Impact of azole antifungal treatment on outcome in acute invasive fungal rhinosinusitis with orbitocranial involvement: a surgical perspective.

PURPOSE: To provide real-life data on azole treatment outcomes and the role of surgery in the current management of invasive fungal rhinosinusitis complicated by orbitocranial fungal infection (OCFI). METHODS: Data was collected retrospectively from a chart review from four participating centers and a systematic literature review. The study group included patients with OCFI treated with azole antifungals. The control cases were treated with other antifungal agents. The cranial and orbital involvement degree was staged based on the imaging. The extent of the surgical resection was also classified to allow for inter-group comparison. RESULTS: There were 125 patients in the azole-treated group and 153 in the control group. Among the patients with OCFI cranial extension, 23% were operated on in the azole-treated group and 18% in the control group. However, meninges and brain resection were performed only in the controls (11% of patients) and never in the azole antifungals group. Orbital involvement required surgery in 26% of azole-treated cases and 39% of controls. Despite a more aggressive cranial involvement, azole-treated patients' mortality was significantly lower than in controls, with an OCFI-specific mortality rate of 21% vs. 52%. A similar, though not statistically significant, trend was found for the extent of the orbital disease and surgery. CONCLUSION: Despite less aggressive surgical intervention for cranial involvement, OCFI patients treated with azoles had a higher survival rate. This finding suggests we may improve morbidity with a more conservative surgical approach in conjunction with azole treatment. The same trend is emerging for orbital involvement.

Reconstructing silenced biographical issues through feeling-facts.

The undiscussible within daily discourse can have intentional and unintentional forms. The first occurs when someone intentionally gears the discourse so that it will not reveal certain facts which have happened (such as being an abused child, or a perpetrator during the Holocaust). We assume that even if they were difficult to reconstruct as part of one's biography, these facts could be verified externally (not only through the feelings of the victim). In the first part of the paper, we analyze the paradoxical nature of such discourse, and show how difficult it is to work through intentional undiscussibility. In the second part, we discuss what happens when the undiscussible facts can not be verified, meaning that there is doubt if events have taken place. By presenting a case study of a German woman who tried to construct a biography in face of certain undiscussibility in her family, we discuss the different social reactions evolving in such reconstruction of feeling-facts. We thereby hope to confront the psychoanalytic approach to narrative analysis with the constructivist hermeneutic one.

Causal attribution by patients, their spouses and the physicians in relation to patient outcome after a first myocardial infarction: subjective and objective outcome.

Ninety-eight men <60 years of age with a first myocardial infarction (MI), their spouses and treating physicians were interviewed at the patients' hospitalization. The aim was to determine the three groups' perception of the causes of the patients' MI, and the importance of those for patient outcome 6 months after the MI. Patients and spouses agreed in general and attributed the MI to similar causes, while the patients and physicians had a lower level of agreement. The patients tended towards the more 'social' and 'psychological' items, while the physicians relied on medical information. The causal attributions of each of the groups were more important than background variables when subjective and objective outcome measures were estimated.

Determinants of lifestyle changes after a first myocardial infarction.

Ninety-eight men aged <60 years with a first myocardial infarction were followed for 6 months. The aim was to characterize patients who succeeded in changing their lifestyles by modifying risk factors and to correlate them to subjective and objective outcome. We focused on the interplay between the patient's causal attribution of the infarction and compared this with the influence of background factors. The patient attribution most often predicted positive objective outcome and subjective functioning. This study shows that background factors are of prognostic value, but the patient's attribution and his own ideas about coping add information on the outcome of the rehabilitation as evaluated by more specific outcome measures.

Quality of life in normotensives compared to hypertensive men treated with isradipine or methyldopa as monotherapy or in combination with captopril: the LOMIR-MCT-IL study.

Quality of life (QOL) measures were assessed in a multi-center, double-blind, case-controlled trial of 1 year's duration. A total of 368 hypertensive male patients were randomly assigned to monotherapies of either isradipine, methyldopa or placebo. If normotension was not achieved, captopril was added. QOL assessments in the hypertensives and in 155 normotensives included a self-structured scale to measure the subjective perception of QOL, the severity, desirability and controllability of recent critical life events, semantic memory, physical dysfunction, sleep disorders, sexual difficulties, depression and work-related stress. The overall withdrawal rate during the trial was 19%, mainly due to lack of efficacy and adverse experiences. At baseline, and at the end of the trial, the normotensives as compared to hypertensive patients, had significantly better scores in most QOL measures. Patients treated with the combination of isradipine and captopril reported more favorable changes in the subjective measure of QOL (P < 0.03) and in semantic memory (P < 0.001) than patients treated with any of the monotherapies or with methyldopa in combination with captopril. There were no statistically significant differences among treatments for changes of other indices of QOL. In most QOL measurements, normotensives rated better then hypertensives. Patients treated on long-term therapy with the combination of isradipine and captopril showed improvement in self-structured QOL measures and semantic memory, compared to patients treated either with methyldopa or placebo.

Positive-negative evaluation (PNE) scale: a new dimension of the subjective domains of quality of life measure.

A new subjective measure of Quality of Life (QOL), the Subjective Domains of Quality of Life Measure (SDQLM), developed by Bar-On and Amir, is a qualitative and quantitative self-structured method shown to have internal reliability and construct validity compared with quantitative pre-structured measures and evaluations by spouses and physicians. To earlier analyses on a sample of male hypertensives and normotensives, we added a content analysis which is reported here, in which the elicited QOL domains were assessed according to whether the respondent evaluated his QOL domains as positive, negative or neutral/mixed. The content analysis showed that respondents may be classified on a continuous scale from stable positive to stable negative evaluations of their QOL domains (before-after measurement). The scale was assembled by ordinal ranging of the answers at two points in time (one year apart). A respondent who evaluated his domain as positive at both such points was ranked highest on the scale, negative at both points the lowest and the two remaining possibilities constituted the middle range. Analysis of the data showed that the SDQLM with this additional content analysis correlated significantly with depression scale scores, sexual functioning, physical fitness, work satisfaction, quality of sleep, hardiness, education and age, as well as individual self-rating of QOL. The subjective measure based on self-elicited domains with PNE was shown to be an important construct compared with pre-structured measures of QOL.

Long-term prognosis of low-risk, post-MI patients: the importance of subjective perception of disease.

In 1980, 87 male patients (age range 34-60 years), hospitalized after their first myocardial infarction (MI), were asked why they believed they got the infarct and what would help them cope with it. In a multiple regression analysis, their causal attributions accounted for 15% of the explained variance in their physical, sexual, social and work functioning after 6 and 18 months, their level of education accounted for 25% and the severity of their infarct for 10%. This result was replicated in a cross-cultural study. A follow-up study shows that 12 years after the MI, the patients' initial causal attributions still accounted for part of their rehabilitation and life expectancy. Of the original 87, 23 had died between 1980-1992 from cardiac causes and 50 male patients were located and re-interviewed at the Soroka ICCU, in 1992. This suggests a very low-risk post-MI sample. The only risk-factor, accounting for the difference between the surviving and the deceased patients, was the initial obesity of the latter. The functional capacity outcome of the survivors was accounted for by their age (24%) and initial causal attributions (26%). Also the initial causal attributions (5%) still accounted for the subjective perception of functioning among the survivors. These results suggest that the initial causal attributions may have created positive or negative self-fulfilling prophecies which had long-term consequences, especially in a low-risk, post-MI population, in which risk factors hardly effected long-term prognosis.

Does the combination of ACE inhibitor and calcium antagonist control hypertension and improve quality of life? The LOMIR-MCT-IL study experience.

The LOMIR-MCT-IL study was designed to investigate the effects of different antihypertensive drugs on the quality of life (QoL) of men with mild-to-moderate hypertension. This report focuses on the subgroup of patients treated with the combination of the angiotensin converting enzyme (ACE) inhibitor captopril and the calcium antagonist isradipine. The LOMIR-MCT-IL was a double-blind multicenter, placebo-controlled, one-year follow-up study in which 368 hypertensive men, aged 40-65 years, were randomly allocated to receive either isradipine, methyldopa or placebo at three titration levels. If diastolic blood pressure (DBP) remained > 90 mmHg, captopril was added openly. The QoL evaluation introduced a qualitative self-structured subjective measure in addition to prestructured quantitative measures. The quality of life was assessed at baseline, after 6 months and at the end of the study. Methyldopa normalized DBP in 50% of patients when given as monotherapy and an additional 34% with the addition of captopril (84% total). With placebo, 36% normalized DBP and another 39% on addition of captopril (75% total) and, with isradipine, 64% normalized DBP and an additional 26% with added captopril (90% total). Assessment of QoL showed that both the placebo and the isradipine+captopril groups showed significant improvement in semantic memory after antihypertensive treatment. The isradipine+captopril group showed a clear tendency towards lower depression scores, better quality of sleep, better subjective evaluation of QoL and a more positive evaluation of personal life events in comparison to the other groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Reexamining the quality of life of hypertensive patients. A new self-structured measure.

This study included the introduction of a new, qualitative, self-structured measure of quality of life (QOL) after meta-analysis had shown that prestructured quantitative measures yielded insignificant results. This study compared the pre- and post-treatment evaluations of 268 men with mild hypertension, aged 40 to 65 years, who were randomly allocated to three treatment groups (methyldopa, isradipine, and placebo) with that of 155 normotensive subjects. It was found that the study participants defined QOL qualitatively differently from the way it was defined by physicians. Normotensive subjects showed a better QOL status in most prestructured measures whereas the patients taking isradipine showed better results on evaluation of the current level of their self-defined domains. The combined quantitative and qualitative approach to measuring QOL may help to clarify this important aspect of medical research, both conceptually and methodologically.

The relationship between causal attribution and rehabilitation in patients after their first myocardial infarction. A cross cultural study.

Full rehabilitation of a patient following myocardial infarction (MI) involves resumption of work and the restoration of quality of life. Two groups of patients (87 Israeli and 98 Swedish) were admitted to the CCU and followed up after their first MI. To evaluate the patients' own perception of events ('causal attribution theory'), sequential interviews were scheduled. Physical risk factors correlated poorly with rehabilitation outcome at 6 months. However, two patient clusters were pinpointed according to the patients' subjective explanation of the factors contributing to their MI. These 'causal attribution scores' had a predictive value, independent of culture, age, education, disease severity and depression. It is therefore concluded that evaluation of patient perception may assist in planning intervention for high risk psychologically debilitated patients, and thus favourably enhance their rehabilitation outcome.

Children of perpetrators of the Holocaust: working through one's own moral self.

The present study tests stages in the ability of some children of perpetrators of the Holocaust in Germany to work through emotional and moral issues regarding their fathers' perpetrating role during the Third Reich. The following questions are raised: Did they try to distance themselves by playing down the Holocaust and the moral meaning of their fathers' involvement in it? Did any children try to work through issues relating to their fathers' impaired morality? Did any children successfully reach the stage of integration? Fifty-seven persons were contacted by the author between September 1985 and June 1987, of whom 9 refused to be interviewed. Thirty interviewees were children whose fathers had taken an active part in the implementation of the euthanasia program, in the Einsatzgruppen, in the extermination camps or in related activities. The fathers of the remaining 18 interviewees were affiliated with SS units at times and in places where the atrocities took place, but what they actually did or did not do was not proven. In general, there was an almost total silencing of accounts of the extermination process in homes and schools. Acknowledgment, if any, of the atrocities appeared through accounts of trials and friends and in newspapers or, only recently, through the children's active searching. When children who learned what their father-perpetrator had done during the war also came to understand the moral implications, they usually experienced severe emotional conflict, which they had to confront on their own. Only a few succeeded in walking across a very narrow bridge to a working through of the related issues and emotions. The implications of the present analysis for future research on the prevention and outcomes of genocide are discussed.

R.D. Laing: creative analyst or false prophet?

One of R.D. Laing's recent books 'Politics of experience' is discussed from a critical point of view. In his first books Laing defined the schizophrenic as a sensitive person who was squeezed into the 'double-bind' messages of his intimates. In the book discussed here, Laing views the schizoid experience as a symbol of health. He suggests that everyone use this schizoid experience as a means of rediscovering his lost 'real' self by divesting oneself of society and its evils. This change in Laing's writings is viewed here critically: instead of urging us to find a way to change society, as questionable as it may be, he suggests we keep the 'status-quo' and find a 'solution' for ourselves. The article lastly deals with Laing's argument in the context of the Kibbutz. The question why so many youngsters in the Kibbutz are influenced by Laing's point of view, is discussed.