Prevention of propofol-induced injection pain by remifentanil: a placebo-controlled comparison with lidocaine

In a randomised, double-blind study we compared the efficacy of continuous remifentanil infusion (0.25 microg x kg(-1) x min(-1) with 40 mg lidocaine and placebo in the prevention of injection pain due to intravenous propofol administration (1.5-2 mg x kg(-1)) in 155 patients scheduled for elective surgery. Pain severity was evaluated using a four-point scale. The incidence of injection pain was 62% in the placebo group and could be reduced significantly by using remifentanil (30%; p < 0.0015) or lidocaine (33%; p < 0.005). Analysis of the pain scores showed a significant difference between remifentanil and placebo (p < 0.00005) as well as between lidocaine and placebo (p < 0.0002). There was no significant difference between remifentanil and lidocaine. Remifentanil provided effective pain relief, comparable with lidocaine, and is an alternative as part of an intravenous anaesthesia regimen to using another concomitant drug.     

Changes in perceived social support after group therapy for complicated grief

This study investigated changes in perceived social support after group therapy for patients who developed complicated grief reactions subsequent to a variety of death losses. Sixty-one psychiatric outpatients, who received either interpretive or supportive group therapy, rated their perceptions of social support from 3 sources (family, friends, a special person) before treatment onset, after treatment completion, and 6 months after treatment. For patients in both forms of therapy, perceived social support from all 3 sources changed significantly during the follow-up period, but not during the treatment period. Changes (pretherapy to 6-month follow-up) in depressive symptomatology were found to be associated with changes in perceived social support. The results suggest that perceived support improves after, but not during, psychiatric treatment of complicated grief, and that a reduction in depression severity is associated with improvement in perceived social support. Possible explanations and implications of these findings are discussed.     

Sternal wound debridement and muscle flap reconstruction: functional implications

The mortality rate for poststernotomy infection, which occurs in as many as 5% of median sternotomy incisions after cardiovascular surgery, was 37.5% until sternal debridement with muscle or omental flap reconstruction became the standard treatment for this postoperative complication and lowered the mortality rate to just more than 5%. There are few reports in the literature of physical functional deficits and long-term outcome resulting from such reconstruction. The authors evaluated two groups of patients who had undergone coronary bypass surgery at least 6 months earlier. One group had no postoperative complications; the other group had developed marked sternal wound infections that required debridement and pectoralis major or rectus abdominis muscle reconstruction. Both groups underwent pectoralis and rectus muscle strength testing, evaluation of pain and ability to perform those activities of daily living that are dependent on pectoral and rectus muscle function, and completed self-assessment questionnaires. Differences between the two groups were significant (p<0.05) with regard to pain and patient satisfaction with appearance and general functional capacity. Pectoral muscle function and strength were significantly different in patients in whom that muscle was transposed. Rectus muscle strength was not affected by the transposition of a single rectus muscle. Physical morbidity and loss of strength seemed to be related directly to loss of sternal stability stemming from marked infection and debridement rather than from loss of the muscles used in reconstruction.     

Addressing the phenomenon of disruptive physician behavior

This timely article provides current information on an age-old issue of disruptive physician behavior within the hospital setting. Documented in medical literature over 100 years ago, disruptive physician behavior has been an ongoing challenge to the hospital staff and the quality of patient care in the hospital. Covered in this article are the negative consequences of disruptive physician behavior and the call to respond. If allowed to go unchecked, a physician exhibiting disruptive behavior may threaten a hospital's image, staff morale, finance, and quality of care. Failure to respond undermines the leadership of the hospital and the trust of the community in the hospital's mission. Included in this article are suggestions obtained from the literature and from the author's experience in responding to disruptive physician behavior. Of emphasis is a methodology that includes supporting bylaws and policies to manage disruptive physician behavior.     

Suicide Tourism in Manhattan,New York City, 1990–2004

Suicide accounts for over 30,000 deaths per year in the United States and is associated with psychiatric illness and substance abuse. Research suggests a strong relationship between method of suicide and the lethal means that are readily available in one’s community of residence. However, certain individuals may also seek the opportunity for suicide outside their proximal environment, often in well-known places. Whereas prevention efforts have been aimed at certain repeatedly used sites for suicide (i.e., Golden Gate Bridge), little research has studied “suicide tourism,” the phenomenon of out of town accompanied by suicide. We collected data on all suicide deaths in New York City (NYC) between 1990 and 2004 from the Office of the Chief Medical Examiner of NYC. We examined trends and correlates of out-of-town residents who committed suicide in NYC. Manhattan accounted for 274 of the 407 nonresident suicides in NYC, which represented over 10% of all suicides committed in Manhattan. The most common methods of suicide for the Manhattan nonresidents were long fall, hanging, overdose, drowning, and firearms; the most common locations included hotels and commercial buildings, followed by outside locations such as bridges, parks, and streets. Nonresident victims tended to be younger, more often white and Asian and less often black and Hispanic than their residential counterparts. An analysis of nonresident suicides in Manhattan revealed that it is a location where individuals travel and take their lives, often by similar means and in similar locations. A comparison with residential suicide implied that a different type of individual is at risk for nonresidential suicide, and further research and prevention efforts should be considered. Gross and Tardiff are with the Department of Psychiatry, Weill Cornell Medical College, Cornell University, New York, NY, USA; Gross is with the Subprogram in Clinical Psychology, The Graduate Center, City University of New York, New York, NY, USA; Markham Piper, Bucciarelli, Vlahov and Galea are with the Center of Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY, USA; Galea is with the Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Galea is with the Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA.     

The novel brain neuropeptide, orexin-A, modulates the sleep-wake cycle of rats

Orexin-A is a novel neuropeptide initially isolated from hypothalamic extracts but now known to be present in fibres distributed throughout the rat CNS including many regions associated with sleep-wake regulation. The recognition of a particularly dense innervation of orexinergic nerves in the locus coeruleus, together with the observed increase in firing rate of locus coeruleus neurons following application of orexin-A in vitro, further highlighted a potential involvement of the peptide in modulating the arousal state. The present study was undertaken to determine the effects of intracerebroventricularly (ICV) administered orexin-A on the sleep-wake cycle of conscious rats using electroencephalographic and electromyographic recordings. When administered at the onset of the normal sleep period, orexin-A (1, 10 or 30 microg/rat ICV) produced a dose-dependent increase in the time rats spent awake during the second and third hours after dosing. The enhancement of arousal was accompanied by a marked reduction in paradoxical sleep and deep slow wave sleep at the highest dose. The latency to the first occurrence of paradoxical sleep was also prolonged. This overall profile of increased arousal and decreased paradoxical sleep is consistent with a high rate of firing of locus coeruleus neurons as would be expected to occur following ICV administration of orexin-A. It is concluded that orexin-A may play an important physiological role in regulating the sleep-wake state, a hypothesis considerably strengthened by the recently reported narcoleptic phenotype of prepro-orexin (the precursor for orexin-A) knockout mice.     

A new analogue of 10-deazaaminopterin with markedly enhanced curative effects against human tumor xenografts in mice

Purpose: These studies sought to evaluate the biochemical and cellular pharmacokinetic properties, cytotoxicity and antitumor efficacy of a new analogue of 10-deaza-aminopterin (PDX) against human tumors. Methods: Studies were conducted with a group of human tumor cell lines in culture examining PDX and other folate analogues as permeants for mediated membrane transport, as inhibitors of dihdrofolate reductase and as substrates for folylpolyglutamate synthetase. These same analogues were examined for their cytotoxicity following a 3-h pulse exposure, in experiments providing a value for IC₅₀. Other studies with these analogues were conducted in nude mice bearing subcutaneously implanted human tumors. Treatment of the mice was initiated 4 days after implantation of the tumor using a schedule of administration of one dose per day for 5 days. The tumors were measured 6 days after cessation of therapy and compared to controls for assessment of response. Results: In the CCRF-CEM cell system, PDX was 2- to 3-fold less effective as an inhibitor of dihydrofolate reductase than aminopterin (AMT), methotrexate (MTX) or edatrexate (EDX) but much more effective as a permeant for one-carbon, reduced folate transport inward (PDX >AMT ≃ EDX >MTX) and substrate for folylpolyglutamate synthetase (PDX >AMT >EDX >MTX). As predicted by these results, PDX was 15- to 40-fold more cytotoxic than MTX and 3- to 4-fold more cytotoxic than the highly potent EDX following a 3-h pulse exposure in culture of CCRF-CEM cells and cells from a panel of three human breast and two human nonsmall-cell (NSC) lung cancers. The same relative differences were shown for the therapeutic efficacy of these three analogues at equitoxic doses in studies with the human MX-1 and LX-1 tumors and the human A549 NSC lung tumor xenografted in nude mice. On a schedule of qd × 5 given 3–4 days posttransplant, MTX was minimally active (modest tumor growth delay) against all three tumors. EDX was highly active (25–35% complete regressions and 5–10% cures) against the MX-1 and LX-1 tumors but very modestly active (no regressions) against the A549 tumor. In contrast, PDX was even more active (75–85% complete regressions and 25–30% cures) than EDX against the MX-1 and LX-1 tumors and highly active (30% complete regressions and 20% cures) against the A549 tumor. Conclusions: These studies showed significantly enhanced antitumor properties of PDX compared with MTX and EDX. Based upon these results, clinical trials of PDX in patients with metastatic breast and NSC lung cancer appear to be warranted. Received: 24 September 1997 / Accepted: 16 December 1997     

How do the corresponding eyes avoid disturbing contour overlaps? Historical answers (1859 - 1981)

The visual system has a limited capacity to fuse overlapping impressions. It takes advantage of three principles of organization: (1) The mixing of different impressions resulting in a new entity (compensation principle); examples are the mixing of colors, dark and light at the retina, Fechner's paradox. The twelve researchers whose work is reported here analyzed two other unifying principles: (2) Selection by successive contrasts (polarization principle) and (3) subordination in a hierarchy of vision (differentiation principle).     

Degradation of porstaglandin F2alpha in the human pulmonary circulation.

Degradation of prostaglandins (PGs) during passage through the human pulmonary circulation was investigated by measuring the transpulmonary plasma PGF2 alpha difference during continuous intravenous infusion of PGF2 alpha (5-10 mug/min). Seven patients with cardiological disorders and two patients with extensive pulmonary abnormalities were investigated during diagnostic cardiac catheterization. PGF2 alpha levels were measured by radioimmunoassay. The seven cardiac patients were found to have transpulmonary PGF2 alpha differences of 47-88%, indicating metabolism of the PG in the lungs. A patient with extensive bronchiectasis had an apparently normal transpulmonary PGF2alpha difference despite gross abnormalities in routine lung function tests. A patient with primary pulmonary arterial hypertension showed no metabolism of PGF2alpha in the pulmonary circulation. The results show that PG degradation is an aspect of normal lung function and suggest that it becomes imparied when extensive pulmonary vascular damage exists.