Interpersonal aspects of the syndromes of schizophrenia

Raters listened to interviews with schizophrenic patients and rated each participant using Wiggins's Interpersonal Adjective Checklist-Revised, a measure of interpersonal behavior. It was predicted that three symptom dimensions (disorganization, psychoticism and negative symptoms) would be associated with unique patterns of interpersonal behavior. Results indicated that symptoms of psychoticism (systematized delusions and auditory hallucinations) were rated as evidencing Arrogant-Calculating characteristics. Negative symptoms were associated with Unassured-Unassuming and Aloof-Introverted patterns. Symptoms of disorganization were associated with Quarrelsome behavior. Increased knowledge of the interpersonal styles associated with different subsyndromal patterns of schizophrenic symptoms, and the reactions they are likely to elicit in others, can provide a useful framework for the design of social-cognitive rehabilitation programs.     

Premature adult mortality and short-stay hospitalization in Western Australia attributable to the smoking of tobacco, 1979-1983

The proportions of total deaths and premature adult mortality in 1979-1983, and of short-stay hospital admissions and bed-days in 1983, that were attributable to the smoking of tobacco were estimated in Western Australia by the use of aetiological fractions that had been derived from the published literature. Premature adult mortality was measured by the person-years of life that were lost from ages 15 to 69 years (PYLL 15-69). In men it was estimated that 25% of all deaths and 14% of PYLL 15-69 were attributable to smoking. In women the corresponding proportions were 15% of deaths and 8% of PYLL 15-69. The proportions of short-stay hospital bed-days that were attributable to smoking were estimated at 7% in men and 3% in women; for hospital admissions the estimates were 4% and 1% in men and women, respectively. In all, tobacco-related disease and injury accounted for around 1700 deaths and 7500 short-stay hospitalizations each year in a population of 1.4 million persons.     

A critical look at the assumptions of cognitive therapy

The cognitive perspective has been a dominant force in psychology and psychotherapy since the 1970s. Cognitive therapists assume that changing cognition is the key to bringing about changes in emotional reactions and symptomatic behaviors. This article examines evidence that is not consistent with the assumptions of cognitive therapy. First, neurobiological evidence is not consistent with the assumption that cognitions are necessary for emotions. Limbic structures allow for the possibility that emotions can be experienced without cortical processing. Second, research indicates that experiences can be stored as isolated affective fragments that distort cognitive functions. The assumptions of contemporary psychoanalytic models of therapy are consistent with this evidence.     

Reliability of a modified Gartland classification of supracondylar humerus fractures

Fracture-classification systems are used to recommend treatment and predict outcomes. In this study, a modified Gartland classification system of supracondylar humerus fractures in children was assessed for intraobserver and interobserver variability. Five observers classified radiographs of 50 consecutive children with extension supracondylar humerus fractures on three separate occasions. After a 2-week interval, 90% of fractures were classified the same on both readings, with and intraobserver kappa value of 0.84. After a 36-week interval, 89% of the fractures were classified the same, with a kappa value of 0.81. Interobserver reliability was evaluated by pairwise comparison among observers, resulting in an overall kappa value of 0.74. The reliability of the Gartland classification for supracondylar humerus fractures in children is better than that published for other fracture-classification systems. However, 10% of the time, a second reading by the same observer is different. This makes treatment recommendations based only on fracture type imprecise.     

Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: an assessment of procedures

OBJECTIVE: To determine whether the procedure of unreamed femoral nailing is simpler, faster, and safer than reamed femoral intramedullary nailing. DESIGN: Prospective randomized. SETTING/PARTICIPANTS: One hundred femoral shaft fractures without significant concomitant injuries admitted to an academic Level 1 urban trauma center. INTERVENTION: Stabilization of the femoral shaft fracture using a reamed or unreamed technique. OUTCOME MEASUREMENTS: The surgical time, estimated blood loss, fluoroscopy time, and perioperative complications were prospectively recorded. RESULTS: One hundred patients with 100 femoral shaft fractures were correctly prospectively randomized to the study. Thirty-seven patients received reamed and sixty-three patients received unreamed nails. All nails were interlocked proximally and distally. The average surgical time for the reamed nail group was 138 minutes and for unreamed nail group was 108 minutes (p = 0.012). The estimated blood loss for the reamed nail group was 278 milliliters and for the unreamed nail group 186 milliliters (p = 0.034). Reamed intramedullary nailing required an average of 4.72 minutes, whereas unreamed nailing required 4.29 minutes of fluoroscopy time. Seven perioperative complications occurred in the reamed nail group and eighteen in the unreamed nail group. Two patients in the unreamed group required an early secondary procedure. Iatrogenic comminution of the fracture site occurred during three reamed and six unreamed intramedullary nailings. Reaming of the canal was required before the successful placement of three nails in the unreamed group because of canal/nail diameter mismatch. CONCLUSIONS: Unreamed femoral intramedullary nailing involves fewer steps and is significantly faster with less intraoperative blood loss than reamed intramedullary nailing. The unreamed technique, however, was associated with a higher incidence of perioperative complications, although the difference was not statistically significant (p = 0.5).     

Immunomodulation and adenoviral gene transfer to the lungs of nonhuman primates

Previous data from our laboratory and others have demonstrated a critical role for the CD4+ T lymphocyte in in vivo immune responses to recombinant adenoviral vectors. In rodent models, this subset of T cells is required for T cell proliferation, subsequent cytotoxic T cell generation, and production of anti-adenoviral antibodies by B cells. Both depleting and nondepleting anti-CD4 antibodies can attenuate these immune responses to recombinant adenovirus. On the basis of these data, we hypothesized that a nondepleting CDR-engrafted anti-human CD4 antibody (OKT4A) with cross-reactivity to rhesus macaques would attenuate both T and B cell responses to intrapulmonary administration of recombinant adenovirus and permit prolonged reporter gene expression and permit secondary gene transfer. Juvenile rhesus macaques were treated with PBS or OKT4A antibody (10 mg/kg) daily beginning 1 day prior to and up to 11 days after gene transfer. OKT4A resulted in significant attenuation of lymphocyte recruitment into the lung, lymphocyte-proliferative responses to both adenovirus capsid proteins and transgene protein, and adenovirus-induced interferon-gamma elaboration in whole blood and hilar lymph nodes. However, OKT4A was ineffective in attenuating adenovirus-induced IL-4 production in whole blood or hilar lymph nodes, generating neutralizing anti-adenoviral antibodies, or permitting secondary gene transfer. As all the monkeys in this protocol had baseline-detectable anti-adenoviral antibodies by ELISA that were nonneutralizing, analogous to most patients with cystic fibrosis, we postulate that anti-CD4 did not block the proliferation of memory B cells. Moreover, these data suggest that for transient immunomodulation to be successful, strategies need to focus specifically on B cell activation independent of CD4+ T cell help.     

The difficult airway with recommendations for management – Part 2 – The anticipated difficult airway

Background

Appropriate planning is crucial to avoid morbidity and mortality when difficulty is anticipated with airway management. Many guidelines developed by national societies have focused on management of difficulty encountered in the unconscious patient; however, little guidance appears in the literature on how best to approach the patient with an anticipated difficult airway.

Methods

To review this and other subjects, the Canadian Airway Focus Group (CAFG) was re-formed. With representation from anesthesiology, emergency medicine, and critical care, CAFG members were assigned topics for review. As literature reviews were completed, results were presented and discussed during teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made, and levels of evidence were assigned.

Principal findings

Previously published predictors of difficult direct laryngoscopy are widely known. More recent studies report predictors of difficult face mask ventilation, video laryngoscopy, use of a supraglottic device, and cricothyrotomy. All are important facets of a complete airway evaluation and must be considered when difficulty is anticipated with airway management. Many studies now document the increasing patient morbidity that occurs with multiple attempts at tracheal intubation. Therefore, when difficulty is anticipated, tracheal intubation after induction of general anesthesia should be considered only when success with the chosen device(s) can be predicted in a maximum of three attempts. Concomitant predicted difficulty using oxygenation by face mask or supraglottic device ventilation as a fallback makes an awake approach advisable. Contextual issues, such as patient cooperation, availability of additional skilled help, and the clinician’s experience, must also be considered in deciding the appropriate strategy.

Conclusions

With an appropriate airway evaluation and consideration of relevant contextual issues, a rational decision can be made on whether an awake approach to tracheal intubation will maximize patient safety or if airway management can safely proceed after induction of general anesthesia. With predicted difficulty, close attention should be paid to details of implementing the chosen approach. This should include having a plan in case of the failure of tracheal intubation or patient oxygenation.