FM sonography in diffuse liver disease: prospective assessment and blinded analysis

FM sonography - a signal-processing technique that uses frequency and phase information as well as amplitude data - shows promise in evaluation of patients with diffuse liver disease. In a prospective blinded review of 37 patients with biopsy-proved liver disease and 42 healthy volunteers, FM sonography was clearly superior to traditional amplitude-based (AM) sonography in distinguishing healthy from diseased subjects. Statistically significant differences were seen in accuracy (FM, 98.7%; AM, 84.8%), sensitivity (FM, 97.3%; AM, 70.3%), and negative predictive value (FM, 97.7%; AM, 78.8%). Our data also suggest that current FM sonographic techniques cannot differentiate among histologic findings associated with different hepatic parenchymal abnormalities. It is unclear, therefore, whether FM imaging can reduce the numbers of patients who require biopsy for diagnosis or the frequency of biopsy procedures in patients with known disease.     

Inappropriate social and sexual responses to a female student by male patients with dementia and organic brain disorder

Little attention has been directed toward inappropriate social and sexual approaches by patients with dementia diagnoses and organic disorders of the brain. A female student who approached patients who had dementia and organic brain disorders was frequently approached and touched in a sexual manner that was distressing to her and led her to believe that she was behaving in a manner that elicited these responses. It is recommended that students and volunteers be prepared for experience in settings with patients with these diagnoses through individual or group discussion, training and role playing as a way of enhancing their experiences and avoiding unnecessary feelings of guilt and embarrassment.     

Identification of non-amplifying CYP21 genes when using PCR-based diagnosis of 21-hydroxylase deficiency in congenital adrenal hyperplasia (CAH) affected pedigrees

Steroid 21-hydroxylase deficiency is among the most common inborn errors of metabolism in man. Characterization of mutations in the 21- hydroxylase gene (CYP21) has permitted genetic diagnosis, facilitated by the polymerase chain reaction (PCR). The most common mutation is conversion of an A or C at nt656 to a G in the second intron causing aberrant splicing of mRNA. Homozygosity for nt656G is associated with profoundly deficient adrenal cortisol and aldosterone synthesis, secondary hypersecretion of adrenal androgens, and a severe form of congenital adrenal hyperplasia (CAH) characterized by ambiguous genitalia and/or sodium wasting in newborns. During the course of genetic analysis of CYP21 mutations in CAH families, we and others have noticed a number of relatives genotyped as nt656G homozygotes, yet showing no clinical signs of disease. A number of lines of evidence have led us to propose that the putative asymptomatic nt656G/G individuals are incorrectly typed due to dropout of one haplotype during PCR amplification of CYP21. For prenatal diagnosis, we recommend that microsatellite typing be used as a supplement to CYP21 genotyping in order to resolve ambiguities at nt656.      

Fibrin sealant: clinical use and the development of the University of Virginia Tissue Adhesive Center

The utilization of fibrin sealants to augment hemostasis, seal tissues, and facilitate targeted delivery of drugs is increasing. In 1985, a hospital-based program was established to provide autologous and allogeneic cryoprecipitate that serves as a fibrin sealant when combined with bovine thrombin. To date, more than 4,000 patients have been treated with this product at our institution, with an efficacy rate greater than 90%. Collaboration among surgical services and the blood bank fostered multispecialty expertise with this product that led, in 1997, to the establishment of the University of Virginia Tissue Adhesive Center. The Tissue Adhesive Center is a multidisciplinary center whose physician director and nursing and administrative support staff facilitate basic research, laboratory investigation, and preclinical and clinical trials with collaborators throughout the university. The Tissue Adhesive Center also provides educational programs and clinical consultation, and tracks and participates in peer review of sealant use. The licensure of a commercially produced, virally inactivated, pooled-plasma fibrin sealant in May 1998 provided an alternative source of adhesive. Utilization of the commercial product surpassed use of the blood bank product in April 1999. At present, use of the commercial product is approximately 3 times that of the blood bank-produced sealant. This report reviews the clinical uses of fibrin sealant, its regulatory history, the production of fibrin sealants, the evolution of a blood bank fibrin sealant program, the development of the Tissue Adhesive Center, and the utilization of commercial and blood bank-produced sealant at our university hospital.     

How clients with religious or spiritual beliefs experience psychological help‐seeking and therapy: A qualitative study

This qualitative study explored the process of help‐seeking and therapy among clients with religious or spiritual beliefs. Ten clients who were currently in, or had recently finished, therapy were interviewed. Participants reported using their religious or spiritual beliefs to cope with their psychological problems before and during therapy. Prior to therapy, they were worried that secular‐based help might weaken their faith. However, the experience of having psychological distress and the process of receiving therapy were both perceived as strengthening to faith and ultimately part of a spiritual journey. Contrary to expectations, a match between the spirituality or religious affiliation of the therapist and client was not considered important. This implies that the ‘religiosity gap’ between secular therapists and clients with religious/spiritual beliefs is bridgeable. Copyright © 2007 John Wiley & Sons, Ltd.     

Palliative medicine and end of life care in surgery

Surgeons are privileged to offer treatments that often cure disease. Optimizing comfort for those who cannot be cured is also a core part of every clinician's duty: surveys repeatedly tell us that when death is approaching, people value quality of life above length of survival. Recognizing when someone is dying can be difficult. Tools exist to help; it is worth noting that emergency presentation with life-threatening symptoms can be a marker of poor prognosis. Clear, effective communication is crucial: understanding the patient's perspective and expectations is vital before attempting to offer information that allows future care planning. Judicious use of surgery combined with careful prescribing will optimize comfort, allowing the patient to live as well as possible for as long as possible. Anticipatory prescribing includes opioid, anti-emetic, anti-secretory and sedative medication. Attention should also be given to care of the bereaved. Generalists should understand when to refer to specialist palliative care and remember that reflecting on care when someone has died can be beneficial for professional wellbeing.     

Ocular manifestations of systemic infections

Awareness of atypical presentations and understanding the pathogenesis of uncommon systemic infections will make us better clinicians. Recent literature alerts the ophthalmologist to recent findings and treatment options regarding ocular manifestations of malaria, cysticercosis, histoplasmosis, mucormycosis, subacute sclerosing panencephalitis, and Acanthamoeba infection.     

Involvement of deprivation and environmental lead in neural tube defects: a matched case-control study

OBJECTIVE: To analyse the prevalence of neural tube defects in small geographical areas and seek to explain any spatial variations with reference to environmental lead and deprivation. SETTING: The Fylde of Lancashire in the north west of England. DESIGN: Cases were ascertained as part of a prospective survey of major congenital malformations in babies born in the Fylde to residents there between 1957 and 1981. A matched case-control analysis used infants with cardiovascular system, alimentary tract, and urinary system malformations as controls. Conditional logistic regression was used to assess the effects of more than 10 micrograms/l lead in drinking water and the Townsend deprivation score. RESULTS: The prevalence of neural tube defects in 1957-73 was higher in Blackpool, Fleetwood, and North Fylde, whereas the three control groups showed no significant spatial variation. In 1957-81 mothers living in electoral wards with either a higher proportion of houses with more than 10 micrograms/l lead in the water or a higher deprivation score had a greater risk of having a baby with a neural tube defect. For spina bifida and cranium bifidum alone, this was also true. For anencephaly, deprivation was less important although the effect of lead was still seen. In some neural tube defects, lead may act independently of other possible factors associated with deprivation. It seemed unlikely that lead levels changed significantly during the survey. The percentage of houses with 10 micrograms/l or more of lead in the water in 1984-5 was similar to that found in Great Britain 10 years previously. CONCLUSION: There is evidence to suggest that lead is one cause of neural tube defects, especially anencephaly. This could link the known preventive actions of hard water and folic acid. Calcium is a toxicological antagonist of lead. One cause of a deficiency of folic acid is impaired absorption secondary to zinc deficiency, which may be produced or exacerbated by lead.