Surgery in a Patient with Haemophilia A and Lymphoma.

An increased incidence of haematologic malignancies and other cancer types among patients with haemophilia compared with matched controls has been reported in several longitudinal studies. Tumours initially misdiagnosed as haematomas and conversely haematomas mistaken for tumours have been reported. Here, we describe the case of a 43-year-old man with severe haemophilia A and a diffuse large B-cell lymphoma, originally diagnosed as a haematoma, who underwent a splenectomy and several associated surgeries as part of his lymphoma treatment. Perioperative treatment with octanate® (human coagulation factor VIII) enabled the successful performance of all surgical interventions required in the context of lymphoma treatment. Nevertheless, differential diagnosis of posttraumatic haematoma in patients with haemophilia should include the consideration of malignancy.

Single-cuff forearm tourniquet in intravenous regional anaesthesia results in less pain and fewer sedation requirements than upper arm tourniquet.

BACKGROUND: A limitation of Bier's block or i.v. regional anaesthesia (IVRA) is tourniquet pain. We hypothesized that tourniquet placement on the forearm vs upper arm during IVRA for distal upper extremity surgery may result in less tourniquet pain, lower the need for analgesic interventions, and decrease post-anaesthesia care unit (PACU) admission. METHODS: Patients for distal upper extremity surgery were randomized into upper or forearm single-cuff tourniquet placement. IVRA was either performed with 15 ml of 2% lidocaine and 20 mg ketorolac in the upper group or 8 ml of 2% lidocaine and 10 mg ketorolac in the forearm group. Vital signs and visual analogue scale (VAS) score were recorded. If VAS score was >4, 50 µg fentanyl was injected. If the patient had VAS scores >6 with fentanyl, deep sedation with propofol was administered. RESULTS: Twenty-eight subjects were in each group. There were no significant differences in patient characteristics, tourniquet time, or pressure between the groups. Ten patients in the forearm vs 27 in the upper arm group had a VAS score >4. The mean fentanyl use was 30 µg in the forearm group vs 104 µg in the upper arm group. One patient in the forearm group required propofol vs 22 in the upper arm group. PACU bypass to phase 2 recovery occurred 19 times in the forearm group vs zero times in the upper arm group (P<0.0001). CONCLUSIONS: Our results indicate that the placement of the tourniquet on the forearm resulted in less discomfort, fewer sedation interventions, and greater likelihood of bypassing the PACU when compared with upper arm tourniquet.

Vein visualization: patient characteristic factors and efficacy of a new infrared vein finder technology.

BACKGROUND: We investigated the patient characteristic factors that correlate with identification of i.v. cannulation sites with normal eyesight. We evaluated a new infrared vein finding (VF) technology device in identifying i.v. cannulation sites. METHODS: Each subject underwent two observations: one using the conventional method (CM) of normal, unassisted eyesight and the other with the infrared VF device, VueTek's Veinsite™ (VF). A power analysis for moderate effect size (ß=0.95) required 54 samples for within-subject differences. RESULTS: Patient characteristic profiles were obtained from 384 subjects (768 observations). Our sample population exhibited an overall average of 5.8 [95% confidence interval (CI) 5.4-6.2] veins using CM. As a whole, CM vein visualization were less effective among obese [4.5 (95% CI 3.8-5.3)], African-American [4.6 (95% CI 3.6-5.5 veins)], and Asian [5.1 (95% CI 4.1-6.0)] subjects. Next, the VF technology identified an average of 9.1 (95% CI 8.6-9.5) possible cannulation sites compared with CM [average of 5.8 (95% CI 5.4-6.2)]. Seventy-six obese subjects had an average of 4.5 (95% CI 3.8-5.3) and 8.2 (95% CI 7.4-9.1) veins viewable by CM and VF, respectively. In dark skin subjects, 9.1 (95% CI 8.3-9.9) veins were visible by VF compared with 5.4 (95% CI 4.8-6.0) with CM. CONCLUSIONS: African-American or Asian ethnicity, and obesity were associated with decreased vein visibility. The visibility of veins eligible for cannulation increased for all subgroups using a new infrared device.

GlideScope-assisted nerve integrity monitoring tube placement for intra-operative recurrent laryngeal nerve monitoring.

OBJECTIVE: The proper positioning of the Nerve Integrity Monitoring® endotracheal tube during recurrent laryngeal nerve monitoring is of paramount importance. This article describes our experience with the GlideScope® and explains how it can facilitate the accurate placement of the Nerve Integrity Monitoring endotracheal tube. METHODS: Endotracheal intubation with the Nerve Integrity Monitoring endotracheal tube was performed in 250 patients undergoing thyroidectomies using the GlideScope video laryngoscope. The correct positioning of the tube was determined according to impedance values of less than 5 kohm and an impedance imbalance of less than 1 kohm. RESULTS: Successful intubation was achieved in all cases. The GlideScope aided the correct placement of the Nerve Integrity Monitoring endotracheal tube in the majority of the cases. CONCLUSION: The GlideScope provides an excellent means to ensure the correct positioning of the Nerve Integrity Monitoring tube. It allows both the surgeon and the anaesthesiologist to participate in the intubation process and confirm correct placement of the tube, whilst also allowing gentle intubation with improved visibility.

Comparison of psychosocial and behavioral profiles of victimized and nonvictimized homeless women and their intimate partners.

The purpose of this study was to examine the psychosocial, behavioral, and environmental profiles of homeless women, both those with and without a history of victimization, and their intimate partners. Five hundred seven homeless women and their intimate partners participated in the study. Thirty-nine percent of the women reported being physically and/or sexually assaulted as adults. Controlling for potential confounders, victimized women were more likely than others to have a history of childhood sexual and physical abuse, lifetime substance use, greater mental health symptomatology, and current risky sexual activity. Thus, homeless women with mental health and substance abuse problems ought to be screened for violent experiences and encouraged to obtain treatment appropriate to their problems to reduce their ongoing risk of victimization.

The group as selfobject: brief psychotherapy with women.

This article applies the theory of self psychology, which was developed by Heinz Kohut, to brief group psychotherapy. The article discusses the significance of the group as an expanded selfobject for individuals who do not have appropriate, available selfobjects in their environment. The article addresses the rationale for developing a 12-week women's group from a self-psychological perspective and illustrates key theoretical concepts in the beginning, middle, and end phases with group process. The role of the therapist in each phase of group development is emphasized.

Clinical social work and family medicine: a partnership in community service.

Traditionally, family physicians have been called on to handle the emotional problems of their patients. Their ability to address these concerns has been inconsistent. In hospital settings, where interdisciplinary teams are common, nonmedical professionals have been able to provide counseling services to patients. But this is a problem in private medical practices. This article presents a model for collaboration between family medical and clinical social work practice and describes a holistic approach for primary care practice.

Comparison of oxime-initiated reactivation of organophosphorous-inhibited acetylcholinesterase in brains of avian embryos.

Organophosphorous (OP) insecticide-induced inhibition and oxime reactivation of acetylcholinesterase (AChE) was determined in whole-brain homogenates prepared from 15-d-old chick embryos. Doses of chlorpyrifos, parathion, acephate, and trichlorfon that inhibited AChE >70% were administered to the embryos. Following insecticide exposure, an in vitro system compared the capability of the oximes pralidoxime (2-PAM), obidoxime, TMB-4, and HI-6 to reactivate the OP-inhibited AChE. Concentration-related increases in AChE activities were noted in embryo brains reactivated with 2-PAM, TMB, and HI-6. 2-PAM was the most effective reactivator of trichlorfon-inhibited AChE; 2-PAM and obidoxime were relatively similar in effectiveness for reactivation of AChE inhibited with the other OP insecticides used as test agents. All oximes were similarly effective against acephate, but HI-6 was the least effective reactivator of AChE in chick embryo brain homogenates inhibited by the other OP insecticides. These results suggest that both the OP insecticide inhibiting AChE and the oxime reactivating this enzyme can contribute to the effectiveness of the avian brain AChE reactivation.

The impact of physical or sexual abuse on chronic depression in adolescent mothers.

This longitudinal investigation explored the impact of a childhood history of physical and sexual abuse on perinatal depressive symptomatology, suicide attempts, and maternal behavior in an ethnically diverse sample of 95 adolescent mothers. Maternal role attainment theory and the cognitive-interpersonal theory of depression provided the conceptual framework for this study. This investigation helps to expand theory on adolescent maternal role attainment by identifying a relationship between history of abuse, depressive symptoms over time, and maternal role behavior problems. Findings do not indicate that a history of childhood maltreatment alone increases a young mother's risk for maternal-child interaction problems.

Assessment of orientation: relationship between informant report and direct measures.

Although informant reports of everyday functioning are often used in dementia assessments, the actual correspondence between such indirect reports of functioning and actual performance has not been examined. Orientation results on the Dementia Questionnaire for Mentally Retarded Persons were compared to those obtained in direct assessment of orientation of 138 adults with mental retardation. Fair to good agreement was found between informant report and direct assessment. However, for some orientation items, nonverbal IQ, cause of mental retardation, and age affected the level of agreement. Thus, both informant report and direct measures of orientation are necessary in dementia assessments, and further work is needed on informant scale validation.

The interaction of temperature with thiopental and etomidate on extracellular dopamine and glutamate levels in Wistar-Kyoto rats subjected to forebrain ischemia.

BACKGROUND: Many studies demonstrate an association between brain damage and the extracellular release of catecholamines and amino acids during cerebral ischemia. While the clinical value of hypothermia during periods of compromised cerebral blood flow and oxygen delivery is well established, the role of anesthetic agents is less clear. Furthermore, the interaction between these agents and hypothermia remains to be elucidated. The purpose of this study was to examine the interactive effects of temperature, sodium thiopental (STP) and etomidate (ETOM) on extracellular neurotransmitter accumulation in the rat corpus striatum during cerebral ischemia. METHODS: Animals were randomly assigned to one of six subgroups: normal saline (NS-norm, pericranial t approximately equal to 37 degrees C, and NS-hypo, t=30 degrees C), etomidate (ETOM-norm and ETOM-hypo), and sodium thiopental (STP-norm and STP-hypo). Microdialysis probes were inserted into the corpus striatum. Dopamine (DA), glutamate, 3,4-dihydroxyphenylacetic acid (DOPAC) and homovanillic acid (HVA) levels were measured. At zero minutes, animals received a 10-min infusion of STP (3 mg x kg(-1) x min(-1)), ETOM (0.6 mg x kg(-1) x min(-1)), or NS. Prior to ischemia, animals were given either intravenous STP (10 mg x kg(-1)), ETOM (3 mg x kg(-1)), or NS in bolus form. Each animal was then subjected to 10 min of forebrain ischemia (Is1) followed by a reperfusion interval (Rep1). The entire sequence was then repeated. RESULTS: There were significant interactions between temperature and drug for DA (Is1, P=0.006, Is2, P=0.032) and its metabolites (DOPAC, Is1 P=0.01, HVA, Is1 P=0.03), and for glutamate (Is1, P=0.03, Is2 P=0.06). The nature of this interaction differed for DA and glutamate. The reduction in DA accumulation seen during hypothermia was offset by the addition of either STP or ETOM, whereas the addition of these drugs did not affect the reduced glutamate levels seen with hypothermia. During normothermia, STP and ETOM resulted in diminished DA accumulation compared to controls, yet they increased the accumulation of extracellular glutamate. CONCLUSIONS: Consistent with other studies, hypothermia was associated with diminished extracellular DA concentrations during forebrain ischemia. However, depending on the temperature condition, the addition of STP or ETOM in our forebrain ischemia model led to unexpected findings. The administration of these agents during normothermia diminished ischemia-induced DA accumulation yet resulted in significantly higher concentrations of extracellular glutamate. In contrast, STP and ETOM during hypothermia were noted to significantly offset the DA-reducing effects of hypothermia.

Recognizing the early stages of dementia.

Dementia is the most common psychiatric problem seen in the elderly, a steadily growing patient group. Cognitive impairment may be difficult to recognize, particularly in early phases, being mistaken for depression, hypochondriasis, or other conditions. Early, correct diagnosis of dementia reduces cases of inappropriate treatment and polypharmacy, and increases likelihood of improving quality of life.

Depressed adolescent mothers' perceptions of their own maternal role.

Although there is a growing body of research in the area of adolescent pregnancy and parenting, little is known about the more personal experiences of these teens. Ethnographic research methods were used in the present study with the goal of narrowing existing gaps in knowledge about the affective component of adolescent mothers' role attainment. The sample consisted of 15 voluntary informants who reported depressive symptoms during pregnancy or postpartum. The findings suggest that for some adolescent mothers the experience of motherhood may help them improve their previously self-destructive lives. Many adolescent mothers have engaged in impulsive high-risk activities prior to their pregnancies. Through the establishment of a maternal identity and simultaneous development of a strong sense of maternal protectiveness these young women are making realistic, future-oriented decisions that are motivating them to leave gang life, finish high school, go to college, and get vocational training. However, a subset of adolescent mothers who experience chronic depressive mood along with social isolation in the postpartum period may be at increased risk for development of problematic maternal behaviors.

Health-related problems in a vulnerable population: pregnant teens and adolescent mothers.

Childbearing adolescents are susceptible to a myriad of health-related problems. For these youth, health-related problems include both physiological and psychological disease states that negatively impact both their own and their children's lives. Suicide attempts, parenting problems (including child abuse), domestic violence, poor birth outcomes, and sexually-transmitted diseases (including HIV) are just some of the problems encountered. This article focuses on the relationship between lack of social and environmental resources and the risk factors for health problems in adolescent mothers and provides recommendations for nursing assessment and intervention. The complex nature of the relationship between lack of resources and the many risk factors for health-related problems in the lives of childbearing adolescents makes comprehensive health care a requirement. Nurses in school-based clinics and community settings are in a unique position to provide access to the physical and mental health services necessary for pregnant adolescents and teen mothers.

Dementia in adults with Down syndrome: diagnostic challenges.

Although dementia associated with Down syndrome is often presumed to be progressive and irreversible, variations in disease course have been described. In addition, prevalence rates have varied widely among studies. This interim report is a description of the status of 70 adults with Down syndrome who are being followed for signs of dementia. Of the 70, 12 met all criteria for dementia, 40 met subsets of criteria, and 18 met no criteria. Information is provided on instruments used, rationale for choice and revision of instruments as well as criteria used to identify dementia and changes in the status of the participants. The results suggest that extreme care is needed when diagnosing dementia in adults with Down syndrome, for both clinical and research purposes.

"Sometimes you don't feel ready to be an adult or a mom:" the experience of adolescent pregnancy.

PROBLEM: To obtain a description of pregnant adolescents' responses to the preparation for motherhood class curriculum. METHODS: The design of this study was based in the anthropological tradition of qualitative research, ethnography; N = 36. FINDINGS: Within one category identified in this study, maternal role, three primary themes emerged: responsibility, respect, and reparation. CONCLUSIONS: The findings of this study indicate that for some adolescents, pregnancy implies a desire and an opportunity to heal childhood wounds if relevant psychotherapeutic interventions can be provided. Nurses can identify pregnant teens who are already suffering with depression and encourage them to seek counseling prior to the birth of their baby before they are experiencing the added stressors inherent in new motherhood.

Ritanserin in the treatment of cocaine dependence.

Sixty-five cocaine-dependent subjects were enrolled into a 10-week randomized, double-blind study to determine the safety and efficacy of the serotonin-2 receptor antagonist, ritanserin (10 mg/day), in reducing cocaine consumption and craving. All subjects also participated in a structured intensive outpatient psychosocial program. Seventy-three percent of the participants completed the treatment program and follow-up. Subjects experienced a significant reduction in craving: 66.4% and 32.5% for the placebo and ritanserin groups, respectively. These reductions in craving were not paralleled by substantial decreases in cocaine use. Self-reported cocaine use was less frequent in the placebo group; paradoxically, blood levels of its metabolite, benzoylecgonine, were also higher although insignificantly so. Generally, ritanserin was well tolerated but significantly prolonged the QTc interval on the electrocardiogram. This outpatient program is effective at maintaining cocaine-dependent individuals in treatment and reducing craving. Ritanserin (10 mg/day) is not an efficacious adjunct to psychosocial treatment for cocaine dependence.