Confrontations with Death: Psychological Responses During Internship

During internship, the daily confrontation with the consequences of disease contributes much to the distress which young physicians experience (I). Not only are interns responsible for first line medical care, they must also provide emotional support for their patients struggling with pain, disability and impending death. This paper seeks to examine some of the factors responsible for the turmoil involved in caring for these dying patients. Our conceptions of death and dying are determined to a large extent by the cultural context in which we live. Compared with other times in which death was not so ego alien, we presently live in a time and culture which Aries has called death-denying (2). Eissler has suggested that death is one of those unsavory facts which cannot be integrated into (our present), essentially hedonistic civilization . . . (It) must therefore remain a foreign body, denied by silence rather than recognized as the possible Alpha and Omega of life itself\u27 (3)

Psychiatric Manifestation of Vitamin B-12 Deficiency: An Update

Psychiatric manifestations of vitamin B-12 deficiency are reviewed from 1986 to the present. Specific clinical entities reviewed include depression, organic psychosis, obsessive-compulsive disorder, childhood manifestations and dementia. We recommend that consideration be given to B-12 deficiency as an etiological factor in some cases of depression, organic psychosis, certain childhood disorders and dementia. Routine screening of people overage 65 is addressed

Maternal Morbidity Outcomes in Idiopathic Moyamoya Syndrome in New York State

Background: Pregnancy is associated with an increased risk of stroke in young women. Idiopathic moyamoya syndrome (IMMS) is a rare condition characterized by progressive narrowing of large cerebral arteries resulting in flimsy collaterals prone to rupture or thrombosis. Data are limited on pregnancy outcomes in women with IMMS. We hypothesized that IMMS would be associated with increased pregnancy morbidity, including stroke. Conclusion: Pregnancies within 1 year prior or any time after IMMS diagnosis did not have increased maternal morbidity compared to unexposed pregnancies after adjusting for age and clustering of women with multiple pregnancies. Prospective studies are needed to better characterize increased maternal risks for women with moyamoya syndrome and develop preventive strategies

A comparison of nefazodone, the cognitive behavioral-analysis system of psychotherapy, and their combination for the treatment of chronic depression

Background Patients with chronic forms of major depression are difficult to treat, and the relative efficacy of medications and psychotherapy is uncertain. Methods We randomly assigned 681 adults with a chronic nonpsychotic major depressive disorder to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both. At base line, all patients had scores of at least 20 on the 24-item Hamilton Rating Scale for Depression (indicating clinically significant depression). Remission was defined as a score of 8 or less at weeks 10 and 12. For patients who did not have remission, a satisfactory response was defined as a reduction in the score by at least 50 percent from base line and a score of 15 or less. Raters were unaware of the patients’ treatment assignments. Results Of the 681 patients, 662 attended at least one treatment session and were included in the analysis of response. The overall rate of response (both remission and satisfactory response) was 48 percent in both the nefazodone group and the psychotherapy group, as compared with 73 percent in the combined-treatment group (P Conclusions Although about half of patients with chronic forms of major depression have a response to short-term treatment with either nefazodone or a cognitive behavioral-analysis system of psychotherapy, the combination of the two is significantly more efficacious than either treatment alone

Tryptase Levels as an Indicator of Mast-Cell Activation in Systemic Anaphylaxis and Mastocytosis

Abstract Better methods are needed to assess mastcell activation In vivo and to distinguish the activation of mast cells from that of basophils. Tryptase, a neutral protease selectively concentrated in the secretory granules of human mast cells (but not basophils), is released by mast cells together with histamine and serves as a marker of mast-cell activation. In 17 patients with systemic mastocytosis, concentrations of tryptase in plasma were linearly related to those of histamine (P\u3c0.01). Eleven of the 17 patients had tryptase levels of 4 to 88 ng per milliliter, indicating ongoing mast-cell activation. In each of six patients who experienced corresponding anaphylactic reactions after penicillin, aspirin, or melon ingestion, a wasp sting, exercise, or antilymphocyte globulin injection, tryptase levels in serum ranged from 9 to 75 ng per milliliter, indicating mast-cell activation during each of these events. In contrast, serum tryptase levels were less than 5 ng per milliliter in all patients presenting with myocardial disease (n = 8, 6 with hypotension) or sepsis (n = 6, 3 with hypotension) and in the controls (n = 20). One patient had a myocardial infarction after anaphylaxis in response to a wasp sting and an elevated tryptase level of 25 ng per milliliter. Thus, the plasma or serum tryptase level is a diagnostic correlate of mast-cell-related events. (N Engl J Med 1987; 316: 1622–6.

A Quality Improvement Checklist for the Perioperative Management of Surgical Patients with Opioid Addiction on Buprenorphine

Background: Buprenorphine is a semisynthetic opioid agonist-antagonist that displays antagonism at kappa receptors and partial agonist at mu receptors. Buprenorphine has the unfortunate effect of interfering with the actions of opioids administered for medical indications. When patients on buprenorphine present for surgery or procedures requiring anesthesia, it can become a substantial challenge. Currently, there are no guidelines or checklists that would help the anesthetist to provide adequate pain management for the OUD patient population. Objectives: (1) Understand the perioperative management of patients with opioid addiction on buprenorphine. (2) Demonstrate increased knowledge and confidence in understanding the challenges, pharmacokinetics, and pharmacodynamics of managing a patient on buprenorphine. (3) Discuss and manage perioperative interventions of patients taking buprenorphine with opioid addiction. Methodology: The primary methodology of the proposed project was to administer an online Zoom educational module to providers that focus on the perioperative management of patients with OUD who take buprenorphine. The project was implemented by conducting an online pre-assessment test, zoom educational module, and a post-assessment test that assessed the anesthesia providers\u27 knowledge about managing a patient with OUD on buprenorphine during the perioperative period. Pre-assessment and post-assessment testing were used to measure the effects of the educational module. Statistical analysis was applied to assess the effectiveness of the educational module. Results: There was a total of five Certified Registered Nurse Anesthetists (CRNAs) that participated in the quality improvement project. The results reflected an improvement in knowledge based on the pre-test and post-test scores. Knowledge showed an average gain of (25%). In addition, the post-test demonstrated that participants are most likely (n=4, 80%) or somewhat likely (n=2, 20%) to implement a perioperative checklist for surgical patients with opioid addiction taking buprenorphine. Conclusion: An evidence-based educational module determined an increase in participants\u27 knowledge of managing surgical patients with OUD taking buprenorphine during the perioperative period. There is no consensus on the management of buprenorphine; however, the recommendation is to continue buprenorphine during the perioperative period

IMMUNODEFICIENT R2G2 MOUSE STRAIN YIELDS SPLEENS WITH UNUSUAL CYTOARCHITECTURE AND SYMPATHETIC INNERVATION

The nervous system and immune system contact one another through two-way communication in order to establish and preserve homeostasis. The sympathetic neurotransmitter norepinephrine has an impact on how the immune system responds by affecting regional blood flow and activation of adrenergic receptors on leukocytes. Former studies showed that immune cells are capable of releasing nerve growth factor allowing for the establishment and continuation of sympathetic nerves in targeted tissues. From this gathered information, it was hypothesized that sympathetic nerves would prove to be less frequent in spleens from the immunodeficient R2G2 mouse strain (Envigo) when compared to 129P3/J (129) and C57BL/6 (C57) strains. R2G2 mice are an immunodeficient strain that lacks functional T, B, and natural killer cells. Ten to eleven week aged-matched male mice were measured by body weight, spleen weight, and temperature. Spleens were cut and fixed for histological investigation. Sympathetic nerves were labeled by immunostaining tyrosine hydroxylase (TH). Hematoxylin & eosin (H&E) was used to stain spleen sections in order to evaluate cytoarchitecture. Von Willebrand factor (VWF) was used to immunostain for megakaryocytes. R2G2 mice showed slightly higher temperatures and body weights but yielded a significantly smaller spleen weight (R2G2, 38.20 ± 1.48; 129, 65.08 ± 11.71; C57, 81.33 ± 8.38; P\u3c 0.0001, ANOVA). TH stain revealed sympathetic innervation in all strains but location and morphology differed in R2G2 mice compared to controls. Control spleens had nerves which entered white pulp regions of the spleen and were closely related to leukocytes. Fiber profiles in the controls were filamentous with small acute bends. R2G2 differed by having (TH+) nerve fibers more associated with arteries and less localized in the surrounding parenchyma. The fibers were abnormally swollen and held a more granular shape instead of a filamentous shape. The H&E stain showed clear red and white pulp zones in the control spleens with 129 showing more distinct germinal centers than C57. R2G2 H&E sections showed cytoarchitecture with indistinct pulp areas. VWF staining revealed R2G2 mice had an abundant amount of megakaryocytes versus control mice megakaryocyte counts (R2G2, 11.28 ± 3.87 per 20X field; 129, 1.73 ± 0.70; C57, 1.42 ± 0.13; P\u3c 0.0001, ANOVA) and extramedullary hematopoiesis was highly prominent. This evidence supports that leukocytes secrete neurotrophic factors or are vital to establishing normal growth of TH+ nerves toward the white pulp. Leukocytes may not be required for sympathetic innervation of blood vessels in the spleen, however, lack of leukocytes shows TH+ nerve fibers with abnormal morphology in severely immune threatened mice

The Persistence of Common-Ratio Effects in Multiple-Play Decisions

People often make more rational choices between monetary prospects when their choices will be played out many times rather than just once. For example, previous research has shown that the certainty effect and the possibility effect (two common-ratio effects that violate expected utility theory) are eliminated in multiple-play decisions. This finding is challenged by seven new studies (N = 2391) and two small meta-analyses. Results indicate that, on average, certainty and possibility effects are reduced but not eliminated in multiple-play decisions. Moreover, in our within-participants studies, the certainty and possibility choice patterns almost always remained the modal or majority patterns. Our primary results were not reliably affected by prompts that encouraged a long-run perspective, by participants’ insight into long-run payoffs, or by participants’ numeracy. The persistence of common-ratio effects suggests that the oft-cited benefits of multiple plays for the rationality of decision makers’ choices may be smaller than previously realized

The Persistence of Common-Ratio Effects in Multiple-Play Decisions

People often make more rational choices between monetary prospects when their choices will be played out many times rather than just once. For example, previous research has shown that the certainty effect and the possibility effect (two common-ratio effects that violate expected utility theory) are eliminated in multiple-play decisions. This finding is challenged by seven new studies (N = 2391) and two small meta-analyses. Results indicate that, on average, certainty and possibility effects are reduced but not eliminated in multiple-play decisions. Moreover, in our within-participants studies, the certainty and possibility choice patterns almost always remained the modal or majority patterns. Our primary results were not reliably affected by prompts that encouraged a long-run perspective, by participants’ insight into long-run payoffs, or by participants’ numeracy. The persistence of common-ratio effects suggests that the oft-cited benefits of multiple plays for the rationality of decision makers’ choices may be smaller than previously realized