Problems for paraprofessionals in mental health services

Issues of changing positions and roles for paraprofessionals are considered in the context of the hierarchical structure and process of mental health organizations. A brief history of paraprofessionals in mental health is presented, showing their function as low-status staff who control a troublesome patient population. The mental health organization is examined as a social system with a functional division of labor and a professional caste system. Discussion focuses on problems arising when paraprofessionals are promoted in the functional hierarchy while continuing to occupy the lowest level in the professional caste system, and from the organization's continuing need for low-level staff to serve on the boundary between professional staff and difficult clients.Marjorie Bayes is a member of the Department of Psychiatry, Yale University School of Medicine. T. Kerby Neill is Coordinator of the Children's Service Program, Bluegrass East Comprehensive Care Center, Lexington, Kentucky.     

Gastric antiulcer and anti-inflammatory activities of the essential oil from Casearia sylvestris Sw

To investigate the antiulcer and antiinflammatory activities of the essential oil from Casearia sylvestris leaves (EOCS) the following tests were used: rat paw edema, granulomatous tissue test, vascular permeability, writhing test, gastric ulcer stress-induced and evaluation of gastric secretion (pylorus ligation test). The total yield of EOCS was 2.5% with LD50 of 1100 mg/kg in mouse. The major compounds identified using gas chromatography were caryophyllene, thujopsene, alfa-humulene, beta-acoradiene, germacrene-d, bicyclogermacrene, calamenene, germacrene B, spathulenol and globulol. The EOCS orally administered to the rats at 125 mg/kg resulted 36% of inhibition in carrageenan-induced edema in the rat paw assay (p<0.05, Student's t-test). However, both rat paw edema dextran-induced and vascular permeability assay using histamine showed no significant inhibition. Mice submitted to the writhing test using acetic acid presented 58% and 56% of inhibition in writhes with EOCS and indomethacin, respectively. Furthermore, EOCS inhibited 90% of stress-induced gastric ulcer, while cimetidine inhibited 70% (p<0.05, Student's t-test). The volume of gastric secretion in the group treated with EOCS was greater than the group treated with cimetidine. The EOCS also showed no changes related to H+ levels in the gastric secretion. With the overall results obtained in this study the authors suggest an anti-inflammatory activity for the EOCS of Casearia sylvestris beyond its anti-ulcer activity.     

Pancreas-Protocol Imaging at a High-Volume Center Leads to Improved Preoperative Staging of Pancreatic Ductal Adenocarcinoma

Background  

High-quality preoperative cross-sectional imaging is vital to accurately stage patients with pancreatic ductal adenocarcinoma (PDAC). We hypothesized that imaging performed at a high-volume pancreatic cancer center with pancreatic imaging protocols more accurately stages patients compared with pre-referral imaging.     

Upper and lower trapezius muscle transfer to restore shoulder abduction and external rotation in longstanding upper type palsies of the brachial plexus in adults

Lesions affecting the upper roots of the brachial plexus result in paralysis of shoulder abduction and external rotation. In longstanding lesions, neurological surgery is not recommended in which case muscle transfers become an option to improve shoulder function. We describe the surgical treatment of seven adult patients with longstanding lesions of the upper roots of the brachial plexus, in whom the upper trapezius muscle was transferred to the humeral head, whereas the lower trapezius muscle was sutured to the infraspinatous muscle tendon. Within an average of 11.7 months after surgery, patients had recovered 38° of abduction and 104° of external rotation, as measured from full internal rotation. The results of this preliminary series involving the combined transfer of both the upper and lower trapezius muscle seems promising for the treatment of chronic paralysis of abduction and external rotation following brachial plexus injury.     

Biliary cystic disease

Biliary cystic disease, though uncommon, can present at a wide range of ages with a wide range of symptoms. Choledochal cysts are associated with the development of both cholangiocarcinoma and gallbladder cancer. Thus, most biliary cystic disease is best managed operatively. Many factors should be considered when performing surgery on patients with choledochal cysts, including age, presenting symptoms, cyst type, associated biliary stones, prior biliary surgery, intrahepatic strictures, hepatic atrophy/hypertrophy, biliary cirrhosis, portal hypertension, and associated biliary malignancy. When feasible, surgical treatment should consist of cholecystectomy and complete surgical excision of extrahepatic cysts with Roux-en-Y reconstruction. Because the risk of recurrent cholangitis is significant and additional symptoms and problems are common, the use of long-term soft Silastic biliary stents (Dow Corning Corp., Midland, MI) should be considered when complex intrahepatic and extrahepatic cystic disease is present. Alternatively, the Roux-en-Y jejunal limb can be marked at the fascia for future percutaneous access. Reconstruction via hepaticoduodenostomy and jejunal interposition has been associated with increased postoperative pain due to bile reflux gastritis. Thus, hepaticojejunostomy reconstruction is recommended. For choledochal cysts involving the distal bile duct, the bile duct should be excised at the intrapancreatic portion. Resection of the pancreatic head should be reserved for patients with established malignancies. Surgical excision of the intrahepatic portion of the bile duct should be individualized to include preservation of hepatic parenchyma when the liver is not cirrhotic. If cirrhosis is advanced, hepatic transplantation may be indicated, but this is rare. Oncologic principles should be followed in the presence of a malignancy. Lifelong follow-up is required because of the possibility of a "field" defect increasing susceptibility to cancer throughout the biliary tract epithelium.     

Effects of extreme endurance running on cardiac autonomic nervous modulation in healthy trained subjects

This study examined spectral components of heart rate variability (HRV) during endurance mountain running in 8 healthy trained subjects. The data showed that during this type of mountain running, all spectral components of HRV may severely decrease, particularly very-low-frequency and low-frequency (LF) power, suggesting extreme activation of the sympathetic nervous system. The physiologic response of the heart in this situation was the downregulation of the beta-adrenergic receptors to protect myocardial function, with a subsequent increase in parasympathetic tone, reflected by an increase in high-frequency (HF) power and a decrease in the LF/HF ratio.     

Dental therapeutic practice patterns in the U.S. II. Analgesics, corticosteroids, and antibiotics

This article examines the prescribing practices for peripherally acting and centrally acting analgesics, corticosteroids, and antibiotics following third molar extraction. A nationwide survey involving the prescribing patterns of a random national sample of 850 practicing oral surgeons was performed in 2004. Ibuprofen was the peripherally acting analgesic respondents used most frequently in the previous month, selected by 73.5% of the respondents. The ibuprofen dose prescribed most frequently was 800 mg, followed by doses of 600 mg and 400 mg. The centrally acting analgesic prescribed most frequently was the combination formulation of hydrocodone with acetaminophen, selected by 64.0% of the respondents. Recommendations for oral analgesics to manage postoperative pain relied on the peripherally acting analgesic ibuprofen or the centrally acting analgesic combination formulation hydrocodone with acetaminophen. Routine instructions to use centrally acting analgesics "as needed for pain" suggest that centrally acting analgesics are offered to manage pain that postoperative peripherally acting analgesics and intraoperative long-acting local anesthetics do not control adequately. The frequency with which oral and maxillofacial surgeons administered antibiotics and corticosteroids varied widely based on perceived patient need and dentist expectations.     

Reconstruction of C5 and C6 brachial plexus avulsion injury by multiple nerve transfers: spinal accessory to suprascapular, ulnar fascicles to biceps branch, and triceps long or lateral head branch to axillary nerve

PURPOSE: In C5 and C6 brachial plexus avulsion lesions, elbow flexion, shoulder abduction, and external rotation are the functions that need to be restored. Because the proximal stumps are not available for grafting, surgical repair is based on nerve transfers. The purpose of this study was to describe and report the results of the use of multiple nerve transfers in the reconstruction of these avulsion injuries. METHODS: Ten patients had multiple nerve transfers: cranial nerve XI to the suprascapular nerve, ulnar nerve fascicles to the biceps motor branch, and triceps long or lateral head motor branch to the axillary nerve. Triceps branch transfer was performed through a posterior arm incision. RESULTS: Two years after surgery, all the patients had recovered full elbow flexion; 7 scored M4 and 3 scored M3+ according to Medical Research Council scoring. All the patients had recovered active abduction and external rotation. Abduction recovery averaged 92 degrees (range, 65 degrees-120 degrees) and external rotation, measured from full internal rotation, averaged 93 degrees (range, 80 degrees-120 degrees). Shoulder abduction strength was graded M4 in 3 patients and M3 in the remaining 7 patients. Shoulder external rotation strength was graded M4 in 2 patients, M3 in 5 patients, and M2 in 3 patients. No donor site deficits were observed. CONCLUSIONS: The proposed nerve transfers constitute a valid strategy in C5-C6 avulsion injury reconstruction.     

Assessment of an ultrasonic dermal scanner for skin thickness measurements

The measurement precision of a 20 MHz ultrasound dermal scanning system, Episcan, manufactured by Longport Inc. was investigated for its use in the measurement of skin thickness. Results from measurements of relatively ideal homogeneous, uniformly thick plastic plates indicate that the scanner can accurately measure to depths of 8-34 mm from the surface of the transducer or approximately 18 mm from the surface of the latex probe-cover with a high level of precision, less than 1% of the mean thickness. The precision was determined to be dependent on the depth of the scan. Using the measured optimal gain of 45%, a sample rate of 0.013 micros, and an A-scan record length of 1024 points, we determined the thickness resolution of the device is on the order of 0.003 mm for 2 mm thick layers and 0.01 mm for 5 mm thick layers. We conclude that variations greater than this value for clinical dermal thickness measurements are not due to instrument precision, but must result from the limitations of analyzing the data from real tissue.