Higher postoperative pain and increased morphine consumption follow pre- rather than post-incisional single dose epidural morphine.

BACKGROUND: Neuraxial administration of morphine is an effective way of controlling postoperative pain and reducing analgesic consumption. Some animal models have demonstrated that preemptive administration of neuraxial narcotics reduces pain, while others have revealed the contrary. In addition, there have been no consistent results in clinical settings. This double-blind, randomized study compared the effects of pre- vs. post-incisional administration of neuraxial morphine on postoperative pain perception and analgesic requirements over 48 hours following laparotomy for open colectomy under standardized general anesthesia. METHODS: Twenty patients received epidural morphine (3 mg) before the incision and saline after wound closure (MO1 group), and twenty patients received epidural saline before the incision and morphine after wound closure (MO2 group). Postoperatively, all patients received morphine boluses (1.5 mg) via intravenous patient-controlled analgesia (IV-PCA) and rescue doses of intramuscular diclofenac (75 mg) every 6 hours, as needed. RESULTS: MO1 patients used significantly (P<0.05) more morphine than the MO2 group during the first 24 postoperative hours and activated the PCA device more frequently throughout the 48-hour study period. The MO1 group was characterized by significantly (P<0.05) higher self-rated pain scores than the MO2 group throughout the study. The self-rated levels of sedation and satisfaction of the MO2 patients were also consistently better (P<0.05) than those of the MO1 patients, especially during the second postoperative day. CONCLUSION: Pre-incisional epidural morphine in patients undergoing open colonic surgery under general anesthesia was associated with more postoperative pain, a greater need for analgesics, and poorer patient satisfaction compared to post-incisional morphine administration.

The Children's Play Therapy Instrument (CPTI). Description, development, and reliability studies.

The Children's Play Therapy Instrument (CPTI), its development, and reliability studies are described. The CPTI is a new instrument to examine a child's play activity in individual psychotherapy. Three independent raters used the CPTI to rate eight videotaped play therapy vignettes. Results were compared with the authors' consensual scores from a preliminary study. Generally good to excellent levels of interrater reliability were obtained for the independent raters on intraclass correlation coefficients for ordinal categories of the CPTI. Likewise, kappa levels were acceptable to excellent for nominal categories of the scale. The CPTI holds promise to become a reliable measure of play activity in child psychotherapy. Further research is needed to assess discriminant validity of the CPTI for use as a diagnostic tool and as a measure of process and outcome.

Working through conflict with self-destructive preschool children.

This case history charts the treatment of a preschooler who first presented at the age of three years and ten months with aggressive and self-destructive behaviors. During the initial months of treatment, the therapist focused upon establishing a therapeutic alliance with the child in order to evoke a transference reaction. Compelling evidence of the transference in this case occurred in the ninth month of treatment when the therapist told the child that she would be going on vacation. The child, whose own mother had abandoned him several times, responded with uncharacteristic physical and verbal abuse. Although the child engaged in aggressive and self-destructive play enactments almost from the onset of treatment, these behaviors intensified from the fifth month of treatment onwards, as it became evident that he had entered the working-through phase. Aggressive impulses were shown in his manipulation of toys and other objects, and self-destructive episodes emerged in the child's incessant efforts to jump from chairs and tables, as well as in repeated threats to "shoot" himself with a toy gun. The therapist was sensitive to the child's need to continually repeat and gradually modify these behaviors. She permitted their display without exhibiting shock or alarm, but at the same time, expressed concern for the child's safety and reinforced this concern by setting limits on his unacceptable behavior. Gradually, the child's self-destructive and aggressive tendencies abated. Further evidence that the conflict had been worked through was also seen in the child's ability to express a more realistic assessment of his home environment, one which reconciled the conflict between "good" and "bad" impulses. This advancement in perception was demonstrated by the child's verbal recognition that while his mother was capable of doing "bad" things, she was still his mother and he loved her. Prior to the termination of treatment, both the child's grandmother and teachers reported significant improvement in the child's behavior and linguistic abilities.

Merging and emerging realities: simultaneous treatment of parent and child.

The purpose of this paper is to invite dialogue concerning the variety of modalities possible in the spectrum of child treatment. Many issues remain to be discussed, such as the child's need to possess the therapist entirely, and the role of other family members. Countertransference issues for the therapist are complex and involve the risk of dual loyalties. Simultaneous treatment shares these concerns with other modalities in the spectrum of child treatment. In simultaneous treatment, as parent and child come to share an experience of being cared for, the possibility arises for the dissolution of polarities. Representations of the past give way to adaptations to current reality. Both the parent's and the child's feelings of rage are contained within the therapeutic matrix of relationships; boundaries are maintained to permit repair and growth. Both parent and child reach new levels of integration as the therapist reinforces boundaries and does not permit intrusion by either the parent or the child into the others arena of playful construction.

Early and long-term effects of electroconvulsive therapy and depression on memory and other cognitive functions.

Twenty-seven medication-free, depressed patients (Research Diagnostic Criteria, endogenous subtype) were administered a comprehensive battery testing memory and other cognitive functions before and after a series of bilateral, brief-pulse electroconvulsive therapy (ECT) administered according to a dosage-titration procedure (8.9 +/- 1.981 treatments). A subset of patients (N = 14) were reexamined at 1 month and 6 months after the conclusion of the treatment. Anterograde (verbal and visuospatial tasks), as well as retrograde (famous and personal events), memory function was significantly impaired at the end of the ECT series. By 1 month follow-up, performance had improved to pre-ECT (depression) levels on both anterograde and retrograde tasks and exceeded these by 6 months. The memory deficits induced by ECT were not a consequence of generalized cognitive impairment. Furthermore, depression and ECT were shown to independently affect memory, and recovery from depression was not a consequence of the amnestic action of the treatment. The results generally confirm previous reports regarding the nature of ECT-induced memory impairment, in a different language and culture. They suggest that long-term effects of the treatment on memory are even less prominent than previously observed.

Retrieval from semantic memory using meaningful and meaningless constructs by depressed, stable bipolar and manic patients.

Eleven depressed, 11 stable bipolar and six manic patients, 20 normals and eight late middle-age normals were tested for speech production using a word-fluency task. Fluency was prompted by either a letter (a relatively automatic task), or a semantic category (an effort-demanding task). The results showed that depressed patients were more impaired in speech production than other patients when prompted by a semantic category than when prompted by a letter. A post hoc matched-tasks check suggested that this finding was not due to differences in discriminating power between the two word-fluency tasks. Manic and stable bipolar patients did not differ in their speech production, although matched on age. The results suggest that depressives perform better on more automatic than on effort-demanding tasks, and that manic and stable bipolar patients do not differ in speech production when experimentally imposed restrictions are present.

Frequency of carriers of chronic (type I) Gaucher disease in Ashkenazi Jews.

In this study we estimate the frequency of carriers of chronic (type I) Gaucher disease among Ashkenazi Jews by examining the glucocerebrosidase activity in leukocytes in a population of 635 blood donors (441 Ashkenazi) and 57 obligatory heterozygotes. Estimation using the defect in the enzyme glucocerebrosidase (beta-glucosidase) in leukocytes is complicated by the existence of considerable overlap between enzyme activity in normals and in heterozygotes. The assay was carried out with a natural substrate labeled with 14C. Discriminant analysis was used to establish an optimal cutoff point between the obligatory heterozygotes and normal (non-Ashkenazi) subjects for the purpose of estimating frequency of carriers. Applied to the Ashkenazi group, the cutoff point identified 3.17% as heterozygotes. Corrected for errors in classification, the carrier rate was estimated as 4.67%. This figure is in good agreement with a carrier rate of 4% estimated from the number of known cases of clinical Gaucher disease ascertained in Israel.

Glucocerebroside storage in normal monocyte cultures.

Glucocerebroside in Gaucher disease is stored in large Gaucher cells of monocyte-macrophage origin. Our aim was to achieve storage of this substrate in monocytes in vitro, in order to mimick the Gaucher cells in vivo. The method described using glucocerebroside-albumin complex, enabled such uptake and storage. The monocytes used changed to large hellical cells. Glucocerebrosidase activity was not affected by the accumulation and storage of the substrate. Although morphological evidence for the accumulation of glucocerebroside within the lysosomes has not yet been obtained, we suggest that these monocytes might represent an in vitro model for the study of Gaucher cells.

Familial correlation of memory function in schizophrenia.

Chronic schizophrenic patients with first- or second-degree schizophrenic relatives were evaluated for memory function. Wechsler memory scale scores were significantly correlated between index cases and relatives (r = 0.56, p less than 0.05), suggesting that poor memory function in schizophrenia may represent a familial subtype.

Ineffectiveness of vasopressin in the treatment of memory impairment in chronic schizophrenia.

A vasopressin derivative or placebo was administered to 21 chronic schizophrenia patients for 3 weeks in a randomized crossover double-blind design. The patients were divided into those above and below the median on baseline memory measured by the Wechsler memory scale. Vasopressin treatment did not improve memory either in those patients with below median baseline memory or in the group as a whole.

Strabismus surgery and its effect upon infant development in congenital esotropia.

Parents of children with congenital esotropia have reported improvements in their child's fine motor development and visual functions after surgery. Eighteen patients with congenital esotropia were tested pre- and post-operatively with The Bayley Scales of Infant Development to determine if these observations were valid. A three-point increase in the Bayley raw score of strabismus patients was noted after operation that is significant at the 0.01 level, as compared to the performance of age-matched controls. An improvement in fine motor skills was observed in 35% of the children, and visually directed reaching and grasping increased in 41%. Item #87 on the Bayley, which requires the child to recognize depressions without monocular clues, appears to be related specifically to depth perception. On this item, the study population showed the greatest improvement.

Chemical and biochemical studies in human fetuses affected with Niemann-Pick disease type A.

Chemical and biochemical studies were performed on two unrelated fetuses affected with Niemann-Pick disease type A, following abortion at about the 19th week of gestation. Abortion was performed as a consequence of previous findings, in amniotic fluid cell cultures, that sphingomyelinase activity was completely absent. Phospholipid analyses of various organs of the fetuses revealed an excess of sphingomyelin in all viscera as compared to control nonaffected fetuses. Spleen and liver were the organs mostly affected. Interestingly enough considerable accumulation of sphingomyelin was found in the placenta. The brain was the only organ in which sphingomyelin storage could not be proved. In addition to sphingomyelin a slight accumulation of cholesterol was noticed. Deficiency of sphingomyelinase activity measured at pH 5.0 was the general characteristics of the affected tissues. It could be concluded that the accumulation of sphingomyelin in various organs throughout the body of fetuses affected with Niemann-Pick disease, was suggestive of the essential role of the enzyme sphingomyelinase and its biochemical maturation, even during the early stages of gestation.

Sphingomyelinase activity levels in human peripheral blood leukocytes, using [3H]sphingomyelin as substrate: study of heterozygotes and homozygotes for Niemann-Pick disease variants.

Patients and heterozygous carriers of Niemann-Pick disease types A and B as well as the primary (genetic) sea-blue histiocyte syndrome were investigated for their leukocyte sphingomyelinase activity. In parallel, glucocerebrosidase activity was determined in all cases studied. [3H]Sphingomyelin and [14C]glucocerebroside served as substrates for sphingomyelinase and glucocerebrosidase activity measurements, respectively. Conditions for these enzymes' assays are discussed. Sphingomyelinase activity was completely absent in three cases of Niemann-Pick disease type A and significantly diminished in one patient with Niemann-Pick disease type B and two with the sea-blue histiocyte syndrome. Sphingomyelinase activity in obligatory heterozygotes of all variants investigated represented about 40 to 70% of normal activity. Nevertheless, some overlapping with normal values occasionally occurred. Interestingly, glucocerbrosidase activity was elevated in patients with Niemann-Pick disease variants.

Prenatal diagnosis of Gaucher's and Niemann-Pick diseases. Assays of glucocerebrosidase and sphingomyelinase in tissue cultures using natural substrates.

Prenatal diagnosis has been successfully achieved by enzyme assays in cultured amniocytes in three high risk pregnancies for Gaucher's disease and three for Niemann-Pick disease type A. [14C]Stearic acid glucocerebroside and [3H]-dihydrosphingomyelin were used as substrates for glucocerebrosidase and sphingomyelinase activity measurements, respectively. Values for the above two enzyme levels in cultured amniotic fluid cells of normal controls and in the pregnancies at risk are presented. The diagnosis made in utero in one fetus affected with Niemann-Pick disease was subsequently confirmed following abortion (at 19 weeks gestation), by the specific biochemical and pathological features of various organs of the afflicted fetus (to be published). Confirmation of diagnoses made in utero for heterozygous and healthy fetuses was obtained by post-partum examination of glucocerebrosidase and spingomyelinase activity levels in leukocytes of the appropriate infants.