Systemic Challenges in Internship Training for Health-Service Psychology: A Call to Action From Trainee Stakeholders

The challenges observed in health service psychology (HSP) training during COVID-19 revealed systemic and philosophical issues that preexisted the pandemic, but became more visible during the global health crisis. In a position paper written by 23 trainees across different sites and training specializations, the authors use lessons learned from COVID-19 as a touchstone for a call to action in HSP training. Historically, trainee voices have been conspicuously absent from literature about clinical training. We describe longstanding dilemmas in HSP training that were exacerbated by the pandemic and will continue to require resolution after the pandemic has subsided. The authors make recommendations for systems-level changes that would advance equity and sustainability in HSP training. This article advances the conversation about HSP training by including the perspective of trainees as essential stakeholders.

Online rapid sampling microdialysis (rsMD) using enzyme-based electroanalysis for dynamic detection of ischaemia during free flap reconstructive surgery

We describe an enzyme-based electroanalysis system for real-time analysis of a clinical microdialysis sampling stream during surgery. Free flap tissue transfer is used widely in reconstructive surgery after resection of tumours or in other situations such as following major trauma. However, there is a risk of flap failure, due to thrombosis in the flap pedicle, leading to tissue ischaemia. Conventional clinical assessment is particularly difficult in such ‘buried’ flaps where access to the tissue is limited. Rapid sampling microdialysis (rsMD) is an enzyme-based electrochemical detection method, which is particularly suited to monitoring metabolism. This online flow injection system analyses a dialysate flow stream from an implanted microdialysis probe every 30 s for levels of glucose and lactate. Here, we report its first use in the monitoring of free flap reconstructive surgery, from flap detachment to re-vascularisation and overnight in the intensive care unit. The on-set of ischaemia by both arterial clamping and failure of venous drainage was seen as an increase in lactate and decrease in glucose levels. Glucose levels returned to normal within 10 min of successful arterial anastomosis, whilst lactate took longer to clear. The use of the lactate/glucose ratio provides a clear predictor of ischaemia on-set and subsequent recovery, as it is insensitive to changes in blood flow such as those caused by topical vasodilators, like papaverine. The use of storage tubing to preserve the time course of dialysate, when technical difficulties arise, until offline analysis can occur, is also shown. The potential use of rsMD in free flap surgery and tissue monitoring is highly promising.

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A Literature Review of Subtle-Obvious Items on the MMPI

This article chronologically reviews the literature relating to subtle and obvious items of the Minnesota Multiphasic Personality Inventory. Wiener's original development of subtle and obvious subscales, Seeman's support for the concept of subtlety, and Duffs arguments concerning empirical versus face validity are discussed. Later research exploring demand characteristics are then reviewed, such as the paradoxical relationships under differing instruction sets and population issues. The work from Auburn University researchers on the development of a 5-point subtlety scale, the interaction with personality factors, and individual scale research is critiqued.

CD 271 (P75 neurotrophin receptor)

P75NTR (or CD271) is a member of the Tumor Necrosis Factor receptor (TNFR) super family of transmembrane proteins that share significant homology in their extracellular domains. Subsets of TNF receptors, including CD271, have a cytoplasmic death domain, although CD271 has unique intracellular structure and downstream signaling partners. CD271 is also differentiated from other members of the TNFR receptor family in that it binds pro and mature neurotrophins and affects the growth, differentiation and death of the nervous system. The ligands for CD271 are neurotrophins, which are Nerve Growth Factor (NGF), Brain-Derived Growth factor (BDNF), Neurotrophin 3 (NT3) and Neurotrophin 4/5 (NT4/5). Recent studies have provided evidence that CD271 also serves as a receptor for the pro-forms of these neurotrophins.

Preliminary findings in the neurophysiological assessment of intercostal nerve injury during thoracotomy

OBJECTIVE

Previous work has suggested that intercostal nerve injury is a major factor in the aetiology of chronic post-thoracotomy pain. The aim of this study was to establish if there was identifiable intercostal nerve injury during thoracotomy.

METHODS

Intercostal nerves were stimulated and motor evoked potentials were recorded from intercostal muscles in 13 patients undergoing thoracotomy. Measurements were taken before and after entering the pleural space, after removal of the rib retractor and after intercostal space closure.

RESULTS

Intercostal nerves functioned normally before and after entering the pleural space. After the rib retractor was removed, there was a total conduction block in the nerve immediately above the incision in every patient. In the nerves above this, six had a total block, one a partial block and three had normal conduction. There was a total conduction block in the nerve immediately below the incision in all but one patient. Of the nerves below this, four had a total block, two a partial block and three had normal conduction. In the cases of total conduction block, there was either a discrete block at the level of the distal end of the rib retractor or impairment throughout the whole nerve. Intercostal space closure did not injure any previously uninjured nerve. In a solitary patient where rib retraction was not employed, there was no impairment of the intercostal nerves throughout the operation.

CONCLUSIONS

This study demonstrates for the first time that intercostal nerve injury occurs routinely due to rib retraction during thoracotomy. We believe that it may be an important step toward understanding the cause of post-thoracotomy neuralgia.

Coexisting achalasia and paraoesophageal hiatal hernia

Disorders of the oesophagus present a diagnostic and therapeutic challenge. The presenting symptoms of dysphagia, reflux, pain and vomiting are almost universal, irrespective of the underlying pathology. A combination of endoscopy, barium studies, pH studies and manometry are often required to determine the exact diagnosis and to plan the most effective treatment. Paraoesophageal hiatal hernia is an uncommon condition, present in 14% of all hiatal hernias, which requires urgent correction to prevent life-threatening complications. It is unusual for other oesophageal disorders to coexist. We present a case where achalasia and a paraoesophageal hiatal hernia probably coexisted.

Airway fire during tracheostomy: prevention strategies for surgeons and anaesthetists

Airway fires are an uncommon but real and devastating complication of tracheostomy. One such fire in a 31-year-old man is described. Surgical fires are discussed, and 15 reported cases of tracheostomy fire are reviewed. A tracheostomy protocol, adopted by our department and designed to avoid this life-threatening complication, is described. Surgeons and anaesthetists involved in tracheostomy must understand the fire hazard and how to avoid it.

Surgical treatment of para-oesophageal hiatal hernia

The development of laparoscopic antireflux surgery has stimulated interest in laparoscopic para-oesophageal hiatal hernia repair. This review of our practice over 10 years using a standard transthoracic technique was undertaken to establish the safety and effectiveness of the open technique to allow comparison. Sixty patients with para-oesophageal hiatal hernia were operated on between 1989 and 1999. There were 38 women and 22 men with a median age of 69.5 years. There were 47 elective and 13 emergency presentations. Operation consisted of a left thoracotomy, hernia reduction and crural repair. An antireflux procedure was added in selected patients. There were no deaths among the elective cases and one among the emergency cases. Median follow-up time was 19 months. There was one recurrence (1.5%). Seven patients (12%) required a single oesophagoscopy and dilatation up to 2 years postoperatively but have been asymptomatic since. Two patients (3%) developed symptomatic reflux which has been well controlled on proton-pump inhibitors. Transthoracic para-oesophageal hernia repair can be safely performed with minimal recurrence.

Pneumonectomy for non-small cell lung cancer: predictors of operative mortality and survival

OBJECTIVE

The purpose of this study was to identify predictors of operative mortality and survival following pneumonectomy for non-small cell lung cancer (NSCLC).

METHODS

All 206 patients having a pneumonectomy for NSCLC between 1991 and 1997 in our unit were prospectively studied. There were 162 males (79%) and 44 females (21%) with a mean age (+/- standard deviation) of 61+/-7.7 years (range 34-81 years). Squamous cell (75%) and adenocarcinoma (17.0%) were the predominant histological types. The possible impact of 29 parameters on operative mortality and survival was tested with univariate and multivariate analysis. The mean follow-up was 2.3+/-1.2 years, ranging between 0 and 6.8 years, and it was complete.

RESULTS

Operative mortality was 6.8% (14 deaths). On multiple logistic regression older age (P=0.04) and the development post-operatively of bronchopleural fistula (BPF) (P=0.01) were independent predictors of operative mortality. The overall, Kaplan-Meier, 1-, 3- and 5-year survival (+/- standard error from the mean), inclusive of operative mortality, was 68+/-3.3, 42+/-4.1 and 35+/-4.5%. On Cox proportional hazards regression adenocarcinoma (P=0.006), the development of BPF (P=0.003), older age (P=0.03) and higher pathological stage (P=0.02) were independent adverse predictors of survival.

CONCLUSION

Pneumonectomy for NSCLC carries a considerable, but acceptable, operative mortality and provides an important survival benefit. This study suggests that older age and BPF are major determinants of an unfavourable in-hospital outcome; older age, BPF, adenocarcinoma cell type and higher pathological stage significantly reduce the probability of a long-term survival.

Surgical aspects of chronic post-thoracotomy pain

Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.

Functional limitations and key indicators of well-being in children with disability

OBJECTIVES

To compare measures of well-being in children with and without different types and severity of limitations.

DESIGN

Nationally representative data for American children aged 5 to 17 years were drawn from the 1994 and 1995 National Health Interview Surveys on Disability (NHIS-D) (N = 41,300) and the Year 2000 Health Supplement to the 1994 NHIS-D (N = 9530). Family resources, safety, health status, and health access were measures of environment. The presence and severity of limitations were measured in the domains of mobility, self-care, communication, and learning.

RESULTS

Children with functional limitations were more likely to live in families with limited resources and have greater exposure to secondhand smoke, less access to health care, and lower health status. Children with a limitation were not less likely to have a regular source of medical care, but they more often were delayed or prevented from getting necessary health care due to cost or insurance.

CONCLUSIONS

Standard measures of child well-being were appropriate for children with functional limitations and showed their unfavorable situations. Children with functional limitations more often have unfavorable family resources, less healthy home environments, poorer health status, and less health service access than other children, making them more susceptible to developmental difficulties beyond those difficulties associated with the challenges of their specific functional limitations.

Improved disability population estimates of functional limitation among American children aged 5-17

OBJECTIVES

This paper (a) creates and validates measures for population survey data to assess functional limitation in mobility, self-care, communication, and learning ability for school-age American children; (b) calculates rates of functional limitation using these measures, and provides population estimates of the number of children with limitations; and (c) examines these limitations as a function of socioeconomic factors.

METHOD

The study is based on data for children aged 5-17 collected in the 1994 National Health Interview Survey on Disability. Ordinal values are assigned to survey items in the four functional areas and analyzed to produce scales of high reliability. These measures are used to identify within a 95% confidence interval the number of children with these limitations. Ordered logistic regression models measure the effects of functional limitations on disability and societal limitation. Socioeconomic differences are measured with an ordered logistic regression model that predicts severity and comorbidity.

RESULTS

Limitations in learning ability (10.6%) and communication (5.5%) are the most common, with mobility (1.3%) and self-care (0.9%) occurring less often. Six percent of children have one serious functional limitation and 2.0% have two or more serious functional limitations. This corresponds to 4.0 million school-age American children with serious functional limitations. Functional limitation is strongly linked to socioeconomic disadvantage and to residence in single-mother households.

CONCLUSIONS

Future population research should use multiple-item scales for four distinct areas of functional limitation, and a summary that takes into account both severity and comorbidity. The improved estimates of the number of school-age children with functional limitation in this paper may help contribute to a more informed scientific and policy discussion of functional limitation and disability among American school-age children. Future research on the disability process among children must consider the role of socioeconomic disadvantage and family structure.

Platelet-derived growth factor, insulin-like growth factors, fibroblast growth factors and transforming growth factor beta do not account for the cell growth activity present in bovine milk

Cation-exchange chromatography effectively concentrates the cell growth activity present in whey and we have used this process as a basis to characterise further the growth factors present in bovine milk. Under neutral conditions, total bioactivity in the growth factor-enriched cation-exchange fraction chromatographed with an apparent molecular mass of 80-100 kDa. In contrast, acid gel-filtration chromatography resolved two peaks of cell growth activity. A peak at 15-25 kDa contained the bulk of growth activity for Balb/c 3T3 fibroblasts while bio-activity for L6 myoblasts and skin fibroblasts eluted with a molecular mass of 6 kDa. A peak of inhibitory activity for Mv1Lu and MDCK cells also eluted at 15-25 kDa. Both IGF-I and IGF-II were purified from fractions that eluted at 6 kDa, although the IGF peptides alone did not account for the total bioactivity recovered. Platelet-derived growth factor (PDGF), identified by radioreceptor assay, eluted at a slightly higher molecular mass than the peak of growth activity for Balb/c 3T3 cells, and an anti-PDGF antibody was without effect on the growth of Balb/c 3T3 cells in response to the whey-derived factors. Further purification of the inhibitory activity for epithelial cells yielded a sequence for transforming growth factor beta (TGF-beta), and all inhibitory activity for Mv1Lu cells was immunoneutralised by an antibody against TGF-beta. In contrast, this antibody decreased the growth of Balb/c 3T3 fibroblasts in the whey-derived extract by only 10%. Finally, a cocktail of recombinant growth factors containing IGF-I, IGF-II, PDGF, TGF-beta and fibroblast growth factor 2 stimulated growth of Balb/c 3T3 cells to a level equivalent to only 51% of that observed in the milk-derived growth factor preparation. We conclude that: (i) cell growth activity recovered from bovine whey is present in acid-labile high molecular weight complexes; (ii) all cell growth inhibitory activity for epithelial cells can be accounted for by TGF-beta; (iii) IGF-I and IGF-II co-elute with the major peak of activity for L6 myoblasts and skin fibroblasts, although the IGF peptides alone do not explain the growth of these cells in the whey-derived extract; and (iv) neither PDGF nor TGF-beta account for the 15-25 kDa peak of Balb/c 3T3 growth activity. These data suggest the presence of additional mitogenic factors in bovine milk.

Transforming growth factor beta in bovine milk: concentration, stability and molecular mass forms

Transforming growth factor beta (TGF-beta) is one of the predominant growth factors present in milk. The concentration, molecular mass forms and stability of TGF-beta in bovine milk were investigated using a standard bioassay measuring the growth inhibition of a milk lung epithelial cell line. Most of the TGF-beta bioactivity in milk was found to be in a latent form, which was also retained in the whey fraction. After acid activation, the total TGF-beta concentration was 4.3 +/- 0.8 ng and 3.7 +/- 0.7 ng TGF-beta per ml of milk and cheese whey respectively. Cation-exchange chromatography at pH 6.5 was used to concentrate latent whey-derived TGF-beta, which could be activated by transient exposure to extremes of pH, urea or heat. Heparin did not significantly activate milk-derived TGF-beta. Neutral gel filtration of the cationic whey fraction revealed a major peak of latent TGF-beta with a molecular mass of 80 kDa and a smaller peak at 600 kDa. Transient acidification of the cationic whey fraction prior to neutral gel filtration, or gel filtration under acidic conditions, released low molecular mass TGF-beta from both high molecular mass peaks. Whey-derived TGF-beta was purified using a five-step chromatographic procedure. An N-terminal sequence was obtained for TGF-beta 2, which accounted for over 85% of the TGF-beta bioactivity in whey. All TGF-beta activity in whey could be neutralised by a monoclonal antibody directed against TGF-beta 1, -beta 2 and -beta 3. The results suggest that the majority of TGF-beta in bovine milk is present in a small latent complex.

Milk-derived growth factors as serum supplements for the growth of fibroblast and epithelial cells

We have investigated the response of several epithelial and fibroblastic cells to a mitogenic extract of bovine milk. Cation exchange chromatography was used to produce a mitogen-rich fraction from an industrial whey source that, although comprising only 0.5% of total whey protein, contained the bulk of the growth factor activity. This fraction was a source of potent growth promoting activity for all mesodermal-derived cells tested, including human skin and embryonic lung fibroblasts, Balb/c 3T3 fibroblasts, and rat L6 myoblasts. Maximal growth of all these cell types exceeded that observed in 10% fetal bovine serum. Feline kidney and baby hamster fibroblasts and Chinese hamster ovary cells were less responsive, achieving a maximal growth response of 50-75% that observed in 10% fetal bovine serum. Maximal growth achieved in whey-extract-supplemented cultures of Balb/c 3T3 and human skin fibroblasts, and L6 myoblast cultures exceeded that seen in response to recombinant acidic or basic fibroblast growth factor, platelet-derived growth factor, insulin-like growth factor, or epidermal growth factor. Importantly, addition of low concentrations of fetal bovine serum to the whey-derived mitogenic fraction produced an additive response. However, concentrated milk-derived factors were found to be inhibitory to the growth of all epithelial lines tested, including rat intestinal epithelial cells, canine kidney epithelial cells, and mink lung cells. It is concluded that industrial whey extracted in this form constitutes an important source of potent growth-promoting agents for the supplementation of mesodermal-derived cell cultures.

Factors influencing recall of childhood sexual abuse

Selective literatures providing perspective on recall of childhood sexual abuse memories are reviewed. These include known patterns of autobiographical memories in adulthood, metacognitive mechanisms, interpersonal influences, and automatic cognitive processing which can influence judgments and reports of memory recall in children and adults. Some factors in adult experience such as mood state, presence of emotional disorders, past and current relationships, and participation in psychotherapy which can influence autobiographical memory and recall of childhood events are delineated. Available studies directly exploring recovered memories of childhood abuse are considered in light of these studies. Finally, some applications to clinical work and suggestions for future research are outlined.

Identification of fibroblast growth factors in bovine cheese whey

Acidic and basic fibroblast growth factors (FGF) were identified in bovine cheese whey after partial purification using a two step procedure. Cation-exchange chromatography produced a mitogen-rich extract which was loaded on to a heparin-sepharose column and eluted stepwise with 0.8, 1.2 and 2.0 M-NH4HCO3. Mitogenic activity was found in all three fractions by cell growth assays using Balb/c-3T3 fibroblasts. Immunoblotting identified acidic FGF in the 1.2 M-eluate and basic FGF in the 2.0 M-eluate, but neither acidic nor basic FGF was detected in the 0.8 M-fraction. Quantitative radioreceptor assays indicated 5.8 ng of acidic FGF-like activity and 19.8 ng of basic FGF-like activity per 1 whey in the appropriate eluates. This study represents the first direct demonstration of FGF in milk.

Factors to consider in assessing adult litigants' complaints of childhood sexual abuse

Based on limited research, clinical and forensic experience and observations, factors hypothesized to be potentially useful in forensic evaluation of claims of decades-delayed discovery of childhood sexual abuse are delineated. Factors considered include: (1) alleged victim factors, (2) memory factors, (3) therapist/examiner factors, (4) external influences on the abuse account, (5) evidential patterns. Differences among a limited sample of cases seen by the author are described. Present knowledge does not provide a basis for reliable determination of whether a specific recollection is true or false, based only upon the claimant's account. At this time, there is no empirically validated method for discriminating valid from invalid cases. Experts testifying for either side must exercise caution and restraint as it may be premature and even unethical in many cases to propound opinions about the validity or invalidity of the memories.

A retrospective study: osteoporosis and hormone replacement therapy

The purpose of this study was to determine if women who undergo hormone replacement therapy postmenopausally, will demonstrate less osteoporosis than women who do not undergo HRT. The osteoporosis subjects were 195 women who volunteered to participate in an NIH-sponsored double-blind clinical trial entitled Safety and Efficacy of Fluoride Therapy in Osteoporosis. A convenience sample of 78 controls was obtained by inviting women seeking regular medical attention to join an epidemiological investigation of osteoporosis. The data were analyzed using Chi-square and Student's t-ratio. The study concludes that future retrospective and prospective analyses appreciate the complexity of the problem in terms of individual risk for osteoporosis.

Metabolism of carbohydrate derivatives by Pseudomonas acidovorans

Wild-type Pseudomonas acidovorans strain A1 was unable to grow on glycerol or glucose as sole source of carbon and energy although it grew well on gluconate. Spontaneous glycerol-positive mutants, which apparently had become permeable to glycerol, were readily isolated, but glucose-positive mutants did not occur. P. acidovorans lacked glucose dehydrogenase and glucokinase, which were sufficient to account for its inability to grow on glucose. Gluconate was degraded exclusively via a noncoordinately induced Entner-Doudoroff pathway. Phosphogluconate dehydrogenase was undetectable. In contrast to P. aeruginosa, P. acidovorans possessed a single glyceraldehyde-phosphate dehydrogenase activity, which was NAD+ specific and constitutive, and an inducible pyruvate kinase. Moreover, growth of glycerol-positive strain K2 on glycerol did not induce any of the enzymes related to metabolism of hexosephosphate derivatives as occurs in fluorescent pseudomonads.