Self-implanted artificial nodules: a computed tomography mimic of penile pathology

Self-introduction of foreign bodies along the penile shaft has been reported in several ethnic and social groups, mainly in Asia, and recently has been described in Europe. We present the case of a 34-year-old homeless Russian immigrant who had an abdominal CT performed during an emergency department visit. On the CT scan, several hyperdense, well-demarcated subcutaneous nodules along the penile shaft were noted. Following a focused history and physical examination, the nodules were found to represent artificial foreign bodies made of glass, which were self-introduced by the patient in order to allegedly increase the pleasure of sexual partners. Penile nodules may be a manifestation of diverse pathological entities including infectious, inflammatory, and neoplastic processes. It is important for the radiologist to be familiar with this social phenomenon and its radiological appearance in order to avoid erroneous diagnosis.

The gut in systemic inflammatory response syndrome and sepsis. Enzyme systems fighting multiple organ failure

The prognosis and care of critically ill ICU patients has improved over recent years, but the development of multiple organ failure (MOF) continues to cause significant morbidity and mortality. Shock, with resultant organ ischemia, appears to play a critical role in the development of MOF. It is our global hypothesis that MOF is a gut-derived phenomenon and that novel interventions can improve outcome in shock-induced gut inflammation and dysfunction in critically ill patients. We have found that the anesthetic agent ketamine has a profound impact on the response to endotoxic shock. This review summarizes our findings on the mechanisms of action by which ketamine is able to modulate the nitric oxide, cyclo-oxygenase and heme-oxygenase enzyme systems to attenuate endotoxin-induced organ dysfunction.

Medications in the treatment of borderline personality disorder 2006

This review covers all significant randomized controlled trials and open trials of medications for the treatment of borderline personality disorder. New developments in the effectiveness of mood stabilizers and antipsychotics are discussed. Differences were found in the effectiveness of medications based on the presence or absence of depression and significant anger symptoms. Medications continue to be recommended as adjuncts to psychotherapy. Most of the trials discussed require replication, and more trials that investigate the effectiveness of medications in combination with psychotherapy are recommended.

The sandwich omental flap for abdominal wall defect reconstruction

We present a case of a large full thickness abdominal wall defect following excision of a huge basal cell carcinoma, uniquely reconstructed with a sandwich omental flap, vicryl/prolene (vypro II) mesh and split thickness skin graft.

Malignant melanoma metastasis to the sentinel node in the popliteal fossa

Malignant melanoma metastasis to regional nodes is a well-recognised clinical event. Increasingly, sentinel lymph-node biopsy is being advocated for diagnostic and prognostic purposes. The lymphatic spread of tumour from the lateral aspect of the lower leg and foot is classically described as draining directly to the groin. We discuss the role of lymphoscintigraphy and popliteal dissection with reference to a recent case of a patient with a malignant melanoma at the level of the lateral malleolus that was shown to drain directly to a sentinel node in the popliteal fossa.

A gap approach to exploring quality of life in mental health

Improving quality of life (QoL) is an important treatment outcome for the serious mentally ill. There is, however, a need for an instrument which both captures consumers own assessments and gives direct information for intervention. A useful approach is to define QoL as the gap between actual and ideal life circumstances, which is weighted by importance. In this paper we detail how we developed and evaluated a QoL instrument which follows this model. This instrument, the 'QoL-GAP', is based on self-appraised items within various life domains. For each item respondents firstly identify what they have (actual) and then what they would like (ideal). They then rate the item for its importance and make any comments. A weighted gap score for each item is subsequently derived from the ideal actual gap being weighted by the importance rating. This weighted gap score is then related to domain satisfaction ratings, while their average from each domain is related to overall satisfaction and well-being. We surveyed 120 individuals with a serious and enduring mental illness living in different types of residences, such as psychiatric hospitals, hostels, or their own homes, in a largely urban part of Queensland. Sixty-eight percent were males, and 92% had schizophrenia or related disorders. We found that our approach demonstrated good psychometric properties, and that the model-based predictions were borne out: weighted gap measures were consistently more strongly related to domain satisfaction than were the actual circumstances alone. While further work is being undertaken--in such matters as short-forms and further evaluation of the QoL-GAP in a longitudinal study--our results suggest that this 'gap' approach helps consumers state their own goals and give their opinions and so is particularly relevant for consumer-focused mental health delivery and research.

Modeling the economic benefits of better TB vaccines

OBJECTIVE

To describe the economic benefits of a better tuberculosis (TB) vaccine by modeling prevented TB medical spending and lost productivity throughout the world.

DESIGN

One model is based on benefits obtained from reducing the impact of TB on health spending. An alternative model is based on minimizing the impact of TB on health spending and lost productivity due to death and disability. Both models are applied to various world populations based on secondary data.

RESULTS

In terms of avoided medical spending, preventing 100% of the TB risk in a single individual is estimated to be worth from $38 for males in formerly socialist countries to S0.23 for children in Asia. More than 1 billion people would reckon their expected medical savings to exceed $25.00 if they received a 75% effective vaccine of 10 years' duration. Preventing lost productivity is worth substantially more throughout the world.

CONCLUSIONS

Improved TB vaccines would be of substantial immediate financial value to most of the populations of the world, including the poorest. The scientific uncertainties surrounding the development of a better vaccine could be a larger obstacle than investor uncertainty over whether a vaccine would be profitable.

Ward managers' attitudes towards external consultants in Ashworth, a special hospital, 1992-1994

This case study elaborates the aftermath of the Blom-Cooper Inquiry (1992), which forced the special hospital, Ashworth, into a radical 'culture change'. To this end, two groups of external consultants--a management consultancy and a professional task force--were introduced into the hospital. Newly established ward managers were to spearhead the organizational change by bringing social and clinical order to the wards over which the higher management had lost control. Few studies have mapped out the interaction between segments of an organization and expert outsiders. In this study, the interaction of the ward manager to the newly appointed external management consultancy and task force was analysed. It was clear that ward managers rated poorly the efforts of the management consultancy and task force--it was considered that they were not giving value for money. The task force rated slightly more favourably than the management consultancy. The fact that the management consultancy did not have ward credibility in this closed forensic setting was attributed to low prestige. The management consultancy also failed to fulfill the organizational ambitions of ward managers, who wished to be central to the hospital's major decision-making process.

Professional convergence in forensic practice

This paper outlines the development and convergence of forensic science and secure psychiatric services in the UK, locating the professionalization of forensic nursing within a complex web of political, economic, and ideological structures. It is suggested that a stagnation of the therapeutic enterprise in high and medium security provision has witnessed an intrusion of medical power into the societal body. Expanding technologies of control and surveillance are discussed in relation to the move from modernity to postmodernity and the ongoing dynamic of medicalized offending. Four aspects of globalization are identified as impacting upon the organization and application of forensic practice: (i) organized capitalism and the exhaustion of the welfare state; (ii) security versus danger and trust versus risk; (iii) science as a meta-language; and (iv) foreclosure as a mechanism of censorship. Finally, as a challenge for the profession, some predictions are offered about the future directions or demise of forensic nursing.

Q methodology, risk training and quality management

The results of a Q methodological study of professional understandings of the notion of risk in mental health services within the UK are discussed in relation to the relevance for staff training and quality assurance. The study attempted to access the diversity of understandings of risk issues amongst a multi-professional group of staff (n = 60) attending inter-agency risk training workshops in 1998. Q methodology is presented as both an appropriate means for such inquiry and as a novel experiential technique for training purposes. A tentative argument is advanced that the qualitative accounts generated by Q research could assist in systematic reviews of quality, complementing the singularly quantitative approaches typically represented in the audit process.

Successful control of epidemic diphtheria in the states of the Former Union of Soviet Socialist Republics: lessons learned

Epidemic diphtheria reemerged in the Russian Federation in 1990 and spread to all Newly Independent States (NIS) and Baltic States by the end of 1994. Factors contributing to the epidemic included increased susceptibility of both children and adults, socioeconomic instability, population movement, deteriorating health infrastructure, initial shortages of vaccine, and delays in implementing control measures. In 1995, aggressive control strategies were implemented, and since then, all affected countries have reported decreases of diphtheria; however, continued efforts by national health authorities and international assistance are still needed. The legacy of this epidemic includes a reexamination of the global diphtheria control strategy, new laboratory techniques for diphtheria diagnosis and analysis, and a model for future public health emergencies in the successful collaboration of multiple international partners. The reemergence of diphtheria warns of an immediate threat of other epidemics in the NIS and Baltic States and a longer-term potential for the reemergence of vaccine-preventable diseases elsewhere. Continued investment in improved vaccines, control strategies, training, and laboratory techniques is needed.

Comparison of intra-articular fentanyl and intra-articular bupivacaine for post-operative pain relief after knee arthroscopy

A randomized double-blinded study consisting of 107 patients was conducted to compare the effect on post-operative pain relief of intra-articular fentanyl and intra-articular bupivacaine after knee arthroscopy. The results showed that intra-articular bupivacaine produced superior analgesia in the immediate post-operative period. At 2 h post-operatively, the intra-articular bupivacaine group had a mean pain score of 2.0 (standard deviation 2.1, P < 0.05) compared with the intra-articular fentanyl group which had a mean pain score of 3.2 (standard deviation 2.3, P < 0.05). After 2 h post-operatively, intra-articular bupivacaine and intra-articular fentanyl had a similar effect on pain scores. The mean pain score 18 h post-operatively was 2.7 for the intra-articular bupivacaine group (standard deviation 2.2, P value 0.6) compared with the intra-articular fentanyl group which had a mean pain score of 2.8 (standard deviation 1.9, P value 0.6).

Good & Evil in the Crusade of Care: Social Constructions of Mental Disorders

Forensic nursing is a product of medicalized criminality, where social and moral issues are managed within a psychiatric ideology. The narrative accounts of nursing staff reflect a tension between scientific and lay interpretations of offending behavior. A nonprofessional discourse about "evil" presents a challenge to the structural and clinical credibility of forensic practice.

Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study

BACKGROUND

This was a multicenter investigation examining the efficacy of 4 psychosocial treatments for cocaine-dependent patients.

METHODS

Four hundred eighty-seven patients were randomly assigned to 1 of 4 manual-guided treatments: individual drug counseling plus group drug counseling (GDC), cognitive therapy plus GDC, supportive-expressive therapy plus GDC, or GDC alone. Treatment was intensive, including 36 possible individual sessions and 24 group sessions for 6 months. Patients were assessed monthly during active treatment and at 9 and 12 months after baseline. Primary outcome measures were the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the past month.

RESULTS

Compared with the 2 psychotherapies and with GDC alone, individual drug counseling plus GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score. Individual group counseling plus GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the past month. Hypotheses regarding the superiority of psychotherapy to GDC for patients with greater psychiatric severity and the superiority of cognitive therapy plus GDC compared with supportive-expressive therapy plus GDC for patients with antisocial personality traits or external coping style were not confirmed.

CONCLUSION

Compared with professional psychotherapy, a manual-guided combination of intensive individual drug counseling and GDC has promise for the treatment of cocaine dependence.

Prehospital identification of acute coronary ischemia using a troponin T rapid assay

OBJECTIVE

To evaluate the performance of a rapid assay for cardiac troponin T (cTn-T) in patients with chest pain in the prehospital setting.

METHODS

A prospective, observational clinical trial in a rural county served by a single emergency medical services system and two emergency departments. Patients fulfilling prehospital criteria to identify acute coronary ischemia (ACI) had a blood sample applied to the cTn-T rapid-assay device. Quantitative analysis of cTn-T was also performed on each sample at a later time. Medical records were reviewed to determine ultimate diagnoses. Non-admitted patients were followed by telephone at one week. Main outcome measures included the sensitivity, specificity, positive predictive value, and negative predictive value of the rapid cTn-T assay for detecting ACI defined as acute myocardial infarction (AMI) or unstable angina (UA) within one week of presentation.

RESULTS

Of 87 patients enrolled, 29 were identified with ACI. This included 15 patients diagnosed as having AMI and 14 patients diagnosed as having UA. The cTn-T rapid-assay device was positive for five of 87 patients (5.7%); three were associated with AMI and two with UA. Measurement of a single cTn-T to detect ACI had a sensitivity of 17.2% (0.058, 0.358), specificity of 100% (0.950, 1), positive predictive value of 100% (0.549, 1), and negative predictive value of 70.7% (0.609, 0.806).

CONCLUSION

The cTn-T rapid-assay device may be useful in the prehospital setting to identify a small number of patients with ACI. The authors caution, however, that a negative test in the prehospital setting cannot be used to rule out significant disease.

Effects of endotoxin on regulation of intestinal smooth muscle nitric oxide synthase and intestinal transit

BACKGROUND

The disrupted intestinal transit during endotoxemia may be mediated by nitric oxide (NO). We hypothesized that the isoforms of nitric oxide synthase (NOS) are up-regulated in intestinal smooth muscle during endotoxemia and that the scavenging of NO will normalize transit.

METHODS

Rats were given Escherichia coli lipopolysaccharide (LPS) 10 mg/kg intravenously and were killed 4 hours later. To determine the activity of NOS isoforms in the jejunum and ileum, the conversion of tritiated L-arginine to tritiated L-citrulline was measured. Western immunoblots were performed by incubating the extracted protein with specific polyclonal antibodies. To determine intestinal transit, rats were divided into 4 groups: 0.9% sodium chloride 1 mL/h intravenously for 5 hours, LPS 10 mg/kg intravenous bolus plus 1 mL/h 0.9% sodium chloride intravenously, LPS plus oxyhemoglobin 0.5 g/kg/h intravenously, and oxyhemoglobin 0.5 g/kg/h intravenously.

RESULTS

LPS increased the constitutive and inducible NOS enzyme activities in the jejunum and ileum. Western blots demonstrated that LPS up-regulates both the NOS1 and NOS2 isoforms in jejunal and ileal smooth muscle. Oxyhemoglobin alone increased intestinal transit compared with controls, whereas endotoxemia increased intestinal transit, which was ameliorated with infusions of oxyhemoglobin.

CONCLUSIONS

NO may play a major role in mediating the rapid intestinal transit induced by endotoxemia.

Angiotensin-converting-enzyme gene insertion/deletion polymorphism and response to physical training

BACKGROUND

The function of local renin-angiotensin systems in skeletal muscle and adipose tissue remains largely unknown. A polymorphism of the human angiotensin converting enzyme (ACE) gene has been identified in which the insertion (I) rather than deletion (D) allele is associated with lower ACE activity in body tissues and increased response to some aspects of physical training. We studied the association between the ACE gene insertion or deletion polymorphism and changes in body composition related to an intensive exercise programme, to investigate the metabolic effects of local human renin-angiotensin systems.

METHODS

We used three independent methods (bioimpedance, multiple skinfold-thickness assessment of whole-body composition, magnetic resonance imaging of the mid-thigh) to study changes in body composition in young male army recruits over 10 weeks of intensive physical training.

FINDINGS

Participants with the II genotype had a greater anabolic response than those with one or more D alleles for fat mass (0.55 vs -0.20 kg, p=0.04 by bioimpedance) and non-fat mass (1.31 vs -0.15 kg, p=0.01 by bioimpedance). Changes in body morphology with training measured by the other methods were also dependent on genotype.

INTERPRETATION

II genotype, as a marker of low ACE activity in body tissues, may conserve a positive energy balance during rigorous training, which suggests enhanced metabolic efficiency. This finding may explain some of the survival and functional benefits of therapy with ACE inhibitors.

Recovery from sevoflurane anesthesia in horses: comparison to isoflurane and effect of postmedication with xylazine

OBJECTIVE

To compare recovery from sevoflurane or isoflurane anesthesia in horses.

STUDY DESIGN

Prospective, randomized cross-over design.

ANIMALS

Nine Arabian horses (3 mares, 3 geldings, and 3 stallions) weighing 318 to 409 kg, 4 to 20 years old.

METHODS

Horses were anesthetized on three occasions with xylazine (1.1 mg/kg), Diazepam (0.03 mg/kg intravenously [i.v.]), and ketamine (2.2 mg/kg i.v.). After intubation, they were maintained with isoflurane or sevoflurane for 90 minutes. On a third occasion, horses were maintained with sevoflurane and given xylazine (0.1 mg/kg i.v.) when the vaporizer was turned off. Horses were not assisted in recovery and all recoveries were videotaped. Time to extubation, first movement, sternal, and standing were recorded as was the number of attempts required to stand. Recoveries were scored on a 1 to 6 scoring system (1 = best, 6 = worst) by the investigators, and by three evaluators who were blinded to the treatments the horses received. These blinded evaluators assessed the degree of ataxia present at 10 minutes after each horse stood, and recorded the time at which they judged the horse to be ready to leave the recovery stall.

RESULTS

Mean times (+/- SD) to extubation, first movement, sternal, and standing were 4.1 (1.7), 6.7 (1.9), 12.6 (4.6), and 17.4 (7.2) minutes with isoflurane; 3.4 (0.8), 6.6 (3.1), 10.3 (3.1), and 13.9 (3.0) minutes with sevoflurane; and 4.0 (1.2), 9.1 (3.3), 13.8 (6.5), and 18.0 (7.1) with sevoflurane followed by xylazine. Horses required a mean number of 4 (2.3), 2 (0.9), and 2 ( 1.6) attempts to stand with isoflurane, sevoflurane, and sevoflurane followed by xylazine respectively. The mean recovery score (SD) for isoflurane was 2.9 (1.2) from investigators and 2.4 (1.1) from blinded evaluators. For sevoflurane, the mean recovery score was 1.7 (0.9) from investigators and 1.9 (1.1) from evaluators, whereas the recoveries from sevoflurane with xylazine treatment were scored as 1.7 (1.2) from investigators and 1.7 (1.0) from blinded evaluators.

CONCLUSIONS

Recoveries appeared to vary widely from horse to horse, but were significantly shorter with sevoflurane than isoflurane, although sevoflurane followed by xylazine was no different from isoflurane. Under the conditions of the study, recoveries from sevoflurane and sevoflurane followed by xylazine were of better quality than those from isoflurane.

CLINICAL RELEVANCE

Sevoflurane anesthesia in horses may contribute to a shorter, safer recovery from anesthesia.

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels.

Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence

This study assessed the effects of training on the performance of 65 therapists in delivering manual-guided therapies to 202 cocaine-dependent patients. Changes in ratings of therapists' adherence and competence was assessed in 3 treatment modalities: supportive-expressive dynamic therapy (SE), cognitive therapy (CT), and individual drug counseling. Effects of manual-guided training on the therapeutic alliance were also assessed. Training effects were examined through a hierarchical linear modeling approach that examined changes both within cases and across training cases. A large effect across cases was detected for training in CT. Supportive-expressive therapists and individual drug counselors demonstrated statistically significant learning trends over sessions but not over training cases. Training in SE and CT did not have a negative impact on the therapeutic alliance, although alliance scores for trainees in drug counseling initially decreased but then rebounded to initial levels.