Acute and Longer-Term Outcomes Using Ketamine as a Clinical Treatment at the Yale Psychiatric Hospital

OBJECTIVE

Ketamine has emerged as a rapid-acting antidepressant, though controversy remains whether sufficient data exist to justify its use outside of research protocols. In October 2014, the authors' institution began providing ketamine as an off-label therapy on a case-by-case basis for patients unable to participate in research protocols. Here, the participant experience during 29 months of providing ketamine as a clinical treatment for severe and treatment-resistant mood disorders through February 2017 is described.

METHODS

Patients were initially treated with a single- or double-infusion protocol (0.5 mg/kg for 40 minutes intravenously) and were later transitioned to a 4-infusion protocol over 2 weeks.

RESULTS

Fifty-four patients received ketamine, with 518 total infusions performed. A subset of 44 patients with mood disorders initiated the 4-infusion protocol, of whom 45.5% responded and 27.3% remitted by the fourth infusion. A subsample (n = 14) received ketamine on a long-term basis, ranging from 12 to 45 total treatments, over a course of 14 to 126 weeks. No evidence was found of cognitive decline, increased proclivity to delusions, or emergence of symptoms consistent with cystitis in this subsample.

CONCLUSIONS

In general, ketamine infusions were tolerated well. The response and remission rates in this clinical sample were lower than those observed in some research protocols. The small number of patients who were treated on a maintenance schedule limits the conclusions that can be drawn regarding the long-term safety of ketamine; however, no long-term adverse effects were observed in this sample.

Effective Research Mentorship for Residents: Meeting the Needs of Early Career Physicians

OBJECTIVE

Challenges in pursuing research during residency may contribute to the shortage of clinician-scientists. Although the importance of mentorship in facilitating academic research careers has been described, little is understood about early career research mentorship for residents. The aim of this study was to better understand the mentorship process in the context of psychiatry residency.

METHOD

Semi-structured interviews were conducted with experienced faculty mentors in a psychiatry department at a large academic medical center. Interviews were analyzed using inductive thematic analysis. Results from faculty interviews identified several key themes that were explored with an additional sample of resident mentees.

RESULTS

Five themes emerged in our study: (1) being compatible: shared interests, methods, and working styles; (2) understanding level of development and research career goals in the context of residency training; (3) establishing a shared sense of expectations about time commitment, research skills, and autonomy; (4) residents' identity as a researcher; and (5) the diverse needs of a resident mentee. There was considerable congruence between mentor and mentee responses.

CONCLUSIONS

There is an opportunity to improve research mentoring practice by providing guidance to both mentors and mentees that facilitates a more structured approach to the mentorship relationship.

A Case Suspended in Time: The Educational Value of Case Reports

Although medical case reports have fallen out of favor in the era of the impact factor, there is a long tradition of using case reports for teaching and discovery. Some evidence indicates that writing case reports might improve medical students' critical thinking and writing skills and help prepare them for future scholarly work. From 2009 through 2015, students participating in the case reporting program at a VA hospital produced 250+ case reports, 35 abstracts, and 15 journal publications. Here, three medical students who published their case reports comment on what they learned from the experience. On the basis of their comments, the authors propose five educational benefits of case reporting: observation and pattern recognition skills; hypothesis-generating skills; understanding of patient-centered care; rhetorical versatility; and use of the case report as a rapidly publishable "mini-thesis," which could fulfill MD thesis or scholarly concentration requirements. The authors discuss the concept of the case report as a "hybrid narrative" with simultaneous medical and humanistic significance, and its potential use to teach students about their dual roles as engaged listeners and scientists. Finally, the authors consider the limitations and pitfalls of case reports, including patient confidentiality issues, overinterpretation, emphasis on the rare, and low initial publication rates. Case reports allow students to contribute to medical literature, learn useful scholarly skills, and participate in a tradition that links them with past generations of physicians. The authors conclude that the case report can be an effective teaching tool with a broad range of potential educational benefits.

Activation of the phonological lexicon for reading and object naming in deep dyslexia

Poor oral reading in some cases of deep dyslexia could be due to difficulty in inhibiting the phonological lexical entries of words semantically related to the correct reading responses. If this is the case, then additional activation of the correct phonological entries should improve reading performance, whereas additional activation of competing entries should lead to errors. This should hold true for object naming as well as for reading, since both depend on a semantically mediated lexical route. These predictions were borne out with an "output" deep dyslexic patient, who made many semantic errors in both reading and naming. Providing phonetic cues (the initial portions of the correct responses) increased his reading and naming accuracy, and providing miscues (the initial portions of words related semantically to the correct responses) led to errors. Furthermore, when the patient was shown a printed word or pictured object and the examiner spoke a correct reading or naming response in isolation, the patient almost always accepted the response as correct, but he also judged that many semantically related foils were correct. Finally, a comparison of reading and naming errors suggested that "visual" errors may sometimes have a phonological basis.

Phonological and semantic factors in the object-naming errors of skilled and less-skilled readers

Children who read poorly have difficulty naming objects, and their errors usually bear a semantic or a phonetic resemblance to the correct words. Excessive semantic and phonetic naming errors could both be due to underlying phonological deficiencies in poor readers. When children cannot name an object because its name is not represented well in long-term memory or cannot be processed well, semantic information as well as partially available phonological information may be used in selecting an alternative response. This hypothesis was tested by looking for the joint influence of semantics and phonology in the naming errors of third-grade children. The same children were asked to name a set of pictured objects, repeat the object names after being spoken by the examiner, and recognize the objects from their spoken names. A separate group of children produced associative responses to the same pictures. First, it was found that, compared with skilled readers, less-skilled readers who named objects without any time pressure had a deficit that could not be attributed to repetition difficulty or limited vocabulary. Second, the naming errors showed a semantic relationship to the correct words that was as strong as that of the associative responses. Third, the naming errors also showed a phonetic relationship to the correct words, whereas the associative responses did not. Finding a joint semantic and phonetic effect in the naming errors of children suggests that the errors may be attributable to phonological deficiencies.

Automatic activation of word phonology from print in deep dyslexia

The performance of deep dyslexics in oral reading and other tasks suggests that they are poor at activating the phonology of words and non-words from printed stimuli. As the tasks ordinarily used to test deep dyslexics require controlled processing, it is possible that the phonology of printed words can be better activated on an automatic basis. This study investigated this possibility by testing a deep dyslexic patient on a lexical decision task with pairs of stimuli presented simultaneously. In Experiment 1, which used content words as stimuli, the deep dyslexic, like normal subjects, showed faster reaction times on trials with rhyming, similarly spelled stimuli (e.g. bribe-tribe) than on control trials (consisting of non-rhyming, dissimilarly spelled words), but slower reaction times on trials with non-rhyming, similarly spelled stimuli (e.g. couch-touch). When the experiment was repeated using function words as stimuli, the patient no longer showed a phonological effect. Therefore, the phonological activation of printed content words by deep dyslexics may be better than would be expected on the basis of their oral reading performance.

Use of hair analysis for evaluating mercury intoxication of the human body: a review

Relationships have been established between the concentrations of mercury in human scalp hair and environmental or dietary mercury exposures. For chronic exposures, the hair/blood ratio for mercury is in the range 200:1-300:1, and scalp hair mercury concentrations of greater than 5 ppm are indicative of mercury intoxication. These observations, coupled with the ease by which samples may be collected, transported and stored, support the use of hair analysis for evaluating mercury intoxication of the human body.

Distinguishing representation deficits and processing deficits in a case of acquired dysgraphia

The same acquired disorder of spelling may be due to deficits affecting lexical representations of word spelling or deficits affecting the mechanisms that process those representations. This study sought to distinguish these possibilities in a dysgraphic patient. The integrity of the patient's lexical orthographic representations was assessed by having him decide whether or not pairs of words presented auditorily rhymed. Although the patient was impaired on a variety of spelling tasks and with all types of stimulus material, he showed a normal effect of spelling on the rhyme task. Like normal subjects, he was faster at deciding that words rhymed when they were spelled similarly (e.g. tool-cool) than when they were spelled dissimilarly (e.g. rule-cool) and slower at deciding that words did not rhyme when they were spelled similarly (e.g. toad-broad) than when they were spelled dissimilarly (e.g. code-broad). Therefore, as the patient's lexical representations of word spelling seemed to be generally intact, his spelling problems were probably due to difficulty in processing those representations.

Limited retention of information in the graphemic buffer

This study examined a patient who mainly made letter deletion errors in spelling. It was hypothesized that his errors were due primarily to limited ability to retain information in the graphemic buffer, a structure that holds sequences of abstract letter identities for output. Consistent with this hypothesis, the patient's spelling accuracy declined on long words, but the number of letters he wrote per response was not related to word length. Moreover, by having him write words forward and backward, it was shown that his accuracy within a word depended on which part of the word he tried to output first. These results also ruled out alternative accounts of the patient's spelling deficit based on neglect or damage to lexical representations.

Cross-modality word matching in letter-by-letter readers

Letter-by-letter readers can match spoken words to printed words they cannot read. Good word-matching ability may be attributable to a priming effect. However, since letter-by-letter readers have intact spelling ability, an alternative hypothesis is that word matching depends on a strategy of scanning printed words for recognizable letters known to be in the target items. In the present study, experimental manipulations that taxed the ability of the two subjects to process key letters (those that distinguished target words from foils) or scan for them caused a decline in word-matching performance. Thus, letter-by-letter readers may rely on sequential letter processing to accomplish cross-modality word matching.

Elevated blood levels of carcinogens in passive smokers

The hypothesis that involuntary exposure to tobacco smoke--passive smoking--results in greater risk of cancer was assessed by measuring the levels of two known carcinogens in the blood of 57 nonsmokers with varying degrees of involuntary exposure, including six heavily exposed bartenders. The concentrations of hemoglobin adducts of 4-aminobiphenyl, a bladder carcinogen, were significantly higher in subjects with confirmed involuntary exposure (plasma cotinine concentrations between 2 and 23 ng/ml) compared with subjects with undetectable levels of cotinine. Similarly, adducts of 3-aminobiphenyl were significantly elevated in subjects with confirmed exposure. The odds of 3-aminobiphenyl adduct levels exceeding 2 pg/g of hemoglobin were 6:7 among the confirmed exposed, compared with the odds of 2:42 among subjects with undetectable cotinine (odds ratio = 18; 95 percent confidence interval = 3.3, 94). The validity of the assay was demonstrated by showing striking declines in adduct levels among quitting smokers.

Effect of cues on object naming in first-grade good and poor readers

Object-naming deficits in children with reading problems may be due to deficiencies in either the phonological stage of processing or the semantic stage. The present study approached this issue by manipulating the type of cue given (semantic or phonetic) when object drawings were not named correctly by first-grade children. Although the children who were poor readers named significantly fewer objects than the good readers, both groups of children benefited from phonetic cues. In contrast, semantic cues had relatively little effect. These results support the view that difficulty on object naming is more likely related to phonological deficiencies.

Repetitive naming and the detection of word retrieval deficits in the beginning reader

The claim has been advanced that children with severe reading disability are generally deficient in word retrieval compared with normal readers. Support for the claim is based largely on studies of rapid naming of repetitively presented pictured objects or other nameable stimuli, a task which is apparently more sensitive to retrieval problems than the confrontation naming of items presented singly. The purpose of this study was to examine whether there is a general relationship between word retrieval speed and reading ability in beginning readers. Although such a relationship has not been detected with confrontation naming, repetitive naming may provide a more sensitive test. Accordingly, second-grade children were required to name as rapidly as possible repeated presentations of five pictured items drawn from a single category. Separate naming tests were made for objects, colors, animals, letters, and words. The results showed that there was no relationship between reading ability and naming times when the test items were selected from sets of objects, colors, or animals, whereas on letters and words, a significant relationship was found. The less-skilled readers were not, therefore, consistently slower in all repetitive naming situations. Instead their word retrieval deficits extended only to the orthographic materials.

The brow-lift 1978

The direct brow-lift for correction of brow ptosis can be one of the most beneficial surgical procedures in cosmetic surgery. Careful preoperative evaluation and proper symmetrical marking of the correction are key elements for successful results. We discuss the surgical technique in detail.

A method for determining cortical auditory thresholds in guinea pigs

A method for measuring evoked cortical potentials to acoustic stimuli through the intact dura mater of the guinea pig without computer averaging studied. After exposure of the dura overlying the auditory cortex on the left side, thresholds to acoustic stimuli presented to the right ear were determined with a double tipped silver electrode by visual detection on an oscilloscope. The thresholds obtained are compared with other methods of determining audibility levels in the guinea pig. With relatively simple instrumentation, this method provides rapid and accurate determination of the audibility curve.

Hearing loss of a central type secondary to anoxic anoxia

The effect of anoxic anoxia on the threshold sensitivity and amplitude of the responses from the auditory cortex, inferior colliculus and cochlea to acoustic stimuli in guinea pigs was studied. Decay of the amplitude of the responses from the auditory cortex and the inferior colliculus occurs faster and is more severe than that of the cochlea. Recovery of the amplitude of the responses is slower at the auditory cortex and the inferior colliculus than at the cochlea. Loss of auditory threshold sensitivity in anoxic anoxia is most prominent at the auditory cortex. The loss of sensitivity at the inferior colliculus is the next most severe. The loss of sensitivity at the cochlea is negligible. The relative vulnerability of the central auditory pathway to anoxic anoxia as compared to the end organ is demonstrated.

Late recurrence of testicular tumor (choriocarcinoma)

A case is presented in which a large choriocarcinoma was excised from the contralateral retroperitoneal area 15 years after a radical orchiectomy for seminoma with elements of embryonal carcinoma.

Benign mesothelial tumor of bladder

Two cases of benign mesothelial tumor of the bladder are presented, one causing urinary retention following surgery for stress incontinence and the other a softball-sized fibroma with a fifteen-year follow-up.