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In appropriately selected patients, PCA safely provides analgesia superior to that obtained with traditional IM prn opioid administration; however, to date, no compelling evidence shows that PCA is associated with a reduction in morbidity or a more rapid recovery. PCA is deceptively easy to prescribe; however, to use it effectively and safely requires experience, frequent patient assessment, and a skilled and knowledgeable nursing staff.
This article necessarily deals exclusively with vein and artery bypass grafts. The venous autograft remains the most versatile operation and data thus far compiled verify its reliability. We advocate normotensive, normothermic perfusion and recommend the interrupted suture technique for most anastomoses. Our guidelines for IMA grafting indicate its applicability for most anterolateral wall vessels, except for unstable emergency patients and those with a large left ventricular mass. We emphasize that the technical details are far more important than the steps involved in coronary artery operations. The operative techniques described and discussed herein are deceptively simple, and direct coronary artery surgery often appears uncomplicated to the inexperienced observerer. However, one should not attempt myocardial revascularization without the benefit of high quality cinecoronary arteriograms. An organized and experienced operative team is mandatory and, above all, the procedure itself must not be an endurance contest between surgeon and patient. Expeditious revascularization produces less morbidity and better overall results.
Placebos have been traditionally regarded as deceptive therapies and have not been understood in the broader context of social symbols and of interpersonal factors that surround the healing process itself. Although the power of inert substances to heal is well recognized, the placebo effect also influences the outcome of conventional therapies. The role of the placebo in modern medicine is poorly defined because of a lack of a common understanding of what the placebo effect is and because of the negative connotions associated with its use. The response rate to placebo varies by illness. The natural course of disease and patient or physician bias can be misinterpreted as a placebo response. In research, the placebo effect is therapeutic noise to be removed by placebo-controlled trials. Few studies are designed to measure the placebo response rate directly. Placebos are a reminder of how little is known about mind-body interaction. The placebo effect may be one of the most versatile and underused therapeutic tools at the disposal of physicians.
Short-term variations in heavy metals concentrations in Antarctic snow have been investigated by analysing 13 metals (Al, V, Cr, Mn, Co, Cu, Zn, Ag, Cd, Ba, Pb, Bi and U) in a series of ultraclean samples collected from two snow pits in Coats Land in the Atlantic sector of Antarctica. The samples covered a approximately 70 years time period from the 1920s to 1990. They were analysed by inductively coupled plasma sector field mass spectrometry and graphite furnace atomic absorption spectrometry. The results conclusively show that there is a pronounced short-term (intra- and inter-annual) variability of heavy metal in Antarctic snow, with the highest concentrations being up to 100 times higher than the lowest ones for metal such as Cr, Mn, Pb and U. Contributions from the different possible natural and anthropogenic sources are found to be extremely variable. This is especially due to the large variability in the transport patterns of heavy metals from Southern America, Southern Africa and Australia to the Antarctic continent. Inputs from several volcanic events were identified in our samples from non-seasalt sulfate concentrations profiles. The only ones that gave clear signals for heavy metals were eruptions at Deception Island the proximity of which allowed for tropospheric transport to Coats Land.
Any analysis of spontaneous AER data must consider the many biases inherent in the observation and reporting of vaccine adverse events. The absence of a clear probability structure requires statistical procedures to be used in a spirit of exploratory description rather than definitive confirmation. The extent of such descriptions should be temperate, without the implication that they extend to parent populations. It is important to recognize the presence of overdispersion in selecting methods and constructing models. Important stochastic or systematic features of the data may always be unknown. Our attempts to delineate what constitutes an AER have not eliminated all the fuzziness in its definition. Some count every event in a report as a separate AER. Besides confusing the role of event and report, this introduces a complex correlational structure, since multiple event descriptions received in a single report can hardly be considered independent. The many events described by one reporter would then become inordinately weighted. The alternative is to record an AER once, regardless of how many event descriptions it includes. As a practical compromise, many regard the simultaneous submission of several report forms by one reporter as a single AER, and the next submission by that reporter as another AER. This method is reasonable when reporters submit AERs very infrequently. When individual reporters make frequent reports, it becomes difficult to justify the inconsistency of counting multiple events as a single AER when they are submitted together, but as separate AERs when they are reported at different times. While either choice is imperfect, the latter approach is currently used by the USDA and its licensed manufacturers in developing a mandatory postmarketing surveillance system for veterinary immunobiologicals in the United States. Under the proposed system, summaries of an estimated 10,000 AERs received annually by the manufacturers would be submitted to the USDA. In quantitative summaries, AERs received from lay consumers are usually weighted equally with those received from veterinary health professionals, although arguments have been advanced for separate classifications. The emphasis on AER rate estimation differentiates the surveillance of veterinary vaccines by the USDA CVB from the surveillance of veterinary drugs as practiced by the Food and Drug Administration (FDA) Center for Veterinary Medicine (CVM). The FDA CVM does, in fact, perform a retrodictive causality assessment for individual AERs (Parkhie et al., 1995). This distinction reflects the differences between vaccines and drugs, as well as the difference in regulatory philosophy between the FDA and the USDA. The modified Kramer algorithm (Kramer et al., 1979) used by the FDA relies on features more appropriate to drug therapy than vaccination, such as an ongoing treatment regimen which allows evaluation of the response to dechallenge and rechallenge. In tracking AERs, the FDA has emphasized the inclusion of clinical manifestations on labels and inserts, while the USDA has been reluctant to have such information appear in product literature or to use postmarketing data for this purpose. The potential for the misuse of spontaneous AER data is great. Disinformation is likely when the nature of this type of data is misunderstood and inappropriate analytical methods blindly employed. A greater danger lies in the glib transformation of AER data into something else entirely. Since approval before publication is not required, advertisements for veterinary vaccines appear with claims such as "over 3 million doses, 99.9905% satisfaction rating," or "11,500,000 doses, 99.98% reaction free." These claims, presumably based on spontaneous AERs, are almost fraudulent in their deceptiveness. Are we to suppose that 11.5 million vaccinations were observed for reactions? In comparing the two advertisements, we find the second presumed AER rate is double the first. (ABSTRACT TRU
An illustrative case of epithelioid sarcoma in the hand of a young man, causing considerable diagnostic problems, is presented. Epithelioid sarcoma is a malignant lesion, first described by Enzinger in 1970. Although epithelioid sarcoma is the third commonest soft tissue sarcoma in the upper extremity (Bryan, 1974) it still causes confusion in differential diagnosis, both to the surgeon and to the pathologist. Because of its deceptively harmless appearance during the initial period and its clinical and microscopical similarity to an inflammatory process, it is often mistaken for a benign lesion. The purpose of our paper is to draw attention to this rare malignant tumour. This case illustrates a course similar to those described previously. (Enzinger, 1970: Santiago, 1972).
Listeria monocytogenes, a food-borne bacterial pathogen, enters mammalian cells by inducing its own phagocytosis. The listerial protein internalin (InlA) mediates bacterial adhesion and invasion of epithelial cells in the human intestine through specific interaction with its host cell receptor E-cadherin. We present the crystal structures of the functional domain of InlA alone and in a complex with the extracellular, N-terminal domain of human E-cadherin (hEC1). The leucine rich repeat (LRR) domain of InlA surrounds and specifically recognizes hEC1. Individual interactions were probed by mutagenesis and analytical ultracentrifugation. These include Pro16 of hEC1, a major determinant for human susceptibility to L. monocytogenes infection that is essential for intermolecular recognition. Our studies reveal the structural basis for host tro-pism of this bacterium and the molecular deception L. monocytogenes employs to exploit the E-cadherin system.
A lack of scientific data remains the principal obstacle to regulating cigarette toxicity. In particular, there is an immediate need to improve our understanding of the interaction between smoking behaviour and product design, and its influence on cigarette deliveries. This article reviews internal tobacco industry documents on smoking behaviour research undertaken by Imperial Tobacco Limited (ITL) and British-American Tobacco (BAT). BAT documents indicate that smokers vary their puffing behaviour to regulate nicotine levels and compensate for low-yield cigarettes by smoking them more intensely. BAT research also shows that the tar and nicotine delivered to smokers is substantially greater than the machine-smoked yields reported to consumers and regulators. Internal documents describe a strategy to maximise this discrepancy through product design. In particular, BAT developed elastic cigarettes that produced low yields under standard testing protocols, whereas in consumers' hands they elicited more intensive smoking and provided higher concentrations of tar and nicotine to smokers. Documents also show that BAT pursued this product strategy despite the health risks to consumers and ethical concerns raised by senior scientists, and paired it with an equally successful marketing campaign that promoted these cigarettes as low-tar alternatives for health-concerned smokers. Overall, the documents seem to reveal a product strategy intended to exploit the limitations of the testing protocols and to intentionally conceal from consumers and regulators the potential toxicity of BAT products revealed by BAT's own research. Tobacco industry research underscores the serious limitations of the current cigarette testing protocols and the documents describe deceptive business practices that remain in place.
BACKGROUND: Treatment interference, the disruption or self-removal of technologic devices, is a primary reason for application of physical restraints in acute and critical care settings. The processes of care surrounding treatment interference and the prevention of device disruption have not been comprehensively analyzed. OBJECTIVES: To describe the processes used by critical care nurses to prevent treatment interference in critically ill older adults. METHODS: Participant observation field research was conducted in medical and intermediate medical intensive care units. Data were analyzed by using the constant comparative method and event analysis. RESULTS: Maintaining technologic devices is almost exclusively a nursing responsibility and involves the skillful assessment of patient awareness and trustworthiness and interpretation of behaviors. Critical care nurses are most protective of those devices for which accidental removal is perceived as life threatening: endotracheal tubes, arterial catheters, and central venous catheters. Nurses assess patients' cognitive status, mobility, strength, and trustworthiness, as well as device considerations such as replacement difficulty and device necessity. In addition to verbal strategies, such as explaining, nurses use distraction, deception, comfort measures, watchful family members, physical restraints, and sedation to prevent treatment interference. CONCLUSION: This analysis considers the social context of the intensive care unit, including roles and the human-technology interaction. It illustrates the tremendous responsibility that nurses assume in maintaining technologic devices. Next steps in research and policy development are also considered.
INTRODUCTION: Profound hypokalemic conditions resulting from cisplatin therapy have been known to produce hypokalemic paralysis in rare cases. We describe such a case of cisplatin-induced hypokalemic paralysis. CASE SUMMARY: A 15-year-old Persian girl with ovarian dysgerminoma presented with severe generalized weakness and paraplegia 1 week after the fourth course of cisplatin-based chemotherapy. On physical examination, there was symmetric flaccid paralysis and areflexia in all of the extremities and particularly in the lower limbs. Her serum potassium concentration was 1.7 mmol/L. Metastatic disease was excluded by a comprehensive systemic evaluation. Complete clinical and paraclinical recovery was achieved after short-term administration of potassium supplement. DISCUSSION: Adverse drug reactions are common with cisplatin, but the drug is only rarely associated with hypokalemic paralysis. Based on the Naranjo causality algorithm, an objective assessment revealed cisplatin to be a probable cause of hypokalemic paralysis in this case. This adverse drug event--whether isolated or secondary to hypomagnesemia--may be deceptive, leading to a fatal mistake in the oncology setting, and should therefore be precisely differentiated from cancer-related complications. CONCLUSIONS: This case suggests that cisplatin should be added to the list of agents causing hypokalemic paralysis. Regular serum electrolyte measurement, the early detection of cation deficiency, and appropriate replacement of cations are all recommended.
Charles A. Tyrrell was a masseur who obtained his MD degree at age 57 in 1900. In addition to his private practice he was editor of several pseudomedical magazines. He also owned two proprietary ventures that he conducted on a mail order basis. One of these involved production and sale of the The Ideal Sight Restorer, a U-shaped device consisting of a rubber bulb at the base, from which on both sides arose an arm of rubber tubing capped by an ivory eye piece. The eye cups were applied to the closed eyelids and the intermittent suction produced by squeezing the rubber bulb was claimed to provide a form of ocular massage capable of curing serious eye diseases (eg. cataract and glaucoma), as well as doing away with the need for spectacles. Although his fraudulent activities and deceptive advertising practices were described on several occasions in the Journal of the American Medical Association, Dr. Tyrrell persisted in his enterprises until he died in 1918.
Overwhelming infections caused by encapsulated bacteria, salmonella spp. and Plasmodium falciparum (in malarious areas) are an important cause of morbidity and death in patients with sickle cell disease. Bacterial infections afflicting these patients include fulminant meningitis and septicaemia caused by Str. pneumoniae and H. influenzae type b, and non-typhoid salmonellosis. Children less than five years of age are at greatest risk for meningitis and septicaemia, while salmonella osteomyelitis is probably common to all age groups. The most important contributing factors to this increased susceptibility to encapsulated bacteria are: a state of functional asplenia, an opsonophagocytic defect due to an abnormality of the alternative complement pathway, and a deficiency of specific circulating antibodies. Devitalisation of gut and bone due to repetitive vaso-occlusive crises, saturation of the macrophage system with red cell breakdown products of chronic haemolysis, and underlying splenic and hepatic dysfunction all predispose to salmonella infections. Seventy per cent of septicaemias and meningitis among under-fives with sickle cell disease is caused by Str. pneumoniae. Septicaemia frequently presents with sudden fever, few prodromal features, and a deceptive appearance of well-being, followed within hours by rapid relentless progression to shock and death. Adrenal haemorrhage is common, and mortality can be as high as 50 per cent, unless intravenous antibiotic, with or without steroid therapy, is promptly initiated. The clinical presentation of bacterial meningitis, its management and mortality follow the normal patterns, but recurrent meningitis and cerebrovascular morbidity are common in patients with sickle cell disease. An acute pulmonary involvement, indistinguishable from bacterial pneumonia (the 'chest syndrome') is the commonest single complication of sickle cell disease at any age. Str. pneumoniae is responsible for about half of the episodes. The protective values of the pneumococcal vaccine and long-term penicillin prophylaxis remain to be established in sickle cell disease. Over 70 per cent of haematogenous osteomyelitis in sickle cell disease is caused by salmonellae. The distinction from vaso-occlusive bone crisis is often difficult, but the presence of multiple, often symmetrical bone involvement, diaphyseal fissuring and involucrum should suggest osteomyelitis rather than bone infarction. Chloramphenicol remains the drug of choice and often has to be given in high doses for up to six weeks. The role of surgery is limited by the presence of multiple bone involvement and the known anaesthetic risks in this group.(ABSTRACT TRUNCATED AT 400 WORDS)
Patients with Munchausen's syndrome--a syndrome characterized by the intentional production of physical symptoms to gain the sick role-present a variety of challenges to health care providers. Their treaters quickly become frustrated by their demanding interpersonal styles, by deception and manipulation, and by multiple unrevealing diagnostic procedures. These difficulties can lead to poor outcomes for patients and staff alike. We present the case of a young woman whose presentation and subsequent evaluation led to significant distress among the hospital staff responsible for her care, and discuss the epidemiology, diagnosis, and management of patients with Munchausen's syndrome. The most important role of the psychiatrist in the treatment of Munchausen's syndrome is to help the primary treatment team manage the patient in the safest and most appropriate way. Such management includes avoiding unnecessary procedures, preventing further self-harm, and avoiding angry or threatening interactions with the patient. The prognosis for patients with Munchausen's syndrome appears to be poor; flexible and creative approaches that emphasize consistency of care and regular outpatient psychiatric treatment have had the greatest success.
Two forms of medical dissimulation-factitious disorder and factitious disorder by proxy-present enormous challenges to clinicians accustomed to receiving valid symptom reports from their patients. The consequences of such "disease forgery" are heightened when a patient simultaneously engages in both forms of deception. We discuss a 34-year-old nurse who simulated or induced a panoply of physical and psychological ailments in both herself and her daughter. The staff's insistence on access to outside information sources proved indispensible in establishing both diagnoses, facilitating ongoing treatment for the patient and ensuring appropriate protection of the child.
We compared effects of 0.3 Hz with 0.01 Hz settings of the high pass amplifier filter, and baseline-to-peak with peak-to-peak measurements of the P300 event-related potential. The key dependent variable of interest was intraindividual rate of accuracy in discrimination of oddball vs. frequent evoked P300 responses, in various paradigms. In Experiment 1 (a lab deception paradigm), we found that the combination of the 0.3 Hz filter setting and the peak-peak measurement of P300 correctly diagnosed oddball vs. frequent in 26 of 26 (100%) cases. This parameter combination outperformed all others. In a second, more field-like experiment (in that the participant knew that the experimenter was blind to ground truth), the peak-peak index again outperformed the base-peak index. It was also observed that the pre-stimulus EEG baseline variability exceeded that of the negative peak (NEG) following P300, i.e. the peak to which the peak-peak index refers P300 for computation. We also observed that the base-peak measurement of P300 is uncorrelated with NEG, and that NEG, seen only in 0.3 Hz channels, correlates highly (-0.67) with the duration of recovery of P300 to the pre-stimulus baseline EEG level as seen in the 0.01-Hz channel. However, in a final experiment using two simple visual and auditory oddball tasks, the base-peak measurement was as diagnostic as the peak-peak measurement.
topographies of contingent negative variation (CNV) were recorded in a paradigm of delayed response with feedback for three kinds of faces: familiar, strange and target. Subjects made responses to the faces according to whether the faces were familiar or not, but also, gave deliberately deceptive responses to target faces to 'cheat the computer'. Subjects were told that the computer could judge whether they were being honest or not. For each trial of the experiment, if subjects cheated the computer successfully and their responses were judged as honest and they were given a reward, otherwise they received a penalty. In this simulated lie detection test, CNV exhibited more negative shifts for target than those for non-target (familiar and strange). These differences could be accounted for by subjects' motivation and uncertainty about passing the test. With the results of further paired t-tests between target and non-target faces at each electrode, CNV was demonstrated as a reliable indicator for lie detection. In addition, vector length was used to capture global CNV information and was found to be a very good indicator, even better than the CNV information at the individual electrode sites.
Locating and capturing food are suggested as significant selection pressures for the evolution of various cognitive abilities in mammals and birds. The hypothesis is proposed that aspects of food procuring behaviour should be strongly indicative of particular cognitive abilities.Experimental data concerning higher mental abilities in mammals and birds are reviewed. These data deal with self-recognition studies, rule-learning experiments, number concept, deceptive abilities, tool-use and observational learning.A Darwinian approach reveals: (1) the adaptiveness of particular abilities for particular niches, (2) that in complex foraging environments, increases in foraging efficiencies in animals should result from the evolution of particular cognitive abilities, (3) that phenomena such as convergent mental evolution should be expected to have taken place across taxonomic groups for species exploiting similar niches, (4) that divergence in mental ability should also have taken place where related species have exploited dissimilar niches.Experimental data of higher mental abilities in animals concur with a Darwinian explanation for the distribution of these cognitive abilities and no anomalies have been found.There are, as a consequence, significant implications for the welfare of animals subject to training when training methodology gives little or no consideration to the various mental abilities of species.
Flowers of the orchid genus Ophrys resemble female insects, and thereby sexually deceive, attract and are pollinated by male insects. Floral bouquet is thought to play a major role in this sexual mimicry, although the search for functional odour components has been something of a chemical ecologist's Holy Grail. Two new papers unravel the exquisite intricacy of the chemical deception by the orchid.