"Opposite speech" in a schizophrenic patient.

"An unusual speech syndrome of a schizophrenic patient, in which "yes" and "no" and other opposites are reversed without awareness on the part of the patient, has been described. In discussion the reversal of a strongly established linguistic discrimination, it was pointed out that learning theorists have largely neglected the study of pathological language… . Evidence was offered to support the view that the opposite speech of the patient served primarily as a means of coping with hostile impulses." (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A "zero tolerance for overtime" increases surgical per case costs

PURPOSE: One technique which some hospitals have used in an attempt to control Operating Room costs is a "zero tolerance for overtime" policy. We used a case cost analysis to determine if this policy was always cost effective. METHOD: A case cost analysis was designed based on a "test case" which would start late in the day. The case would last for three hours of which 1 1/2 hr would be during regular hours, and 1 1/2 hr would incur overtime. Costs were analysed using a "patient pays," "society pays," and "hospital pays" analysis. Costs were based on figures determined from the SMBD-Jewish General Hospital budget, Québec Health Insurance fees, and Government of Canada statistics. RESULTS: Regardless of who pays, in this case scenario it was more cost effective to proceed than to postpone surgery. Costs of proceeding with the surgery in the "patient pays," "society pays," and "hospital pays" models were $1,832.00, $1,227.40, and $1,215.00 respectively. The costs of postponing the surgery in the same three models were $1,937.00, $1,336.80, and $1,436.00. CONCLUSION: A "zero tolerance for overtime" policy may be too rigid to be consistently cost effective.     

On the "folkloric" psychotherapy to schizophrenic patients--based on phenomenological study

Psychotherapeutic treatment of schizophrenia is generally considered difficult. One reason for this is that the doctor and patient can easily fall into a relationship of conflict with each other concerning the propriety of "judgments which are morbidly and mistakenly made (K. Jaspers)", referred to as delusions. We carried out close phenomenological structure-analyses of the delusions and of patients' fundamental experiences, based on the premise that a patient with delusions probably has some actual grounding for these in the patient's own concepts, considering the fact that the patient firmly believes these delusions. As a result, we have clarified the following matters from the primary experience of delusions. 1) We found that patients are in a conflicted mental condition which can be considered a collapse of adaptability to "Seken". 2) In this condition of conflict, patients feel guilt relative to "Seken" or feel that they are indebted and should be punished. When patients complained of their primary experience, we were able to persuade them to reserve their judgment of their primary experience, by 3) having each patient listen to the folktale "Torikuyou" in which the "logic of stealing" and the "logic of being stolen", appear in a reciprocal relationship relative to the constitution of crime and punishment, by 4) explaining to each patient about the ambiguity and reciprocity of reality experienced, 5) instead of disputing the propriety of patient's judgment about primary experience, doctor and patient worked together to enable the patient to form a positive understanding of the primary experience. 6) We reduced the patient's psychological conflict relative to primary experience, and were able to defuse and distance the patient's delusions caused by erroneous judgment of primary experience. 7) Regarding the area in which this type of psychotherapeutic approach shows efficacy, we analyzed the concept of "Seken" as a world which can cause conflicts relative to primary experiences. 8) We also analyzed "Giri" as a norm of "Seken" from which patients misconceive that they have deviated, in addition, 9) from the viewpoints of anthropology and cultural anthropology, we analyzed the bases for "Kotowaza (proverbs)" and "Monogatari (folktale)" such as "Torikuyou", which themselves can show psychotherapeutic efficacy. We consider that the psychotherapeutic approach has previously been developed around the concepts of the "individual" and "society", but we made our psychotherapeutic approach from the concept of "Seken" (yononaka = hito: person) that is a structure with deep strata of tradition and culture in Japan, and have reported its concrete development through the presentation of 3 typical cases of schizophrenia with difficulty in adapting to society due to showing the delusion of persecution in their foreground.     

"Inverse latent" macro square-wave jerks and macro saccadic oscillations

A patient recovering from an acute encephalopathy demonstrated several ocular motor disturbances reflecting cerebellar and brainstem dysfunction. Two of these, macro square-wave jerks and macro saccadic oscillations, have never been reported in the same patient. The macro square-wave jerks disappeared with monocular viewing, a previously undescribed "inverse latent" characteristic.     

"Toxic sock" syndrome

For several months, a 17-year-old male athlete noticed that his feet had an itchy, burning sensation at the heels and toes. His foot odor had become so malodorous (somewhat akin to rotting fish) that he would not remove his shoes except immediately before washing his feet. Washing made the odor somewhat milder, but only for a short time. The patient had tried an over-the-counter "athlete's foot" powder without results. He had no other health problems and was not taking any medication. The accompanying figure shows the toes of his right foot.     

An analysis of "dignity"

The word "dignity" is frequently used both in clinical and philosophical discourse when referring to and describing the ideal conditions of the patient's treatment, particularly the dying patient. An exploration of the variety of meanings associated with the word dignity will note dignity's ambiguous usage and reveal instrumental concepts needed to better understand the discourse of the dying. When applied to a critique of recent and contemporary criticisms of the medical community's handling of the dying, such concepts might provide a more coherent notion of dignity. Rather than a separate construct, a death with dignity might be viewed as an interactive process among the dying and their caretakers. Together, this interdependent amalgam engages in humanizing communication aimed toward understanding the final needs and wants of the patient.     

Traumatic aortic transections: eight-year experience with the "clamp-sew" technique

BACKGROUND: Because traumatic aortic transection is associated with high mortality rates, great debate exists about the appropriate operative technique for treatment of patients who have acute traumatic aortic transection. METHODS: To determine the safety and efficacy of the "clamp-sew" method, we retrospectively reviewed our 8-year experience treating 75 patients who had aortic injuries secondary to blunt trauma. Seventy-one of these patients were treated surgically. The clamp-sew method was used in all of these operations. RESULTS: Aortic cross-clamp time averaged 24 minutes (range, 14 to 36 minutes), with 4/71 having times in excess of 30 minutes. One patient (clamp time, 28 minutes) became paraplegic. Significant associated injuries were seen in 51/75 patients (48/71 patients with operation), including intrathoracic (35 patients), orthopedic (28 patients), intraabdominal (24 patients), and central nervous system (17 patients) damage. No patient died within 24 hours of operation. Overall 30-day mortality was 12% (9/75), with 7/9 having two or more aforementioned associated injuries. Of these 7, 5 had central nervous system injuries. Two of 9 died within 30 days without two or more associated injuries: 1 Jehovah's Witness of low hemoglobin, and 1 patient of sepsis. CONCLUSIONS: Although any of several maneuvers may be appropriate in managing traumatic aortic injuries, the simple "clamp-sew" technique is a safe and effective method for the treatment of traumatic aortic transections.     

"Music of the Brain" in the treatment of insomnia patients

The effects of "Music of the Brain" which is the new nonpharmacological method of treatment of insomnia were studied. The method is based upon the transformation of EEG signals into the music by using a special algorithm developed by the author. Sleep polygramme was registered and analysed. EEG sites of sleep stages and phases which most satisfied usual criteria were selected and transformed into music. The patient listened to the recorded audio cassette just before sleep. 58 patients with insomnia were divided into 2 groups according clinical, formal, psychological and electrophysiological (polysomnography, EEG) methods which were applied before and after 15-day course of treatment. 1st group (44 individuals) was the main group and the 2nd group (14 patients) was the "placebo" group ("Music of the Brain" of other individual was used in this case). The positive effects of "Music of the Brain" were evaluated in patients with insomnia in more than 80% cases. These effects were marked on the basis of both subjective feeling and objective (psychological and neurophysiological) results. The high effectivity of "Music of the Brain" for patients with insomnia combines with the lack of side effects and complications.     

"Traveling affectively alone": a personal derailment in analytic listening

Questioning whether or not we have entered a new "two-person" paradigm, the author shares a traumatic personal experience, considers its impact on her work with a patient, and discusses some clinical and epistemological dilemmas in self-disclosure.     

A-B therapist "types" and responses to patient-communicated hostility: An analogue study.

In prior research by B. J. Betz and R. C. Carson (see 41:5, 41:9) A and B therapists obtained relatively better outcomes with schizophrenic and neurotic patients, respectively. Recent research suggests that 1 basis for these performance differences might lie in therapist-patient "complementarity" with respect to extrapunitive (E) vs. intropunitive (I) modes of handling anger; presumably, As would (E) vs. intropunitive (I) modes of handling anger; presumably, As would respond more effictively to E cues and Bs to I cues in patients To test this theory 90 undergraduate male As, ABs (middles), and Bs wrote self-selected "helpful" responses to brief, tape-recorded patient communications (E and I). Only limited support was obtained for analyses of the helping responses themselves. The predicted interaction effects were supported for Ss' evaluations of their helping performances. As paired with the E and Bs paired with the I patient were more satisfied than Ss oppositely paired (p     

Reflections on the "unknown" in psychotherapy.

Suggests that "darkness" (in contrast to and in alternation with "light") is useful as a metaphor for representing ever-recurring periods in dynamic psychotherapy during which the therapist does not and cannot know what is occurring in the work with his/her patient. Such unfathomable "dark" periods are a fertile matrix from which central meanings in a patient's life will emerge, provided the therapist does not interfere with their unfolding. However, these "dark" periods are anxiety provoking for the therapist and often result in anxiety-instigated, growth-deflecting efforts at prediction and control. Clinical vignettes are presented to illustrate the inevitable rhythm of alternation in therapy between "darkness" and "light," the imponderability of various key therapeutic events, and the therapist's struggles with these issues. (1 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Immunotherapy of cancer with "immune" RNA. A preliminary report

A phase I clinical trial of immunotherapy with "Immune" RNA was undertaken fifteen months ago. Twenty-six cancer patients were treated with RNA extracted from the lymphoid organs of sheep immunized with either autologous tumor cells or allogeneic tumor cells of the same histologic type. Eighteen patients had gross disease and eight had minimum residual disease. RNA was administered weekly, intradermally, at doses up to 9 mg/week without any significant local or systemic toxicity. Four patients improved, thirteen achieved stability of disease or possible improvement, seven were treatment failures, and two are indeterminate. Lymphocyte-mediated cytotoxicity to allogeneic tumor target cells of the same histologic type were monitored in eleven patients. In seven patients, cytotoxicity increased after "Immune" RNA therapy; no change was observed in three patients; a decrease was noted in one patient. There appeared to be a possible correlation between cytotoxicity assessed in vitro and clinical response. There is some evidence that these responses may be specific for the particular tumor used to immunize the RNA donor.     

Coding mammograms using the classification "probably benign finding--short interval follow-up suggested"

OBJECTIVE: Many benign breast lesions revealed by mammography show features indicating that the lesions have a high, but not complete, likelihood of being benign. The Breast Imaging Reporting and Data System (BI-RADS) allows radiologists to classify these mammograms as "probably benign finding-short interval follow-up suggested" (category 3). We explored whether certain factors are associated with the use of category 3 in a national cancer detection program. MATERIALS AND METHODS: We analyzed data from the National Breast and Cervical Cancer Early Detection Program, a comprehensive nationwide program that provides cancer screening for low-income and medically underserved women. The study population included all women at least 40 years old who had undergone mammography on or before September 30, 1996 (n = 372,760). RESULTS: Of the 372,760 mammograms, 7.7% were classified as category 3. The probability of receiving a category 3 classification decreased as patients' ages increased. Women who were symptomatic were nearly twice as likely as women who were asymptomatic to receive a category 3 classification, and women whose clinical breast examinations had abnormal findings were more than twice as likely as women with examinations having normal findings to receive a category 3 classification. The percentage of mammograms classified as category 3 by state or tribal organization ranged from 1.4% to 14.0%. CONCLUSION: Several patient variables, including patient symptomatology, were associated with the probability of having a mammogram classified as category 3. One of the most important determinants was where the patient underwent mammography, which suggests that variability exists among radiologists themselves in using this BI-RADS code for "probably benign" mammographic lesions.     

Protrusion without fracture of the Accufix atrial "J" lead retention wire

The Telectronics Accufix atrial "J" lead has been associated with injury and death. These complications have occurred as the result of retention wire fracture, extrusion, and perforation of cardiac or vascular structures. This report describes a patient who was found to have protrusion of the proximal end of a nonfractured retention wire during fluoroscopic surveillance. The wire extrusion appeared to result from angulation of the lead. The lead was extracted and replaced without adverse consequences. Further prospective analysis will be needed to determine the clinical implications and approach to this complication.     

Spinal microsurgery at the thoracic to sacral level in the "prone-oblique" position

Until the present time, almost all posterior approaches to the thoracic to sacral region have been made in either the knee-elbow or the prone position. Those positions, however, have potential disadvantages such as respiratory suppression and/or disturbance of venous return due to compression of the anterior chest and belly. In order to avoid the above mentioned disadvantages, the patient was laid on the operating table in a "Prone-Oblique" position, with the body rotating about 40 degrees around the long axis. The authors performed, with successful results, spinal operations via the posterior route in the "Prone-Oblique" position in 30 cases. An illustrative case was presented of a metastatic intramedullary tumor at the T11/12 level from an unresectable mammary cancer. The cancer had infiltrated and bulged out of the left anterior chest wall so severely and extensively that an operation in the conventional position was impossible. The metastatic tumor was totally and successfully removed via the posterior approach in the "Prone-Oblique" position without any complications related to the position. This "Prone-Oblique" position seems to be physiologically suitable, giving rise to no harmful compression of any part of the patient's body and it provides the surgeon a comfortable posture and a good operative view during microsurgery.     

"Clinical Judgment" revisited: the distraction of quantitative models

More than 25 years ago, in a book called Clinical Judgment, each act of patient care was described as having an experimental structure. The "experiments" needed substantial scientific improvement, however, in quality of basic data, taxonomic classification of phenomena, and specifications of clinical reasoning. During the past 2 decades, these improvements have not occurred as extensively as expected because many investigators working in clinical forms of clinical research have not addressed these basic scientific challenges in data, taxonomy, and reasoning. Instead, the investigators have applied quantitative "models," derived from non-clinical domains, that focus on hard data, randomized trials, Bayes theorem, quantitative decision analysis, and psychometric strategies for clinimetric measurement. Consequently, the main challenges of clinical judgment still remain generally available for basic scientific research by investigative clinicians.     

BCAM sterile. "A lesson in asepsis"

This article presents the principles and rationale for aseptic practice in the operating room. The mnemonic "BCAM STERILE: has been chosen as the framework in which the principles are presented. The principles apply to all personnel who care for the patient during the intraoperative experience.     

Atypical mycobacteriosis (Mycobacterium xenopi) with "initial aggravation"

A 66-year-old man was admitted to Nara Medical University Hospital because of sputum production and fevre. A chest X-ray film obtained on admission revealed many cysts and an infiltrative shadow in the right upper lung field. The patient was treated with antimycobacterial drugs (isoniazid 400 mg, streptomycin 0.75 g, and rifampicin 450 mg) because acid-fast bacilli were detected in his sputum. Although the symptoms and laboratory data improved, a new infiltrative shadow developed in the right lower lung field two months after the start of treatment. Transbronchial biopsy specimens showed intraluminal organizing exudate and alveolitis. The new lesion resolved when treated with the same antimycobacterial drugs. Mycobacterium xenopi was cultured from the sputum 80 days later. This is the third reported case of atypical mycobacteriosis (non-tuberculous mycobacteriosis) due to M. xenopi in Japan with the "initial aggravation" seen in some patients with typical pulmonary tuberculosis.     

A personal (biased) perspective on cancer "vaccines"

The use of active specific immunotherapy (ASI) for cancer (cancer "vaccines") is still in its scientific infancy despite several decades of clinical and basic research. What has been established is the principle that stimulation of the immune response by "crude" (i.e., whole cell-derived) vaccines has led, in a proportion of patients, to rejection of tumor masses, in some instances for 10 years or more. Scientific investigations into the nature of recognition of tumor antigenic determinants (epitopes) by cytolytic T cells have begun to elucidate the mechanisms underlying rejection, making more precise vaccines possible. Yet there should be caution about assuming that a single epitope or even a few epitopes combined will be as effective as the "crude" materials, which might better be thought of as "polyvalent." ASI in at least one instance may have cured melanoma in a patient with metastatic disease, but that patient developed another immunologically and genetically distinct melanoma. This may provide an example of both immunological surveillance against the emergence of new melanomas and immunological selection of an immunologically resistant tumor. Combinations of vaccines with cytokines, cytolytic T cell infusions, or chemotherapy may improve the response rates and durations of survival achievable with vaccines alone. The best rationale for synthetically derived vaccines may be for prophylaxis-that is, as a true vaccine-where the use of tumor-derived materials in normal individuals is difficult to justify ethically.