The witches’ brew of spirituality and medicine

Recent proposals to join spirituality and medicine are facile and ill defined. The notion that physicians have the time or training to make assessments and recommendations about spirituality is misguided. Whenever a physician demonstrates personal caring for a patient, the healing process is likely enhanced, and in that sense, physicians often promote the spirituality of the patient. However, recent proposals to extend the physician’s task to that of assessing religion and directing the patient toward approved forms of spirituality are inappropriate. The languages of religion and science are radically different. The cultural body-mind split will not be solved by such simplistic solutions as having physicians endorse spirituality, which will result only in denigration of both medicine and religion. Physicians are encouraged to rely on clinically trained ministers for assistance in understanding the patient’s state of mind or spirit and its possible effects on the course of illness and health.     

INTRA-AORTIC BALLOON RUPTURE CAUSING FEMORAL ENTRAPMENT

Rupture of an intra-aortic balloon counterpulsator (IABCP) demands immediate removal. We report a case of thrombus formation within a Datascope IABCP secondary to IABCP rupture, necessitating surgical exploration for removal. There is a disturbing pattern of balloon ruptures with this type of IABCP.     

Guidelines for environmental infection control in health-care facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).

The health-care facility environment is rarely implicated in disease transmission, except among patients who are immunocompromised. Nonetheless, inadvertent exposures to environmental pathogens (e.g., Aspergillus spp. and Legionella spp.) or airborne pathogens (e.g., Mycobacterium tuberculosis and varicella-zoster virus) can result in adverse patient outcomes and cause illness among health-care workers. Environmental infection-control strategies and engineering controls can effectively prevent these infections. The incidence of health-care--associated infections and pseudo-outbreaks can be minimized by 1) appropriate use of cleaners and disinfectants; 2) appropriate maintenance of medical equipment (e.g., automated endoscope reprocessors or hydrotherapy equipment); 3) adherence to water-quality standards for hemodialysis, and to ventilation standards for specialized care environments (e.g., airborne infection isolation rooms, protective environments, or operating rooms); and 4) prompt management of water intrusion into the facility. Routine environmental sampling is not usually advised, except for water quality determinations in hemodialysis settings and other situations where sampling is directed by epidemiologic principles, and results can be applied directly to infection-control decisions. This report reviews previous guidelines and strategies for preventing environment-associated infections in health-care facilities and offers recommendations. These include 1) evidence-based recommendations supported by studies; 2) requirements of federal agencies (e.g., Food and Drug Administration, U.S. Environmental Protection Agency, U.S. Department of Labor, Occupational Safety and Health Administration, and U.S. Department of Justice); 3) guidelines and standards from building and equipment professional organizations (e.g., American Institute of Architects, Association for the Advancement of Medical Instrumentation, and American Society of Heating, Refrigeration, and Air-Conditioning Engineers); 4) recommendations derived from scientific theory or rationale; and 5) experienced opinions based upon infection-control and engineering practices. The report also suggests a series of performance measurements as a means to evaluate infection-control efforts.     

Differentiation between organic and functional psychiatric illness in the elderly: An evaluation of four cognitive tests

One hundred and sixty-four patients admitted to a psychogeriatric unit were given a combination of four different cognitive tests: the Mini Mental State Examination (MMSE), the Abbreviated Mental Test Score, The Felix Post Unit Score and the compilation of tests recommended by the MRC Alzheimer's Disease Workshop. The tests were compared with respect to their ability to sort accurately cases of dementia and depression, and the effects of age and education on test score and misclassification rate with diagnosis controlled for. The MMSE had a very high misclassification rate for the poorly educated and depressed group. The logistical discriminant functional analysis selected only eight items as the best discriminators between organic/ functional or dementia/depression groups. Only one of these eight was not either a memory or orientation test. The value of simply adding up tests of different aspects of cognitive function in dementia assessment or screening is questioned.     

The impact of coding process on observed cancer mortality trends in Switzerland.

Official cancer mortality in Switzerland decreased by about 16% over the 9-year period 1990-1998 and this trend has often been used to suggest that secondary prevention by screening for breast cancer could be useless. However, the clear downshift observed between 1994 and 1995 for some cancers, such as female breast and prostate, and the simultaneous change in ICD classification used by the Federal Office for Statistics in 1995 (ICD-8 to ICD-10) could be related, suggesting an impact of coding process on the observed trend. For every death occurred between 1980 and 1999, the death certificates have been retrieved, the cause of death has been recoded and site-specific mortality rates have been calculated again for each year during this period. As suggested, the trend appears to be overestimated: in order to be comparable with current rates, the mortality observed before 1995 should be lowered by about 7% for men and 5% for women. The error may be partially due to attributing the cause of death to co-morbidity factors not normally (and nowadays) defined as the underlying cause. Logically, the impact of such a miscoding is more important among older people and for cancer sites with long survival. For instance, the correction should be around 15% for female breast, 12% for prostate and up to 40% for testicular cancer.     

Comparison of monochromatic ocular aberrations measured with an objective cross-cylinder aberroscope and a Shack-Hartmann aberrometer.

Repeated measures of wavefront aberrations were taken along the line-of-sight of seven eyes using two instruments: an objective, cross-cylinder aberroscope (OA) and a Shack-Hartmann (SH) aberrometer. Both instruments were implemented on the same optical table to facilitate interleaved measurements on the same eyes under similar experimental conditions. Variability of repeated measures of individual coefficients tended to be much greater for OA data than for SH data. Although Zernike coefficients obtained from a single measurement were generally larger when measured with the OA than with the SH, the averages across five trials were often smaller for the OA. The Zernike coefficients obtained from the two instruments were not significantly correlated. Radial modulation-transfer functions and point-spread functions derived from the two sets of measurements were similar for some subjects, but not all. When average Zernike coefficients were used to determine optical quality, the OA indicated superior optics in some eyes, but the reverse trend was true if Zernike coefficients from individual trials were used. Possible reasons for discrepancies between the OA and SH measurements include difference in sampling density, quality of data images, alignment errors, and temporal fluctuations. Multivariate statistical analysis indicated that the SH aberrometer discriminated between subjects much better than did the objective aberroscope.     

Effects of postoperative pain on lung volume in patients undergoing aortic surgery

To evaluate the potential advantages of the administration of extradural morphine to control postoperative pain and its effects on respiratory function, 39 patients were randomly assigned to one of two groups before aortic surgery. The first group (20 patients) received intravenous analgesia as required (control group). The second group (19 patients) received extradural morphine in a programmed fashion. During the immediate postoperative period the following parameters were measured in both groups: respiratory rate, vital capacity, peak expiratory volume in the first second, PaO2, PaCO2, arterial pH, heart rate, and systolic and diastolic blood pressure. In the group treated with morphine the postoperative increase in heart and respiratory rate was significantly smaller than in the control group (p less than 0.01). Postoperative forced pulmonary volumes were higher in the morphine group (p less than 0.01). However, there were no differences in time of hospitalization between both groups. There were more complications in the control group, but the difference did not reach statistical significance.     

Isoflurane in pulmonary hypertension and failure of the right ventricle

We evaluated the effects of the use of 1.2% isoflurane (group A) in a group of patients (n = 13) referred for mitral valve surgery, with pulmonary hypertension and right ventricular failure. We evaluated the hemodynamic status in baseline conditions, after isoflurane ++ administration and in relative hyper- and hypovolemia. We compared the results with those in 17 patients (group B) in identical clinical state who did not receive isoflurane during anesthesia. The evaluated parameters were: mixed venous Hb saturation (SvO2), heart rate (HR), pulmonary capillary pressure (PCP), central venous pressure (CVP), mean blood pressure (mBP), mean pulmonary arterial pressure (mPAP), cardiac index (CI), arteriolar pulmonary resistances (APR), peripheral vascular resistances (SVR), stroke index (SI), left ventricular work (LVW), right ventricular work (RVW), and O2 consumption (VO2). In group A, after isoflurane ++ administration, CI was 107.05% and 80% of baseline values in relative hypervolemia and hypovolemia, respectively. In group B (control), CI was 121.48% and 88.28% of basal values in relative hypervolemia and hypovolemia, respectively. In group A, SVR were 73.59% and 76.72% in hypervolemia and hypovolemia, respectively, while in group B they were 86.21% and 106.80%. In group A, APR were 90.85% and 89.96% in hypervolemia and hypovolemia, while they were 80.72% and 102.34% in group B. We found that isoflurane results in a greater peripheral than pulmonary vasodilation with a greater impairment in right ventricular function.     

Arthroscopic treatment of elbowarthritis in athletes

Arthroscopy has a valuable role in the treatment of elbow arthritis in the athletic population. General arthroscopicdebridement techniques used in the treatment of arthritis in other joints are quite valuable. Arthroscopic modifications of open techniques unique to the elbow, such as ulnohumeral arthroplasty, also are useful. As in other joints, the benefits of arthroscopic treatment of elbow arthritis may be temporary. Proper patient selection and attention to technical detail are critical in this population.     

Assessment of the potential in vivo genotoxicity of fluoranthene

Fluoranthene is a ubiquitous environmental pollutant. Althoughfluoranthene is mutagenic in bacterial and mammalian in vitrocell systems following metabolic activation by rat liver fraction,information on in vivo mutagenicity is lacking and studies ontumour initiating activity in mice are equivocal. In the presentstudy, the potential genetic hazard to man was assessed usingthe mouse bone marrow micronucleus and rat liver unscheduledDNA synthesis test systems. Fluoranthene did not show any evidenceof genotoxicity in either of the in vivo assays following acuteoral administration at levels of up to 2000 mg/kg b.w. ¹To whom correspondence should be addressed