The effects of ketamine on typical and atypical depressive symptoms.

OBJECTIVE: Ketamine's effects on different dimensions of depressive symptomatology, including typical/melancholic and atypical depression, remain largely unknown. This study examined the effects of a single intravenous dose of ketamine on general depressive symptoms (measured using the Montgomery-Asberg Depression Rating Scale (MADRS), typical/melancholic symptoms (measured using the MADRS5), and atypical symptoms (measured using the Scale for Atypical Symptoms (SAS)). METHODS: Data from 68 participants with treatment-resistant major depressive disorder (MDD) or bipolar depression were pooled from three separate, double-blind, placebo-controlled, crossover studies investigating ketamine's efficacy in depression. MDD participants were unmedicated; bipolar participants received therapeutic-dose lithium or valproate. Clinical symptoms were collected preinfusion and up to 14 days postinfusion. Effect sizes were calculated for days 1 and 3 postinfusion. The primary measures of interest for this exploratory analysis were total MADRS, MADRS5, and SAS scores. Individual symptoms were also analyzed in an exploratory manner. RESULTS: Scores improved significantly at Day 1 postinfusion (MADRS: Cohen's d = 0.64; MADRS5: Cohen's d = 0.61; SAS: Cohen's d = 0.41) and continued to be significantly improved over placebo at Day 3 (MADRS: Cohen's d = 0.49; MADRS5: Cohen's d = 0.43; SAS: Cohen's d = 0.39). Effect sizes were greater for typical/melancholic than atypical symptoms at Day 1 postinfusion. CONCLUSION: Ketamine appears to effectively treat both the typical/melancholic and atypical symptoms of depression, but may have early preferential effects for the former.

Factors influencing medical student attrition and their implications in a large multi-center randomized education trial.

Participant attrition may be a significant threat to the generalizability of the results of educational research studies if participants who do not persist in a study differ from those who do in ways that can affect the experimental outcomes. A multi-center trial of the efficacy of different computer-based instructional strategies gave us the opportunity to observe institutional and student factors linked to attrition from a study and the ways in which they altered the participation profile. The data is from a randomized controlled trial conducted at seven US medical schools investigating the educational impact of different instructional designs for computer-based learning modules for surgical clerks. All students undertaking their surgical clerkships at the participating schools were invited participate and those that consented were asked to complete five study measures during their surgery clerkship. Variations in study attrition rates were explored by institution and by participants' self-regulation, self-efficacy, perception of task value, and mastery goal orientation measured on entry to the study. Of the 1,363 invited participants 995 (73 %) consented to participate and provided baseline data. There was a significant drop in the rate of participation at each of the five study milestones with 902 (94 %) completing at least one of two module post-test, 799 (61 %) both module post-tests, 539 (36 %) the mid-rotation evaluation and 252 (25 %) the final evaluation. Attrition varied between institutions on survival analysis (p < 0.001). Small but statistically significant differences in self-regulation (p = 0.01), self-efficacy (p = 0.02) and task value (p = 0.04) were observed but not in mastery or performance goal orientation measures (p = NS). Study attrition was correlated with lower achievement on the National Board of Medical Examiners subject exam. The results of education trials should be interpreted with the understanding that students who persist may be somewhat more self-regulated, self-efficacious and higher achievers than their peers who drop out and as such do not represent the class as a whole.

Laparoscopy and unsuspected intra-abdominal malignancy with rapid peritoneal spread.

Use of the laparoscopic approach for intra-abdominal malignancy remains controversial because there have been multiple reports of tumor metastases at port sites after laparoscopy. Although several randomized trials have documented no difference in recurrence rates between laparoscopic and open surgery, there are still many questions about the behavior of tumor cells in laparoscopic conditions. The speed of tumor spread and time to recurrence appear to be variable. Abdominal insufflation and other effects of laparoscopy are only now being delineated. It is not clear whether tumor characteristics, preoperative tumor stage, or the laparoscopic milieu itself affect tumor spread during and after laparoscopic surgery. We present an unusual case of very rapid tumor dissemination in a young patient who underwent diagnostic laparoscopy.

Portal vein thrombosis following laparoscopic splenectomy for beta-thalassemia: a case study.

Portal vein thrombosis is a rare but well-recognized complication of splenectomy. We present the case of a 31-year-old woman with transfusion-dependent b-thalassemia who underwent a laparoscopic splenectomy to reduce her transfusion requirements. Postoperatively, she developed portal vein thrombosis, diagnosed by abdominal CT scanning on postoperative day 4. After being treated with anticoagulation and antibiotic therapy, she obtained prompt resolution of her symptoms. This report summarizes the first reported incidence of portal vein thrombosis following laparoscopic splenectomy and presents the current theories regarding the etiology and treatment of postsplenectomy portal vein thrombosis.

Multifactorial analysis of firearm wounds to the head with attention to anatomic location.

Firearm wounds to the head are often fatal and are routinely encountered in the practice of forensic pathology in the United States. Often, the anatomic site of the entrance wound is used to support or refute the manner of death indicated by the scene investigation and/or circumstances of the case. The present retrospective study of 120 fatalities resulting from 140 firearm wounds to the head correlates the anatomic region of the entrance wound and range of fire with the manner of death. Other demographic data analyzed include age, race, and gender of the decedents, as well as evidence of drug and/or ethanol use. It is hoped that this study will provide concrete data to support the largely anecdotal associations between the specific site of entry of firearm injuries to the head and the manner of death.

Laparoscopic Nissen fundoplication in children: a single surgeon's experience.

BACKGROUND AND OBJECTIVES: Adult laparoscopic Nissen fundoplication has been steadily growing since its introduction to the United States in the 1990s. Its advantage over the traditional open approach is manifold. Application of laparoscopic fundoplication to children is slowly but surely following this trend. This study evaluates our initial experience with pediatric laparoscopic Nissen fundoplications. PATIENTS AND METHODS: We reviewed the records of 25 consecutive laparoscopic Nissen fundoplications performed by a single surgeon (GS) at our institution in the past three years. The patient ages ranged from 7 months to 18 years (mean, 7 years). All patients had documented gastroesophageal reflux disease. Complications from the reflux included vomiting in 15 patients, failure to thrive in nine, esophagitis in nine, and pulmonary symptoms in six. RESULTS: All Nissen fundoplications were performed laparoscopically without need for conversion to open technique. Blood loss was less than 50 cc in all cases. A tube gastrostomy was concurrently performed in 17. Mean operative time in all cases was 221 minutes. Average postoperative day on which feedings were begun was day 2, with an average resumption of regular feedings on postoperative day 3.5. Average date of discharge was postoperative day 6.8. Complications included difficulty controlling glucose in an insulin-dependent diabetic, and a lost needle, which added an additional hour to the operative time. There were eight admissions to the pediatric intensive care unit, all for observation secondary to their underlying medical problems. There was one postoperative death due to an underlying medical condition. CONCLUSIONS: Laparoscopic Nissen fundoplication is a safe and effective treatment option for children suffering from significant reflux. Time to regular feeding, analgesia requirements and hospital stay are decreased when compared to traditional procedures. Laparoscopic Nissen fundoplication may well become the procedure of choice for pediatric gastroesophageal reflux disease.

Mucormycosis in diabetes.

Mucormycosis is a rare opportunistic infection caused by ubiquitous fungi typically found in soil, spoiled foods, bread, and dust. The acute infection most commonly is rhinocerebral and is associated with metabolic acidosis. Mucormycosis spreads quickly and can progress from the paranasal area to the brain in a few days. In the case presented, a young diabetic woman had diabetic ketoacidosis and classic signs and symptoms of mucormycosis. Even after aggressive and appropriate treatment with surgical debridement and IV administration of amphotericin B, the fungus invaded the central nervous system. This article discusses current methods of treating mucormycosis and important critical care nursing considerations for patients who have the infection.

Interaction of NT-4 and BDNF with gp145trkb receptor: effect on cellular metabolism.

In the present study a silicon microphysiometer (Cytosensor) was applied in investigating interactions of gp145(trkb), a member of the tyrosine kinase receptor family, with different neurotrophic factors. NIH-3T3 cells transfected with gp145(trkb) receptors (NIH3T3/trkB cells) were utilized in the studies. Treatment with brain-derived neurotrophic factor (BDNF), neurotrophin-4 (NT-4) and neurotrophin-3 (NT-3) induced changes in the metabolic rate of NIH3T3/trkB cells. In contrast, no response was observed with nerve growth factor (NGF). The effects of NT-4 and BDNF on NIH3T3/trkB cells were receptor-specific in that they did not induce metabolic rate changes in wild type NIH3T3 cells or cells transfected with either gp140(trkb) (TrkA) or gp145(trkb) (TrkC) receptors. In contrast, NT-3 induced metabolic rate changes in cells transfected with each of the three different Trk receptors. The activity of NT-4 was significantly higher than that of BDNF. K252a, a protein kinase inhibitor, reduced the NT-4- and BDNF-induced response of the NIH3T3/trkB cells. This suggests that the NT-4 and BDNF-induced metabolic rate changes are associated with autophosphorylation of the tyrosine protein kinase residues. This hypothesis is further supported by results of western blot analysis. The results show that interactions of Trk receptors with neurotrophic factors result in metabolic changes in cells expressing the receptors.

Fine-needle aspiration cytology of pleuropulmonary blastoma: case report and review of the literature.

This report describes the fine-needle aspiration (FNA) cytology of a case of pleuropulmonary blastoma in a 3-yr-9-mo-old male. Pleuropulmonary blastoma is considered by most authors to be distinct from pulmonary blastoma and is a rare malignant tumor of the intrathoracic cavity. FNA smears were cellular with numerous small ovoid to spindled cells with oval to elliptical nuclei exhibiting finely granular chromatin and inconspicuous nucleoli. The cytoplasm was scant and eosinophilic with indistinct borders. Focal chondroid material and blastema-like cells were noted. The differential diagnosis suggested by the cytologic findings included rhabdomysosarcoma, teratoma, neuroblastoma, malignant mesenchymoma, pleuropulmonary blastoma, and metastatic tumor. To our knowledge, this is the first report of the cytology of this tumor.

Firearm-related hunting fatalities in North Carolina: impact of the 'Hunter Orange' Law.

In the decade spanning 1983 through 1992, 68 people were killed by firearms while hunting in North Carolina (average of 1.66 fatalities/100,000 licenses issued). Of these, 58 deaths involved two parties, a shooter and a victim. In 22% of the incidents the victims were mistaken for game. During the 1987-1988 hunting season a "Hunter Orange" law was initially enforced. This law requires sportsmen to wear an article of bright orange clothing while hunting. After enactment of this law, a reduction in the incidence of hunters being killed because they were "mistaken for game" has proven statistically significant. The present study documents that legally mandating bright orange clothing has resulted in fewer firearms-related fatalities due to the victim's being mistaken for game while hunting. The North Carolina experience implies that governmental intervention can influence the incidence of accidental deaths during recreational hunting.

In vivo proton magnetic resonance spectroscopy of alcohol in human brain.

The covariance between blood and brain alcohol levels and subjective reports of mood were examined in 6 healthy adult men after consumption of 0.7 g/kg of beverage alcohol. There was significant (p less than 0.01) temporal concordance between ascending and peak blood alcohol levels and regional brain alcohol levels as measured by in vivo proton Magnetic Resonance Spectroscopy (MRS) when N-acetyl aspartate (N-AA) concentration was used as an internal standard. The frequency of reports of both euphoria and dysphoria also paralleled the ascending limb of the blood and brain alcohol curve. However, peak blood alcohol levels were higher (125.67 +/- 10.91 mg/dl) and earlier (35 min postdrinking) than peak brain alcohol levels (26.25 +/- 6.38 mg/dl) detected 50 min after alcohol intake. This difference in brain and blood alcohol levels appears to be associated with the echo time (TE) parameters of the MRS. A decrease in TE from 270 msec to 50 msec resulted in a marked increase in brain alcohol detectability. MRS measures will permit analysis of regional differences in brain alcohol concentrations and covariance with behavioral, neurophysiologic and neuroendocrine concomitants of acute alcohol intoxication in man.

Hot legs.

The recent glorious weather throughout the country brings with it a recurrent and seemingly unresolveable problem.