Quantitative description of the workload associated with airway management procedures.

STUDY OBJECTIVES: To measure the workload associated with specific airway management tasks. SETTING AND INTERVENTION: Written survey instrument. PATIENTS: 166 Stanford University and 75 University of California, San Diego, anesthesia providers. MEASUREMENTS AND MAIN RESULTS: Subjects were asked to use a seven-point Likert-type scale to rate the level of perceived workload associated with different airway management tasks with respect to the physical effort, mental effort, and psychological stress they require to perform in the typical clinical setting. The 126 subjects completing questionnaires (overall 52% response rate) consisted of 43% faculty, 26% residents, 23% community practitioners, and 8% certified registered nurse-anesthetists (CRNAs). Faculty physicians generally scored lower workload measures than residents, whereas community practitioners had the highest workload scores. Overall, workload ratings were lowest for laryngeal mask airway (LMA) insertion and highest for awake fiberoptic intubation. Airway procedures performed on sleeping patients received lower workload ratings than comparable procedures performed on awake patients. Direct visualization procedures received lower workload ratings than fiberoptically guided procedures. CONCLUSIONS: These kinds of data may permit more objective consideration of the nonmonetary costs of technical anesthesia procedures. The potential clinical benefits of the use of more complex airway management techniques may be partially offset by the impact of increased workload on other clinical demands.

Morphine increases intake of beer among rats.

Rats were maintained on a daily regimen of 22 h of water deprivation followed by a 2-h opportunity to take water and sweetened alcoholic beverage containing 12% ethanol. After 30 days, the alcoholic beverage was changed to beer containing either 3% or 6% ethanol. After 20 daily sessions with beer, they received, before the next session, an injection of saline. On the next day, they received a 1.0 mg/kg injection of morphine before the session. Morphine reliably increased rats' mean intake of both kinds of beer. Subsequently, the concentration of ethanol in each groups' beer was changed. The 3% group's beer was switched to 6%, and the 6% group's to 3%. Both groups altered their mean intake of beer in an apparent attempt to maintain intakes of nearly the same amount of ethanol, but presentation of 6% beer resulted in greater intakes of ethanol.

Beer versus mixed-drink consumption at fraternity parties: a time and place for low-alcohol alternatives.

Blood alcohol concentration (BAC) measurements were taken of university students entering and exiting three fraternity parties: during each party, the rates of drinking beer and mixed drinks were monitored. The parties choose beer or mixed drinks to consume exclusively throughout the evening at no cost. Unbeknownst to the subjects, the following conditions were manipulated across successive parties: (1) at the first party (64 males and 43 females) the beer alternative had standard alcohol content (i.e., 7% alcohol by volume), (2) at the second party (70 males and 48 females) the beer was a low-alcohol beer (3% alcohol) and (3) at the third party (53 males and 41 females) the partiers were randomly assigned to a regular alcohol content conditions of beer or mixed drinks or to a low-alcohol content condition (i.e., 3% beer or mixed drinks made with 7/8-oz of distilled spirits). Since those assigned to the low-alcohol conditions did not consume more beverages than those in the regular alcohol conditions, a titration hypothesis was not supported and the exit BACs were significantly lower for partiers in the low-alcohol conditions. When females drank at the same rate as males, their exit BACs were significantly higher than those of males. Implications for DWI prevention are discussed.

Knowing when to say when: a simple assessment of alcohol impairment.

The use of writing samples as indices of alcohol impairment was explored. Students at a campus fraternity party wrote a sentence and their signatures before and after consuming alcohol (in beer and mixed drinks). Later, undergraduate and graduate students attempted to discriminate between pre- and postparty handwriting samples. The average percentage of correct discriminations of entrance and exit writing samples was 83.7% for sentences and 67.5% for signatures, and the percentage of correct discriminations increased directly with the blood alcohol concentration of the partier who gave the writing sample. When a partier's blood alcohol concentration reached 0.15, all of the judges accurately discriminated 90% or more of the sentences, and 25 of the 28 judges correctly discriminated at least 80% of the signatures. All of the judges correctly discriminated at least 90% of the 18 sentences written by partiers with a blood alcohol concentration of 0.12 or more. Implications of these findings for reducing the risk of driving while intoxicated are discussed, as well as directions for follow-up research.

Experimental analysis and extinction of self-injurious escape behavior.

Three studies are presented in which environmental correlates of self-injurious behavior were systematically examined and later used as the basis for treatment. In Study 1, 7 developmentally disabled subjects were exposed to a series of conditions designed to identify factors that maintain self-injurious behavior: attention contingent on self-injurious behavior (positive reinforcement), escape from or avoidance of demands contingent on self-injurious behaviour (negative reinforcement), alone (automatic reinforcement), and play (control). Results of a multielement design showed that each subject's self-injurious behavior occurred more frequently in the demand condition, suggesting that the behavior served an avoidance or escape function. Six of the 7 subjects participated in Study 2. During educational sessions, "escape extinction" was applied as treatment for their self-injurious behavior in a multiple baseline across subjects design. Results showed noticeable reduction or elimination of self-injurious behavior for each subject and an increase in compliance with instructions in all subjects for whom compliance data were taken. The 7th subject, whose self-injurious behavior during Study 1 occurred in response to medical demands (i.e., physical examinations), participated in Study 3. Treatment was comprised of extinction, as in Study 2, plus reinforcement for tolerance of the examination procedure, and was evaluated in a multiple baseline across settings design. Results showed that the treatment was successful in eliminating self-injurious behavior and that its effects transferred across eight new therapists and three physicians. General implications for the design, interpretation, and uses of assessment studies are discussed.

Behavioral covariation in the treatment of chronic pain.

The successful use of operant procedures to alter behaviors associated with various medical conditions suggests that such behaviors may be learned and that the principles of learning may be applied not only to treatment but also to the study of the pathogenesis of illness behavior. The present study, conducted within an ongoing neuromuscular research project, assessed the covariation of behaviors associated with chronic pain within and across behavioral and drug approaches to treatment. Problems of screaming and five other behaviors (including self-reports of pain) were measured across conditions of varying behavioral contingencies (noncontingent reinforcement vs the removal of reinforcement contingent upon screaming) and varying administration (time since medication and dosage) of Parsidol during attempts to treat the muscle pain of a 24-year-old male with a severe, chronic neuromuscular disorder diagnosed as dystonia musculorum deformans (DMD). Results indicated that: (a) pain behaviors covaried during behavioral and drug conditions even though the behavioral intervention only targeted screaming; (b) effects were greater on nontargeted behaviors during periods that followed rather than preceded drug administration; (c) in contrast to behavioral observation data, physiological measures of neuromuscular activity (EMG) did not differ across conditions. These results suggest that functional response-response relationships exist in patients as the result of their illness experience.

Case report: polysomnographic effects of thalamotomy for torsion dystonia.

We report a patient with torsion dystonia whose polysomnographic recordings revealed poor sleep and a pronounced and almost continuous type of spindle activity during non-rapid eye movement sleep. Rapid eye movement sleep was also reduced. These changes proved to be independent of medications. After a clinically successful unilateral thalamic operation, a normalization of sleep parameters and a reduction of the high amplitude sleep spindles was observed, implying that the regulation of sleep spindles and the advancement of dystonic symptoms are affected by a common mechanism.

Polysomnographic findings in dystonia musculorum deformans.

Twenty-five cases from the literature and four personal cases with dystonia musculorum deformans are described. The polysomnographic EEG findings of severely involved patients were characterized by over abundance of stage 2 sleep, with a characteristic pattern of spindle activity, increased latency to sleep, and reduced sleep efficiency. The similarities between these patients may underscore the importance of sleep spindles as a feature of the dystonia process and may be useful in the investigation of other basal ganglia disorders.