Chronic postsurgical pain (CPSP): an underestimated problem after incisional hernia treatment

BACKGROUND

Chronic postsurgical pain (CPSP) is a potential long-term problem following open incisional hernia repair which may affect the quality of life of patients despite successful anatomical repair of the hernia. The aim of this manuscript was to identify the incidence and outcome of patients following open incisional hernia repair in respect of risk factors to develop CPSP.

METHODS

A single-center retrospective analysis of patients who underwent open incisional hernia repair between 2015 and 2021 was performed. Pre-existing conditions (e.g., diabetes mellitus and malignancy), hernia complexity, postoperative complications, and postoperative pain medication were analyzed using the local database. Quality of life and CPSP were assessed using the EuraHS Quality of Life (QoL) questionnaire.

RESULTS

A total of 182 cases were retrospectively included in a detailed analysis based on the complete EuraHS (QoL) questionnaire. During the average follow-up period of 46 months, this long-term follow-up revealed a 54.4% incidence of CPSP and including a rate of 14.8% for severe CPSP (sCPSP) after open incisional hernia surgery. The complexity of the hernia and the demographic variables were not different between the group with and without CPSP. Patients with CPSP reported significantly reduced QoL. The analgesics score which includes the need of pain medication in the initial days after surgery was significantly higher in patients with CPSP than in those without (no CPSP: 2.86 vs. CPSP: 3.35; p = 0.047).

CONCLUSION

The presence of CPSP after open incisional hernia repair represents a frequent and underestimated long-term problem which has been not been recognized to this extent before. CPSP impairs QoL in these patients. Patients at risk to develop CPSP can be identified in the perioperative setting by the need of high doses of pain medication using the analgesics score. Possibly timely adjustment of pain medication, even in the domestic setting, could alleviate the chronicity or severity of CPSP.

Postoperative Analgesics Score as a Predictor of Chronic Postoperative Inguinal Pain After Inguinal Hernia Repair: Lessons Learned From a Retrospective Analysis

BACKGROUND

Chronic postoperative inguinal pain (CPIP) is a common complication after inguinal hernia surgery and occurs in up to 10-14% of cases. CPIP has a significant impact on daily life, work ability and thus compromises quality of life. The aim of this retrospective study was an in-depth analysis of patients undergoing inguinal hernia repair to further refine the prediction of the onset of CPIP reliably.

METHODS

A single center retrospective analysis of patients with who underwent open or minimally invasive inguinal hernia repair from 2016 to 2021 was carried out. Complication rates, detailed analysis of postoperative pain medication and quality of life using the EuraHS Quality of Life questionnaire were assessed.

RESULTS

Out of 596 consecutive procedures, 344 patients were included in detailed analyses. While patient cohorts were different in terms of age and co-morbidities, and the prevalence of CPIP was 12.2% without differences between the surgical procedures (Lichtenstein: 12.8%; TEP 10.9%; TAPP 13.5%). Postoperative pain was evaluated using a newly developed analgesic score. Patients who developed CPIP later had a significant higher consumption of analgesics at discharge (p = 0.016). As additional risk factors for CPIP younger patient age and postoperative complications were identified.

CONCLUSION

The prospective use of the analgesic score established here could be helpful to identify patients that are at risk to develop CPIP. These patients could benefit from a structured follow-up to allow early therapeutic intervention to prevent chronification and restore the quality of life.

[Older patients in abdominal surgery]

BACKGROUND

The aging society imposes special challenges on operative medicine.

OBJECTIVE

Characteristics in the perioperative treatment of older patients. Consequences for the daily practice.

MATERIAL AND METHODS

Evaluation and summary of existing literature including recommendations for the (peri)operative management of older patients.

RESULTS

Despite the growing relevance there are only few studies focusing on older patients. The altered (patho)physiology and comorbidities are challenging and can lead to complications.

CONCLUSION

The evaluation of the indications for surgery should meticulously take the improvement to be expected into account by weighing up the individual wishes of patients and special risks. The adequate perioperative care including early mobilization and sufficient analgesia are decisive.

Loss of ceramide synthase 5 reduces the development of aortic valve stenosis in mice with high fat diet

Background

Ceramide synthase 5 (CerS5) is essential to maintain C:16 ceramide levels in mice. Ceramides contribute to inflammation and calcification, two hallmarks of aortic valve stenosis development. It is known, that loss of CerS5 function reduces diet-induced obesity.

Purpose

The aim of this study was to investigate the effect of ceramide synthase 5 and high-fat diet on the development of aortic valve stenosis with a mouse model.

Methods

Our experiment consists of four groups of mice: Wild type (WT) and CerS5 (−/−) mice, with normal and high fat diet. We induced the aortic valve stenosis development through a wire-injury. For this model, a coronary angiography wire is introduced into the left ventricle over the right carotid artery, followed by rotation on the aortic valve level to generate a defined injury. Development of aortic valve stenosis was determined by measuring the peak velocity 14, 28 and 42 days after the wire-injury. With histological analysis of the aortic valve, we measured macrophage infiltration with CD68 immunostaining and calcification using von Kossa staining. For statistical analysis ANOVA and Turkeys multiple comparisons were performed.

Results

Histological analysis of the aortic valve revealed, that in CerS5 (−/−) mice with high fat diet (HFD) immune cell infiltration is reduced, while there is no difference between CerS5 (−/−) mice and wild type, when fed with normal diet (A). Also calcification showed a trend towards a reduction in CerS5 mice with high fat diet, but was not statistically significant (B). Echocardiography could detect a reduced peak velocity of CerS5 mice with high fat diet, in comparison to the other groups, four and six weeks after wire injury (C).

Conclusion

Our experiments indicate that loss of CerS5 function reduces the development of aortic valve stenosis in mice with high fat diet, by decreasing immune cell infiltration and calcification. Interestingly, in the groups with normal chow, loss of CerS5 function had no effect. In addition, high-fat diet alone had no negative effect in our mouse model. Based on our results it can be assumed that upon high fat diet CerS5 mediates for pro-inflammatory effects in the aortic valve, which are absent on normal diet.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Ernst & Berta Grimmke Foundation (13/19)

Oral berotralstat for the prophylaxis of hereditary angioedema attacks in patients in Japan: A phase 3 randomized trial

Background

With no approved treatments in Japan for the prevention of hereditary angioedema (HAE) attacks, there is a significant unmet need for long‐term prophylactic therapies for Japanese patients with HAE. Berotralstat (BCX7353) is an oral, once‐daily, highly selective inhibitor of plasma kallikrein in development for prophylaxis of angioedema attacks in HAE patients.

Methods

APeX‐J is a phase 3, randomized, double‐blind, placebo‐controlled, parallel‐group, 3‐part trial conducted in Japan (University Hospital Medical Information Network identifier, UMIN000034869; ClinicalTrials.gov identifier, NCT03873116). Patients with a clinical diagnosis of type 1 or 2 HAE underwent a prospective run‐in period of 56 days to determine eligibility, allowing enrollment of those with ≥2 expert‐confirmed angioedema attacks. Patients were randomly assigned (1:1:1) and stratified by baseline attack rate (≥2 vs. <2 expert‐confirmed attacks/month between screening and randomization) to receive once‐daily berotralstat 110 mg, berotralstat 150 mg, or placebo. The primary endpoint was the rate of expert‐confirmed angioedema attacks during dosing in the 24‐week treatment period.

Results

Nineteen patients were randomized to receive once‐daily berotralstat 110 mg (n = 6), berotralstat 150 mg (n = 7), or placebo (n = 6). Treatment with berotralstat 150 mg significantly reduced HAE attacks relative to placebo (1.11 vs. 2.18 attacks/month, p = .003). The most frequently reported treatment‐emergent adverse events (TEAEs) in berotralstat‐treated patients (n = 13) were nasopharyngitis (n = 4, 31%), abdominal pain, cough, diarrhea, and pyrexia (n = 2 each, 15%).

Conclusions

Orally administered, once‐daily berotralstat 150 mg significantly reduced the frequency of HAE attacks and was safe and well tolerated, supporting its use as a prophylactic therapy in patients with type 1 or 2 HAE in Japan.

Deflighting zoo birds and its welfare considerations

For over a century the practice of deflighting has taken place in zoological collections in order to ensure birds remain in open-topped enclosures. Over time, efforts have been made to improve or develop new (surgical) techniques, reduce risk of complications during deflighting and minimise stress and pain during the procedure. However, increased public interest in issues of animal welfare has coincided with a questioning of the practice of removing a birds ability to fly. The ensuing debate, which continues to progress among a variety of differing stakeholders, has led to various legislative adjustments across a number of countries. Despite significant legislation, the dialogue has been both subjective and highly emotive. A plethora of opinions exist as to why deflighting should be outlawed, why it is necessary, or how it has the potential to improve a birds living conditions. However, most are based on assumption or issues unrelated to welfare. To the authors knowledge, to date, no scientific data have been published on the welfare implications of deflighting for the commonly deflighted bird species, such as waterfowl, flamingos (Phoenicopteridae), pelicans (Pelecanidae), storks (Ciconiidae), cranes (Gruidae) and herons (Ardeidae). The aim of this study is to present an overview of the relevance of deflighting to zoo husbandry, the species primarily affected, the techniques currently in use, the legality in differing countries and the extent of scientific knowledge as regards potential ethological and welfare concerns. An urgent need for evidence-based studies is highlighted, to further inform this practice at a species-specific level.

The role of visceral and subcutaneous adipose tissue fatty acid composition in liver pathophysiology associated with NAFLD

Visceral adiposity is associated with type-2-diabetes, inflammation, dyslipidemia and non-alcoholic fatty liver disease (NAFLD), whereas subcutaneous adiposity is not. We hypothesized that the link between visceral adiposity and liver pathophysiology involves inherent or diet-derived differences between visceral and subcutaneous adipose tissue to store and mobilize saturated fatty acids. The goal of the present study was to characterize the fatty acid composition of adipose tissue triglyceride and portal vein fatty acids in relation to indices of liver dysregulation. For 8 weeks rats had free access to control (CON; 12.9% corn/safflower oil; 3.6 Kcal/g), high saturated fat (SAT; 45.2% cocoa butter; 4.5 Kcal/g) or high polyunsaturated fat (PUFA; 45.2% safflower oil; 4.5 Kcal/g) diets. Outcome measures included glucose tolerance, visceral and subcutaneous adipose tissue triglyceride, liver phospholipids and plasma (portal and systemic) free fatty acid composition, indices of inflammation and endoplasmic reticulum stress in the liver and adipose tissue depots and circulating adipo/cytokines. Hepatic triglycerides were significantly increased in both high fat diet groups compared to control and were significantly higher in PUFA compared to SAT. Although glucose tolerance was not different among diet groups, SAT increased markers of inflammation and ER stress in the liver and both adipose tissue depots. Fatty acid composition did not differ among adipose depots or portal blood in any dietary group. Overall, these data suggest that diets enriched in saturated fatty acids are associated with liver inflammation, ER stress and injury, but that any link between visceral adipose tissue and these liver indices does not involve selective changes to fatty acid composition in this depot or the portal vein.

Pulmonary cryptosporidiosis and immune reconstitution inflammatory syndrome: a case report and review

Cryptosporidium rarely affects the lungs, and is not typically associated with the immune reconstitution inflammatory syndrome (IRIS). We describe the first published case of pulmonary IRIS following the initiation of antiretroviral therapy in a patient with AIDS and pulmonary cryptosporidiosis, and discuss its implications for HIV patient care.

Factors affecting the prevalence of chronic diseases in Palestinian people: an analysis of data from the Palestinian Central Bureau of Statistics

This study determined whether there are significant differences in the prevalence of diabetes, hypertension, cardiovascular disease (CVD) and cancer among Palestinians with respect to different demographic variables using secondary data from the Palestinian Central Bureau of Statistics. Living in the Gaza Strip was a protective factor, with this group being 21% less likely to have diabetes, 35% less likely to have hypertension, and 48% less likely to have CVD than those living in the West Bank. No significant difference was found for cancer. Being a refugee was a significant risk factor for diabetes and CVD while being married/engaged or divorced/ separated/widowed was a risk factor for diabetes and hypertension. Gender was a risk factor for hypertension with females being 60% more likely to have hypertension than males. Living in a rural setting was protective against hypertension. As expected, age was a risk factor for diabetes, hypertension and CVD; the magnitude of this increased risk was alarming, 36 to 434 times greater in those aged 40-65 years compared with those aged 0-19 years.

Interstitial cells of Cajal mediate enteric inhibitory neurotransmission in the lower esophageal and pyloric sphincters

BACKGROUND & AIMS

Previous studies have suggested that a specific class of interstitial cells of Cajal (ICC) act as mediators in nitrergic inhibitory neurotransmission. The aim of this investigation was to examine the role of intramuscular ICC (IC-IM) in neurotransmission in the murine lower esophageal (LES) and pyloric sphincters (PS).

METHODS

Immunohistochemistry and electrophysiology were used to study the distribution and role of IC-IM.

RESULTS

The LES and PS contain spindle-shaped IC-IM, which form close relationships with nitric oxide synthase-containing nerve fibers. The PS contains ICC within the myenteric plexus and c-Kit immunopositive cells along the submucosal surface of the circular muscle. IC-IM were absent in the LES and PS of c-kit (W/Wv) mutant mice. Using these mutants, we tested whether IC-IM mediate neural inputs in the LES and PS. Although the distribution of inhibitory nerves was normal in W/Wv animals, NO-dependent inhibitory neurotransmission was reduced. Hyperpolarizations to sodium nitroprusside were also attenuated in W/Wv animals.

CONCLUSIONS

The data suggest that IC-IM play an important role in NO-dependent neurotransmission in the LES and PS. IC-IM may be the effectors that transduce NO signals into hyperpolarizing responses. Loss of IC-IM may interfere with relaxations and normal motility in these sphincters.

Multicenter trial validation of a camera-based method to measure Tc-99m mercaptoacetyltriglycine, or Tc-99m MAG3, clearance

PURPOSE

To evaluate an improved camera-based method for calculating the clearance of technetium-99m mercaptoacetyltriglycine (MAG3) in a multicenter trial.

MATERIALS AND METHODS

Tc-99m MAG3 scintigraphy was performed in 49 patients at three sites in the United States and Canada. The percentage of the injected dose of Tc-99m MAG3 in the kidney at 1-2, 1.0-2.5, and 2-3 minutes after injection was correlated with the plasma-based Tc-99m MAG3 clearances. The data were combined with the results obtained in 20 additional patients in a previously published pilot study.

RESULTS

Regression models correlating the plasma-based Tc-99m MAG3 clearance with the percentage uptake in the kidney for each time interval were developed; there was no statistically significant difference among sites in the regression equations. Correction for body surface area statistically significantly (P < .005) improved the correlation coefficient for each time interval. For the 1.0-2.5-minute interval, the body surface area-corrected correlation coefficient for the four combined sites was .87, and it improved to .93 when one outlier was omitted from the analysis. Similar results were obtained with the other time intervals. Independent processing by two observers showed no clinically important differences in the percentage dose in the kidney or in relative function.

CONCLUSION

An improved camera-based method to calculate the clearance of Tc-99m MAG3 was validated in a multicenter trial.

Phase I clinical trial with a human major histocompatibility complex nonrestricted cytotoxic T-cell line (TALL-104) in dogs with advanced tumors

The human TALL-104 cell line is endowed with a uniquely potent MHC nonrestricted tumoricidal activity across several species. In view of the potential applicability of TALL-104 cells as an anticancer agent, this study was conducted to evaluate the possible toxicity and efficacy of this new cell therapy in a superior animal model with spontaneous tumors. Nineteen canine cases with advanced, refractory malignancies of various histological types were entered in the study. All dogs had failed all other available treatments and had very limited life expectancy. Cyclosporin A was administered p.o. (10 mg/kg/day) starting from the day before TALL-104 cell administration throughout the treatment to prevent rejection of the xenogeneic effectors. Lethally irradiated (40 Gy) TALL-104 cells (10(8)/kg) were administered systemically following two treatment schedules. In the first schedule, the cells were given every other day for 2 weeks in a row and then once a week for 3 additional weeks; in the second schedule, TALL-104 cells were administered daily for a total of 5 days. None of the 19 cases showed significant clinical or laboratory toxicity; in addition, none of the dogs had to be withdrawn from the study because of immediate adverse reactions to the infusions. The severe side effects usually associated with classical lymphokine-activated killer therapy in association with high doses of interleukin 2, such as "capillary leak syndrome," were absent in this study. Remarkably, TALL-104 therapy induced various degrees of antitumor effects in 7 of the 19 dogs, including 1 complete response (continuing at +13 months), three partial responses (duration of 2 months, 3 months, and continuing at +2 months), and three transient responses. Clinical responses and immunological parameters correlated well in each case. Taken together, these data indicate that systemic administration of lethally irradiated TALL-104 cells in the absence of exogenous interleukin 2 may be regarded as a safe and promising adjuvant type of treatment for advanced cancer patients.

Transmission computed tomography imaging of the head with a SPECT system and a collimated line source

Transmission images of relatively high resolution as compared to SPECT are needed for brain SPECT quantification to provide skull thickness, attenuation coefficients and anatomical correlation. Consequently, a technique to acquire transmission CT images with a SPECT system by using a collimated line source positioned at the focal line of a fanbeam collimator (FBC) has been developed.

METHODS

Computer simulations that model the transmission imaging system optimized the system resolution and tested the validity of a equation for the geometric efficiency of the line source collimator (LSC). Based on the computer simulations, a LSC was constructed with tantalum septa 100 mm long, 0.5 mm thick and spaced 1.0 mm apart. A 600-mm focal length FBC was used. Experiments were conducted to measure the system resolution and to determine the effect of the LSC on the amount of detected scatter.

RESULTS

The simulations showed that without a LSC the transmission images have a longitudinal resolution (LR) characterized by the resolutions of the FBC (depth-dependent, approximately 8 mm FWHM at 150 mm) and the detector (approximately 4 mm). However, with an optimally designed LSC, the contribution of the FBC to the system resolution can be made negligible, creating a system with a LR that is comparable to the detector resolution and independent of object depth. Resolution experiments conducted with a lucite rod phantom showed that the LR and TR are better than 4.8 mm and confirmed the results of the computer simulations.

CONCLUSION

Brain transmission images of relatively high isotropic resolution can be obtained using a SPECT system, a FBC and an optimized LSC.

Use of Edinburgh Postnatal Depression Scale in a North American population

1. The authors mailed the Edinburgh Post-natal Depression Scale to 308 women at six weeks postpartum. 2. It was completed and return by 185 women (60.0%). 3. Thirty-two of them (17.4%) scored 12 and above, the threshold reported to identify most women with postpartum depressive disorder.

Correction for attenuation in technetium-99m-HMPAO SPECT brain imaging

We present a correction technique that uses the effective bone and tissue attenuation coefficients to compensate 99mTc-HMPAO brain SPECT projections for attenuation. Transverse images of a human skull filled with a uniform mixture of 99mTc and gelatin have a greater count density at the center with respect to the periphery when corrected for attenuation with the effective water/tissue coefficient of 0.12 cm-1. An attenuation coefficient of 0.09 cm-1 produces uniform images at the expense of a reduced count density. Additional experiments with phantoms wrapped with aluminum (to simulate bone) indicate that the greater count density at the image center is a result of increased attenuation at the edges of the projections where there is a greater path length through the aluminum (or bone). SPECT projections explicitly corrected for both bone and soft-tissue attenuation result in images of improved uniformity and increased count density.

Effects of dipyridamole infusion on human renal function observed using technetium-99m-DTPA

Our observation that a prolonged dipyridamole infusion reduced or eliminated blood clearance of Gd-DTPA in dogs led us to investigate if dipyridamole, infused intravenously at rates comparable to those used in thallium myocardial perfusion tests, would alter renal filtration in humans. Renal filtration was assessed using a bolus injection of 10 mCi of 99mTc-DTPA in five males (19-63 yr old) with normal serum urea and creatinine. Twenty minutes following the bolus injection a 10-min intravenous infusion of either dipyridamole (0.14 mg/kg/min) or saline sham was given. Four to 10 min following the start of the dipyridamole infusion, a paradoxical rise in counts in the kidney region of interest was observed and persisted for 10 to 27 min. During this time, a 13% to 52% (mean +/- s.d., 40% +/- 16%, p less than 0.007) reduction in the exponential slope defining the clearance of counts from the cardiac region of interest occurred (implying a reduction of glomerular filtration rate), mean heart rate increased 27 +/- 5 bpm, p less than 0.002 and mean diastolic pressure decreased 12.9 +/- 6.4 mmHg, p less than 0.028. This finding indicates that renal clearance of tracers such as thallium or contrast agents such as Gd-DTPA is reduced during dipyridamole infusion.

Hearing screening in a dental office using self-assessment

Experiences in a statewide health fair screening program prompted development of alternate methods for screening hearing of adults including one in a dental office summarized here. Because it was considered impractical to use pure-tone screening, several self-assessment procedures were tested against pure-tone findings in a pilot study. As a result, the Rating Scale for Each Ear (RSEE) was selected for use. In the pilot and main study, 796 adult dental patients were evaluated and 21 to 29% failed the screening, depending on whether self-assessment procedures or pure tones were used. Although the dental office staff was generally supportive of the program, there were some problems in implementation. The number who returned for follow-up (N = 14) was disappointing, but there were several very positive benefits to the program including distribution of earplugs and education on the adverse effects of noise. In terms of general feasibility of such screening, from an epidemiology standpoint the program was judged to have good efficacy and efficiency but there were serious problems in effectiveness.

Cost analysis of magnetic resonance imaging at St. Joseph's Health Centre of London

In April 1986 St. Joseph's Health Centre of London, Ont., completed 3 years of operating a magnetic resonance imaging unit. The first 2 years were devoted to research and development. From Apr. 1, 1985, to Mar. 31, 1986, the unit operated as the first clinical service unit in Canada. Over the 12 months 1671 patients (an average of 9 patients per 12-hour day) were examined. Studies of the brain (62%) and the spine (21%) accounted for most of the procedures. The operating costs for the year were $892,000; revenues totalled $449,000, for a deficit of $443,000. The average technical cost per patient was $534. Increasing the number of patients examined per year would lower the cost to $431.

Magnetic resonance imaging for detecting lesions of multiple sclerosis: comparison with computed tomography and clinical assessment

Eighty-two patients with known or suspected multiple sclerosis (MS) were examined by means of magnetic resonance imaging (MRI) with a 0.15-T resistive scanner. The diagnosis could be made by MRI in 34 (97%) of the 35 patients with chronic, well-documented, stable MS and by high-volume delayed x-ray computed tomography (HVD CT) in only 6 (54%) of 11 patients in this group. The stage of the disease as judged from the MRI scans correlated poorly with the clinical status of the patient and with the known duration of the disease. MRI identified 28 (88%) of the 32 patients in whom MS was subsequently diagnosed by a neurologist, whereas regular contrast or HVD CT identified only 11 (52%) of 21 such patients. MRI is the most sensitive imaging modality for MS but is of little value in assessing the severity of the disease: many of the lesions seen on MRI scans are clinically "silent", and MRI does not usually detect small lesions in the brainstem, cerebellum or spinal cord that may be clinically significant.

Hyperbaric oxygen therapy in chronic stable multiple sclerosis: double-blind study

We carried out a randomized, double-blind, placebo-controlled trial of hyperbaric oxygen therapy (HBO) in patients with chronic stable MS. Eighty-two patients were treated in a multiplace hyperbaric chamber with gas supplied by mask. Forty-one patients received 20 consecutive daily treatments of 100% O2 followed by 7 "booster" treatments in the next 6 months; 41 control patients received "air" (12.5% O2 at 1.75 atmospheres absolute). There was no significant difference in treatment and control groups in the Extended Kurtzke Disability scores, Kurtzke Functional scores, magnetic resonance imaging, or evoked potentials after the initial 20 treatments or after the boosters. HBO is not effective in treating chronic stable MS.

Quantitation of lung water by nuclear magnetic resonance imaging. A preliminary study

Pulmonary edema was produced in four anesthetized dogs by saline lavage. The animals were maintained by assisted ventilation with O2/halothane and examined by a nuclear magnetic resonance (NMR) 0.15T resistive-magnet imager. The distribution of edematous fluid was clearly observed. Image contrast increased with prolongation of the cycle time (TR). Tomographic maps of spin-lattice relaxation times (T1) of the lungs were calculated from the NMR images. Comparison of T1 values with gravimetric measurements of water content of lung samples showed significant correlation (r = .7, P less than .02, n = 12) suggesting a potential for in vivo lung water quantitation by NMR imaging. This in vivo correlation is qualitatively similar to the in vitro correlation. Accurate in vivo determinations of pulmonary T2 values may require respiratory gating.

Microanalysis of action and fear arousal as a function of differential levels of perceived self-efficacy

Two experiments combining intergroup and intrasubject designs were conducted to test the hypothesis that self-percepts of efficacy operate as cognitive mediators of coping behavior and fear arousal. Differential levels of self-efficacy were induced in phobic subjects through either inactive mastery or modeling. Their coping behavior and accompanying fear arousal were then measured. In the next phase, self-efficacy was successively raised to designated levels within the same subjects, whereupon their behavior and fear arousal were again measured. Coping behavior corresponded closely to instated self-percepts of efficacy, with higher levels of perceived self-efficacy being accompanied by greater performance attainments. The efficacy-action relationship was replicated across different modes of efficacy induction, different types of behavioral dysfunctions, and in both intergroup and intrasubject comparisons. The hypothesis that fear arousal stems largely from perceived coping inefficacy also received support from the findings. As subjects' self-efficacy level was raised, they experienced progressively less anticipatory and performance distress while coping with threats. Results of a third experiment using cardiac acceleration and elevation in blood pressure as indicants of arousal further corroborate the generality of the relationship between perceived coping inefficacy and stress reactions.

Microanalysis of action and fear arousal as a function of differential levels of perceived self-efficacy

Two experiments combining intergroup and intrasubject designs were conducted to test the hypothesis that self-percepts of efficacy operate as cognitive mediators of coping behavior and fear arousal. Differential levels of self-efficacy were induced in phobic subjects through either inactive mastery or modeling. Their coping behavior and accompanying fear arousal were then measured. In the next phase, self-efficacy was successively raised to designated levels within the same subjects, whereupon their behavior and fear arousal were again measured. Coping behavior corresponded closely to instated self-percepts of efficacy, with higher levels of perceived self-efficacy being accompanied by greater performance attainments. The efficacy-action relationship was replicated across different modes of efficacy induction, different types of behavioral dysfunctions, and in both intergroup and intrasubject comparisons. The hypothesis that fear arousal stems largely from perceived coping inefficacy also received support from the findings. As subjects' self-efficacy level was raised, they experienced progressively less anticipatory and performance distress while coping with threats. Results of a third experiment using cardiac acceleration and elevation in blood pressure as indicants of arousal further corroborate the generality of the relationship between perceived coping inefficacy and stress reactions.

Radioimmunoassay of serum myoglobin in screening for acute myocardial infarction

Over an 8-month period 289 patients consecutively admitted to a coronary care unit were studied to assess the value of serum myoglobin determinations by radioimmunoassay in screening for acute myocardial infarction. Of the 289 patients 127 (44%) had an infarction. It was found that when blood sampling was done within 5 to 15 hours after the onset of chest pain this assay had a sensitivity, specificity, and positive and negative predictive values of more than 97%. In this study healthy young adults had a mean serum myoglobin level of 37 +/- 11 (standard deviation) ng/ml, and values above 80 ng/ml were considered positive for acute myocardial infarction. False-positive results can be due to stock, vigorous exercise, skeletal muscle damage and several renal failure, but, except for the last one, these conditions also caused an increase in the serum level of the creatine kinase isoenzyme CK-MB.

Relation of cord blood thyroxine and thyrotropin levels to gestational age and birth weight

A program of screening cord blood for evidence of primary neonatal hypothyroidism was implemented in a general hospital. In 13 months 3456 newborns were screened: the thyroxine (T4) and triiodothyronine (T3) concentrations were measured in cord blood samples, and when the T4 level was below 8.0 micrograms/dl thyrotropin was also assayed in the sample. The two-tier program was effective. One hypothyroid newborn was detected and treated. More boys than girls had T4 levels below 8.0 micrograms/dl (9.7% v. 4.7%). The T4 level correlated with birth weight slightly better in the boys (r = 0.28 v. 0.21), and in the boys this correlation was stronger when the birth weight was lower. Regression analysis of the data for 54 sets of twins indicated that the T4 level was more strongly related to gestational age than to birth weight.

The retrocaval ureter: an intrinsic abnormality

An 11-year-old boy underwent resection of an abnormally draining ureteral segment of a retrocaval right ureter. Compression by the inferior vena cava may have caused the faulty drainage. End-to-end ureteroureteral anastomosis was carried out. Intraoperative study of perfusion was helpful in the management of this child's condition.

Effect of insulin-induced hypoglycemia on the serum concentrations of thyroxine, triiodothyronine and reverse triiodothyronine

The effect of insulin-induced hypoglycemia on serum thyroid hormone concentrations was studied in nine healthy individuals. Before, during and after the hypoglycemia blood samples were taken for measurement of the concentrations of glucose, thyroxine (T(4)), triiodothyronine (T(3)), reverse triiodothyronine (rT(3)), catecholamines and pituitary hormones.There was no change in the mean serum T(4) level (+/- the standard error of the mean) of 67 +/- 2 mug/l. However, the T(3) concentrations rose from a mean basal level of 1.86 +/- 0.06 mug/l to a mean peak of 2.51 +/- 0.21 mug/l (P < 0.01) at 45 minutes after the insulin injection, and the rT(3) concentrations fell from a mean basal level of 0.184 +/- 0.008 mug/l to a mean nadir of 0.171 +/- 0.022 mug/l (not a significant change). The mean peak epinephrine level was 545 +/- 103 ng/l and it occurred between 30 and 45 minutes after the insulin injection; the mean peak norepinephrine level was 584 +/- 114 ng/l and it occurred between 30 and 90 minutes after the injection. The growth hormone levels reached a mean peak of 26.1 +/- 4.8 mug/l and the plasma cortisol levels rose to 215 +/- 9 mug/l. The mean basal prolactin level was 8.5 +/- 0.9 mug/l; in five subjects there was a rise to a mean peak of 50.6 +/- 14.6 mug/l, whereas in the remaining four no significant increase occurred. No correlation was found between the changes in the serum T(3) concentration and any of the other factors studied.It was concluded that acute hypoglycemia is associated with a rapid increase in the serum T(3) concentration.

The application of 67Ga scanning in determining the operability of bronchogenic carcinoma

In a prospective study of 34 patients with histologically proven bronchogenic carcinoma, 67Ga scanning of the chest was used to screen for mediastinal involvement. Mediastinal scans and pathologic findings were in agreement in 27 patients. Two patients had false-negative scans and 5 had positive scans but no evidence of mediastinal tumor. These results indicate a sensitivity of 89%, a specificity of 66.6%, an accuracy of 77% for positive scans, and an accuracy of 83% for negative scans. Overall correlation between 67Ga scanning of the chest and mediastinal-tumor involvement is statistically significant (P = 0.003).

Management of acute renal failure due to marked hyperuricemia

Images

Localization of kidney for renal biopsy using chlormerodrin-203Hg

Images