An Empirical Evaluation of Eye Movement Desensitization and Reprocessing (EMDR) with Survivors of a Natural Disaster

Controlled studies of treatments effective with victims of natural disasters are almost nonexistent. This is a small study conducted under difficult conditions to test the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) in treating trauma related reactions following Hurricane Andrew. The results were positive in that EMDR produced significant improvement over wail list controls in perceived posttraumatic avoidance behaviors and thoughts as measured by changes in the Impact of Event Scale and significant improvement in subjective aversive reactions to representative experiences of the hurricane. These results suggest and support other studies that EMDR can be an effective therapeutic intervention for trauma reactions.     

Ulnar distribution of reflex sympathetic dystrophy due to compression of the brachial plexus by a primary venous malformation

An atypical variant of reflex sympathetic dystrophy (RSD) is presented in a 45 year old female with a vascular malformation of the right arm and chest wall. The mechanism was thought to be compression of the brachial plexus by the malformation. The unique scintigraphic features of this presentation of RSD in the ulnar arterial distribution are illustrated.     

Massive strychnine intoxication: serial blood levels in a fatal case.

A fatal case of strychnine intoxication is reported. The patient expired despite early aggressive management and prevention of metabolic complications. Serial blood levels are reported. In contrast to a previous report describing first order elimination kinetics, our data suggest that strychnine follows Michaelis-Menton elimination kinetics. The case illustrates the rapid, dramatic course of severe strychnine ingestions. A review of the toxicokinetics, mechanism of action and treatment of strychnine intoxication follows.     

What has trust got to do with it? Cardiac risk reduction and family physicians' discussions of evidence-based recommendations

The management of patients through the use of evidence-based medicine has become the 'mantra' of medicine within many Western countries. Evidence-based medicine is aimed at providing the best objective, scientific care to all patients, and reducing as far as possible patients' risks of disease and complications from disease. Based on family physicians' discussions of the use of evidence-based recommendations for two cardiac diseases, this paper explores how subjectively-based trust enters into family physicians' decision to use evidence-based medicine. In addition, we show how trust influences physicians' work of recommending evidence-based medicine to patients, and physicians' perceptions of why patients follow recommendations aimed at risk reduction. We conclude that although much of the current discussion about evidence-based medicine assumes a 'rational' model of physician behaviour based on the application of the 'best objective scientific' results, subjectively-based perceptions of trust influence physician practices, and point to the need to understand the power of relational issues in influencing physician practices even when utilizing evidence-based knowledge.     

Prednisone-Free Maintenance Immunosuppression—A 5-Year Experience

Concern persists that prednisone-free maintenance immunosuppression in kidney transplant recipients will be associated with an increase in late allograft dysfunction and graft loss. We herein report 5-year follow-up of a trial of prednisone-free maintenance immunosuppression. From October 1, 1999, through January 31, 2005, at our center, 589 kidney transplant recipients were treated with a protocol incorporating discontinuation of their prednisone on postoperative day 6. At 5 years, actuarial patient survival was 91%; graft survival, 84%; death-censored graft survival, 92%; acute rejection-free graft survival, 84% and chronic rejection-free graft survival, 87%. The mean serum creatinine level (+/-SD) at 1 year was 1.6 +/- 0.6; at 5 years, 1.7 +/- 0.8. In all, 86% of kidney recipients with functioning grafts remain prednisone-free as of April 30, 2005. As compared with historical controls, recipients on prednisone-free maintenance immunosuppression had a significantly lower rate of a number of complications, including cataracts (p < 0.001), posttransplant diabetes mellitus (p < 0.001), avascular necrosis (p = 0.001), and fractures (p = 0.004). We conclude that prednisone-related side effects can be minimized in a protocol incorporating prednisone-free maintenance immunosuppression. Five-year graft outcome remains good.     

Patients' recollections of therapeutic paralysis in the intensive care unit.

BACKGROUND: Neuromuscular blocking agents used for therapeutic purposes, such as facilitating mechanical ventilation and relieving life-threatening agitation, paralyze patients but leave them fully conscious. Aggressive sedation or analgesia is necessary to reduce awareness, relieve fear, produce comfort, decrease anxiety, induce unconsciousness, and minimize possible complications such as posttraumatic stress syndrome. Little information is available on the extent to which patients experience awareness during therapeutic paralysis. OBJECTIVES: To determine and describe the remembered experiences of critical care patients who were given neuromuscular blocking agents and sedatives and/or analgesics to facilitate mechanical ventilation, improve hemodynamic stability, and improve oxygenation. METHODS: A phenomenological approach with in-depth interviews with 11 patients was used. Data were analyzed by using the constant comparative approach. RESULTS: A total of 4 themes and 3 subthemes were identified. The first theme was back and forth between reality and the unreal, between life and death; the subtheme was having weird dreams. The second theme was loss of control; the 2 subthemes were (1) fighting or being tied down and (2) being scared. The third theme was almost dying, and the fourth theme was feeling cared for. CONCLUSIONS: Patients can remember having both negative and positive experiences during neuromuscular blockade. Steps to improve the experiences of patients receiving neuromuscular blockers include improving assessment parameters, developing and using sedation/analgesia guidelines, and investing in quality improvement programs to provide assessment of awareness during therapeutic paralysis and follow-up and referral as necessary. Ways to decrease the use of neuromuscular blockers would also be useful.     

Extra- and intra-cranial blood supply to brains of dog and cat

The dog and cat are useful experimental animals, and information regarding their cerebrovascular patterns and the source of blood supplying their brains is important. Blood vessels to brains and heads of cats and dogs were injected with various contrast media. Extracranial and intracranial arteries were studied grossly and in cleared sections. The proximal part of the internal carotid artery is small in the dog and nonfunctional in the cat. The largest single source of arterial blood supplying the brains of these species comes from the maxillary artery over an anastomotic ramus leading to an internal rete mirabile enmeshed in the cavernous sinus. The distal segment of the internal carotid arises from this anastomosis. The brainstem of both animals is supplied by C₁ branches of the vertebral arteries, and in the dog an occipital ramus makes a large contribution to it. In addition to an internal rete mirabile, the cat possesses a large external rete mirabile surrounding the maxillary artery and giving rise to all branches in the area. It is functionally equivalent to the ramus anastomoticus in the dog. Arterial patterns over brains of Carnivora are similar. They resemble those of lower mammals more than those of primates. Extensive extracranial arterial anastomoses located in the orbit, retia mirabilia and neck musculature are significant and make it difficult to render the brains ischemic.     

Distinct expression and localization of serine protease HtrA1 in human endometrium and first-trimester placenta.

Mammalian embryos cannot survive without the placenta. Development of the human placenta requires trophoblast proliferation, differentiation, and invasion as well as highly coordinated modulation of the maternal uterus. HtrA1 is a member of the recently identified mammalian HtrA (high temperature requirement factor A) serine protease family with a high level of expression in the placenta. In this study, we examined whether HtrA1 expression (mRNA and protein) is associated with placental development in the human. HtrA1 is up-regulated in both endometrial glands and decidual cells during endometrial preparation for embryo implantation and during first-trimester pregnancy at placentation. HtrA1 expression was also detected in certain trophoblast subtypes during early pregnancy. The villous syncytiotrophoblast and cytotrophoblast showed the strongest expression while the interstitial extravillous trophoblast showed the lowest or no expression of HtrA1. The distinct distribution of HtrA1 at the maternal-trophoblast interface suggests that HtrA1 may play a role in placental development.