number of randomised patients, types of participants, the dose and duration of the intervention, and the prevalence of neurological sequelae at follow-up. A pooled odds ratio (OR) for the presence of neurological symptoms at 1-month follow-up was calculated using a random effects model. Bayesian models were also investigated to illustrate the degree of certainty about clinical effectiveness. Eight randomised controlled trials were identified. Two had no evaluable data and were excluded. The remaining trials were of varying quality and two have been published only as abstracts. The severity of CO poisoning varied among trials. At 1-month follow-up after treatment, sequelae possibly related to CO poisoning were present in 242 of 761 patients (36.1%) treated with NBO, compared with 259 of 718 patients (31.8%) treated with HBO. Restricting the analysis to the trials with the highest quality scores or those that enrolled all patients regardless of severity did not change the lack of statistical significance in the outcome of the pooled analysis. We found empiric evidence of multiple biases that operated to inflate the benefit of HBO in two positive trials. In contrast, the interpretation of negative trials was hampered by low rates of follow-up, unusual interventions for control patients and inclusion of less severely poisoned patients. Collectively, these limitations may have led negative trials to overlook a real and substantial benefit of HBO (type II error). There is conflicting evidence regarding the efficacy of HBO treatment for patients with CO poisoning. Methodological shortcomings are evident in all published trials, with empiric evidence of bias in some, particularly those that suggest a benefit of HBO. Bayesian analysis further illustrates the uncertainty about a meaningful clinical benefit. Consequently, firm guidelines regarding the use of HBO for patients with CO poisoning cannot be established. Further research is needed to better define the role of HBO, if any, in the treatment of CO poisoning. Such research should not exclude patients with severe poisoning, have a primary outcome that is clinically meaningful and have oversight from an independent data monitoring and ethics committee.