SENSORY DEPRIVATION ON AN EYE SERVICE—Its Significance and Management

In a detailed investigation of 174 patients who wore patches over both eyes after ocular operations, some 35 per cent were observed to have one or more symptoms of mental aberrations. In a smaller group who had repair of retinal detachment and therefore had to wear eye patches for a much longer time, the incidence of mental symptoms was 100 per cent. A common symptom called “noncompliance” was found which has hitherto been regarded simply as lack of cooperation by the patient.The incidence of postoperative complications was considerably higher in patients who had symptoms of mental disturbance than in those who did not.In these circumstances it would appear worth while to prepare the patient mentally for operation, to give him assurances beforehand, and to take measures to reduce his “isolation” while he has to wear patches.     

From Chattel to Consenter: Adolescents and Informed Consent: 2009 Grover Powers Lecture

Angela Holder was to give the Grover Powers Memorial Lecture at the weekly Grand Rounds conducted by the Yale Department of Pediatrics on Wednesday, May 27, 2009, but unfortunately, she died one month earlier, on April 22, leaving behind her prepared address, “From Chattel to Consenter: Adolescents and Informed Consent,” which she had regarded as the pinnacle of a remarkable career, much of it spent at Yale. As the Grover Powers honoree, the department’s highest honor, Ms. Holder was only the fourth woman of 46 recipients and the first who was not a physician. On the date scheduled for her address, tributes were presented by her son, John Holder, and her longtime colleague, Dr. Robert Levine, co-founder of Yale’s Interdisciplinary Bioethics Center. Their comments follow Angela Holder’s completed but undelivered Grover Powers address. — Myron Genel, MD, Professor Emeritus of PediatricsUnder the common law of England and in the early years of the United States, a minor (defined as anyone under 21) was a chattel or possession of his or her father [1-4]. A father had the right to sue a physician who treated his son or daughter perfectly properly but without the father’s permission because such an intervention contravened the father’s right to control the child. Beginning in the early years of the 20th century, by the end of World War II and into the 1950s, the notion that a 16-year-old was a legally different entity from a 6-year-old gradually became law in all states.¹ The first hospital unit for adolescents was created in 1951 at Boston Children’s Hospital, and the concept of “adolescent medicine” was born [5].As the law in this area currently defines “adolescent,” we are discussing someone 14 or older who may be (1) living at home with his or her parents; (2) Not living at home but still dependent on parents (i.e., a 16-year-old college freshman living in a dorm); (3) an “emancipated minor” who is married, emancipated by a court order, or a parent (other than in North Carolina), living away from home and self-supporting; or (4) a runaway or throwaway. At any time in this country, there are about 200,000 adolescents living on the streets with no adult supervision or involvement [6].Regardless of the age of the patient, informed consent consists of five elements: (1) An explanation of what will happen; (2) explanation of the risks; (3) explanation of the projected benefits; (4) alternatives (including doing nothing); and (5) why the physician thinks it should be done, which I interpret as a right to know one’s diagnosis. While the doctrine of “therapeutic privilege” means that in rare cases a physician may withhold some information from an adult patient if she or he believes the patient cannot “deal with the information,” there can never be any withholding of information from an adolescent. If the patient can’t deal with the information to be presented, then parents have to be involved and give permission to treat the adolescent.In some cases, when parents are involved, they do not want their adolescent to know his or her diagnosis. While this is usually not a good idea, it normally falls under the rubric of “professional judgment,” and the physician has every right to decide to follow the parents’ instruction if she agrees with it. In some situations, however, the adolescent must be told what his or her illness is, whether parents like it or not. For example, if a teenager is HIV positive, he or she must be told, must be instructed about safe sex, and must be asked to divulge the names of any sex partners. Parents who say, “Oh, no, don’t tell him, he would never do anything like that, so it doesn’t matter,” should be tactfully but firmly led to accept the fact that he may well have and if he hasn’t yet, he will certainly in the future. There has been at least one successful malpractice case in which the physician did not, at the request of the parents, tell his adolescent patient that he had HIV. The patient’s girlfriend caught it and sued the physician [7]. I feel sure there are many more cases like this that have been quietly settled and no one will ever hear about.Usually, questions about adolescents giving consent to treatments that their parents don’t know about involve outpatient treatment. In the first place, hospital administrators, who are much more interested in getting paid than they are in advancing the rights of autonomous adolescents, are not going to admit for a non-emergency problem a minor whose parent has not made some sort of financial arrangement to pay for it. Secondly, in most households, if Little Herman doesn’t show up for supper or throughout the evening, someone notices and a few telephone calls later discovers that Little Herman is in the hospital.     

Economic Aspects of “Whiplash” Injury

The term “whiplash,” used to describe a neck injury received in an automobile accident, has no foundation in medical science to support the complaints of persons suing for damages. The term is gaining unwarranted popularity as a term describing an injury, even though there are no clinical or pathological findings to support it.“Whiplash” cases today account for an estimated 30 per cent of all injuries in automobile accidents. Direct compensation for damages paid to persons injured in automobile accidents in the United States in 1961 amounted to approximately one billion, seven hundred million dollars. It has been estimated that five hundred and eighty million dollars of that amount was paid in compensation on allegation of neck injuries.     

INITIAL CARE OF ACUTE BACK INJURIES

The mechanism of injury to the back should be obtained with the utmost accuracy and set down in the history as a separate paragraph under that heading. This is usually best obtained by questioning and requestioning the patient during the course of the examination. A history of any previous back affections should also be obtained at the first visit.The detailed examination of the back is not complete without a general physical examination.X-ray studies should be done immediately in all cases in which the injury has been caused by direct violence or forceful indirect violence (as in “jackknife” injury).Terms such as “disc disease,” “ruptured intervertebral disc” and various others that convey a similar meaning should not be used as the initial diagnosis and should be withheld until such a diagnosis is definitely established.The plan of treatment may include a period in hospital or of rest at home, or it may be carried out with the patient ambulatory. Corsets and braces should be prescribed only when they are to serve a definite function and the same can be said of physiotherapy.     

A Familiar(ity) Problem: Assessing the Impact of Prerequisites and Content Familiarity on Student Learning

Prerequisites are embedded in most STEM curricula. However, the assumption that the content presented in these courses will improve learning in later courses has not been verified. Because a direct comparison of performance between students with and without required prerequisites is logistically difficult to arrange in a randomized fashion, we developed a novel familiarity scale, and used this to determine whether concepts introduced in a prerequisite course improved student learning in a later course (in two biology disciplines). Exam questions in the latter courses were classified into three categories, based on the degree to which the tested concept had been taught in the prerequisite course. If content familiarity mattered, it would be expected that exam scores on topics covered in the prerequisite would be higher than scores on novel topics. We found this to be partially true for “Very Familiar” questions (concepts covered in depth in the prerequisite). However, scores for concepts only briefly discussed in the prerequisite (“Familiar”) were indistinguishable from performance on topics that were “Not Familiar” (concepts only taught in the later course). These results imply that merely “covering” topics in a prerequisite course does not result in improved future performance, and that some topics may be able to removed from a course thereby freeing up class time. Our results may therefore support the implementation of student-centered teaching methods such as active learning, as the time-intensive nature of active learning has been cited as a barrier to its adoption. In addition, we propose that our familiarity system could be broadly utilized to aid in the assessment of the effectiveness of prerequisites.     

ELBOW AND WRIST INJURIES IN SPORTS

Any disabling injury of the elbow or wrist should be studied roentgenographically for evidence of fracture which may not be otherwise evident but which may cause permanent disability unless the joint is immobilized for healing.“Tennis elbow” may be treated with physical therapy and analgesic injection but may require splinting or tendon stripping. Elbow sprain can occur in the growing epiphysis but is rare in adults. A jarring fall on the hand may cause fracture or dislocation at the elbow.Full extension of the joint should be restored gradually by active exercise rather than passive or forcible stretching.Fracture at the head of the radius may cause joint hemorrhage with severe pain which can be relieved by aspiration. A displacing fracture at the head of the radius requires removal of the head to prevent arthritic changes. Myositis ossificans contraindicates operation until after it has cleared.Healing of wrist fractures may be facilitated by exercise of the shoulder and elbow while the wrist is still in a cast. Fractures of the navicular bone are difficult to detect even roentgenographically and splinting may have to be done on clinical evidence alone.     

THE THORNY CHILD

Too many physicians—and parents—hide behind the overworked excuse that “Johnny is just going through a stage.” If the remark is inaccurate a great disservice can be done to both mother and child, and ultimately to society. The well oriented physician would no more permit a young mother to unwittingly feel “guilty” because her two-year-old “little stinker” behaves like a two-year-old little stinker than he would casually reassure when a ten-year-old behaves as though he were two.Actually much of the unpleasant behavior of children is quite normal. If physicians would help all young mothers to recognize this without dismissing abnormal behavior, it would do much to avert the overwhelming sense of inadequacy that so many modern young mothers feel—especially with their first baby. If they can be made comfortable with their first the others usually come easily. Many physicians who care for children are not trained in the rudiments of developmental behavior. By means of a simple outline and drawing of “the thorny child” even the least of the experts can better understand some of the chronologic variations in developmental behavior.     

PSYCHOSURGERY—Present Indications and Future Prospects

Although the advent and widespread use of ataractic drugs has more or less eclipsed lobotomy as a method of dealing with severe psychotic states, variations and adaptations of the operation still can be used with benefit in certain pretty well defined circumstances.“Chemical lobotomy” and regressive electroshock bring about alterations in behavior superficially resembling those of lobotomy, but without the changes in personality that are the object of lobotomy. These desirable changes consist in increased extraversion, decreased preoccupation with self and decreased sensitivity to the opinions of others. With restricted operations, undesirable changes—the “frontal lobe syndrome”—do not occur.Operative failures are due to three main causes: (a) Preoperative emotional deterioration; (b) progress of the underlying disease; (c) relapse, possibly due to inadequate operation.Lobotomy is advisable if the patient does not show sustained improvement after a year of active treatment by other indicated means. The operation often represents the turning point in effective treatment. After the first year of ineffective treatment valuable time is being lost, with danger of fixation and deterioration. Then it is safer to operate than to wait.The future of psychosurgery lies in prompt application, in favorable patients, of selective operations that will reverse the trend of illness.There is particular need for further exploration of the temporal lobes in the hope of finding some procedure that will suppress hallucinations. Some 90 per cent of patients remaining in hospitals after psychosurgery are experiencing hallucinations. If these phenomena can be eliminated without producing serious personality defects, another large field for the application of psychosurgery will be opened.     

A Fundamental Trade-off in Covalent Switching and Its Circumvention by Enzyme Bifunctionality in Glucose Homeostasis

Covalent modification provides a mechanism for modulating molecular state and regulating physiology. A cycle of competing enzymes that add and remove a single modification can act as a molecular switch between “on” and “off” and has been widely studied as a core motif in systems biology. Here, we exploit the recently developed “linear framework” for time scale separation to determine the general principles of such switches. These methods are not limited to Michaelis-Menten assumptions, and our conclusions hold for enzymes whose mechanisms may be arbitrarily complicated. We show that switching efficiency improves with increasing irreversibility of the enzymes and that the on/off transition occurs when the ratio of enzyme levels reaches a value that depends only on the rate constants. Fluctuations in enzyme levels, which habitually occur due to cellular heterogeneity, can cause flipping back and forth between on and off, leading to incoherent mosaic behavior in tissues, that worsens as switching becomes sharper. This trade-off can be circumvented if enzyme levels are correlated. In particular, if the competing catalytic domains are on the same protein but do not influence each other, the resulting bifunctional enzyme can switch sharply while remaining coherent. In the mammalian liver, the switch between glycolysis and gluconeogenesis is regulated by the bifunctional 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase (PFK-2/FBPase-2). We suggest that bifunctionality of PFK-2/FBPase-2 complements the metabolic zonation of the liver by ensuring coherent switching in response to insulin and glucagon.     

WHAT'S NEW IN CEREBRAL PALSY

Among new researches bearing on cerebral palsy are the growth of brain cells in tissue cultures for experimentation; the use of polysaccharides to prevent the formation of a glial barrier to nerve growth after injury; observation of changes in reactions of neurons at various stages of development; the finding of hypernatremia and hyperchloremia in lesions of the frontal lobe and the thalamus; stimulation of cerebral blood flow by injection of sodium bicarbonate and retardation with ammonium chloride; and studies of serial sections of brains of palsied children who died.Study of development in the early months of life has made possible the detection of significant abnormalities in behavior early in life. Loss of hearing may be tested in very young children by measuring minute variations in electrical resistance of the skin upon auditory stimulation of the sympathetic nervous system.Conditions which have been described as having been confused with cerebral palsy are dislocation of a cervical vertebra, hereditary spastic paraplegia, transverse myelopathy, injury to the spinal cord or cauda equina by anomalous growths of the spine, and also encephalitis and meningitis.Sedation has proved a valuable adjunct to electroencephalographic study of cerebral palsy. Better criteria for abnormality in the young child should be determined and the application of them more clearly standardized.Simple exercises are useful for early training of palsied children to stimulate development. “Crossed laterality”—the dominant eye being contralateral to the preferred hand—has been counteracted by special training with great success in eliminating emotional and behavior problems and accelerating development.Recent studies indicate that only 50 per cent of cerebral palsy patients have normal or better intelligence.Subluxation of the hip joint, a common deformity associated with cerebral palsy, can sometimes be corrected by operation if detected at an early stage. Radical ablation of epileptogenic foci in the cortex is also being done in young patients if drug control of seizures fails. Frontal topectomy, cingulate gyrectomy or prefrontal labotomy may be advisable in cases in which proper response to drug therapy is not obtained.Improvement in behavior as well as control of seizures may follow the use of Benzedrine,® Dexedrine,® Dilantin® sodium, Mebaral® and phenobarbital. Alcohol, paraldehyde and chloral hydrate have been effective as relaxants.     

PYOGENIC INFECTIONS IN ORTHOPEDIC SURGERY—Prevention and Management

A problem that confronts surgeons in clinical practice is that a patient may acquire new infections while in the hospital. When such infections occur they are predominantly staphylococcal and these bacteria are often, but not always resistant to penicillin, streptomycin and the tetracycline antibiotics. They are often but neither completely nor uniformly sensitive to the newer or less frequently used antimicrobial agents.The extension of antibiotic usage from proven situations to “routine” prophylaxis has been a widespread practice. There are many reasons to discourage and to reexamine the validity and purpose, as well as the safety of this practice. We now have sufficient background and experience to revert from widespread and indiscriminate use to a practice of discriminate prophylactic therapy.In general, soft tissue lacerations and clean wounds do not require operation under an “antibiotic umbrella.” Similarly, elective orthopedic surgical procedures of soft tissues such as muscle biopsy, tenorrhaphy and muscle and tendon transplants as well as plastic surgical procedures can be safely performed without antibiotic therapy if technique is good and operation not prolonged. Operations of major magnitude on the motor-skeletal system, such as open fractures, internal fixation of fractures with bone grafts, and major operations of joints are indication for antibiotic therapy for impending infection postoperatively for five days. Reliance is mainly on antistaphylococcal drugs to which hospital organisms are predominantly sensitive. The two remaining indications for antibiotic therapy against impending infection are: (1) major crush injury—for example, to the thigh—and (2) the need for a patient with a healing fracture to have other surgical procedures such as tooth extraction or excision of an infected area which might predispose to transient bacteremia and embolic infection in bone or joint.     

Outlook on a Worldwide Forest Transition

It is not clear whether a worldwide “forest transition” to net reforestation will ever occur, and the need to address the main driver–agriculture–is compelling. We present a mathematical model of land use dynamics based on the world food equation that explains historical trends in global land use on the millennial scale. The model predicts that a global forest transition only occurs under a small and very specific range of parameter values (and hence seems unlikely) but if it does occur, it would have to occur within the next 70 years. In our baseline scenario, global forest cover continues to decline until it stabilizes within the next two centuries at 22% of global land cover, and wild pasture at 1.4%. Under other scenarios the model predicts unanticipated dynamics wherein a forest transition may relapse, heralding a second era of deforestation; this brings into question national-level forest transitions observed in recent decades, and suggests we need to expand our lexicon of possibilities beyond the simple “forest transition/no forest transition” dichotomy. This research also underscores that the challenge of feeding a growing population while conserving natural habitat will likely continue for decades to come.     

COUMARIN THERAPY—Prothrombin Activity after Termination of Treatment

Twelve patients receiving coumarin type hypoprothrombinemic agents were studied before, during and after termination of therapy, the prothrombin proconvertin method having been used to assay the prothrombin activity complex.In no instance was post treatment “rebound” demonstrated.Prothrombin activity levels returned to pretreatment values only after ten days following termination of coumarin or Dicumarol administration.If a reactivation of thrombotic tendency occurs following discontinuance of anticoagulant therapy, it would not appear to be related to a “rebound” of prothrombin activity above that which is “normal” for the individual patient.Patients tend to return to the same level of prothrombin activity present before initiation of coumarin therapy.     

Florid Suprascapular Neuropathy after Primary Rotator Cuff Repair Attributed to Suprascapular Notch Constriction in the Setting of Double Crush Syndrome

This report describes a patient who had an open repair of a small supraspinatus tendon tear performed 6 months after an arthroscopic acromioplasty with debridement had failed to provide pain relief. Three months prior to the tendon repair, he had a two-level cervical spine discectomy and fusion (C4–5, C5–6) that improved his neck pain. Florid suprascapular neuropathy was detected 10 weeks after the open rotator cuff repair. Evidence of some nerve recovery resulted in a long period of observation. But unsatisfactory improvement warranted decompression of the suprascapular notch, which was found to be very stenotic. At surgery, there was no evidence of neuroma, cyst, or other compressing lesion or tissue. Therefore, it was ultimately hypothesized that there was an exacerbation of a preexisting, but clinically unrecognized, entrapment of the suprascapular nerve in the suprascapular notch in the setting of cervical radiculopathy (primarily C5). Retrospectively it was also concluded that had this compressive etiology been recognized, it would have favored prompt decompression rather than the long observation period. Three years was required to achieve a good result following suprascapular notch decompression. The underlying C5 radiculopathy may have created a “double crush syndrome” that contributed to the propensity for injury and the prolonged recovery. There should be heightened awareness of this problem in patients who do not have satisfactory improvement in shoulder pain from previous shoulder and neck surgery.     

Saccades during Attempted Fixation in Parkinsonian Disorders and Recessive Ataxia: From Microsaccades to Square-Wave Jerks

During attempted visual fixation, saccades of a range of sizes occur. These “fixational saccades” include microsaccades, which are not apparent in regular clinical tests, and “saccadic intrusions”, predominantly horizontal saccades that interrupt accurate fixation. Square-wave jerks (SWJs), the most common type of saccadic intrusion, consist of an initial saccade away from the target followed, after a short delay, by a “return saccade” that brings the eye back onto target. SWJs are present in most human subjects, but are prominent by their increased frequency and size in certain parkinsonian disorders and in recessive, hereditary spinocerebellar ataxias. Here we asked whether fixational saccades showed distinctive features in various parkinsonian disorders and in recessive ataxia. Although some saccadic properties differed between patient groups, in all conditions larger saccades were more likely to form SWJs, and the intervals between the first and second saccade of SWJs were similar. These findings support the proposal of a common oculomotor mechanism that generates all fixational saccades, including microsaccades and SWJs. The same mechanism also explains how the return saccade in SWJs is triggered by the position error that occurs when the first saccadic component is large, both in the healthy brain and in neurological disease.     

Validity of anecdotal reports of suspected adverse drug reactions: the problem of false alarms

Suspected adverse drug reactions first reported in 1963 in the “British Medical Journal,” the “Lancet,” the “Journal of the American Medical Association,” and the “New England Journal of Medicine” were reviewed 18 years later to assess their initial validity and subsequent verification. Of 52 first reports, five were deliberate investigations into potential or predictable reactions, and in each case causality was reasonably established; the other 47 reports were essentially anecdotal. Of these 47 reports, 14 related to categories of adverse reaction where false-positive reports were unlikely: immediate reactions, local reactions, and known reactions caused by a different mode of administration or a brand previously thought or claimed to be safe. The problem of false alarms rose in the remaining types of reactions: general reactions that did not occur immediately after administration and arose for the first time with a new chemical entity. Of 33 reports of such suspected adverse reactions, validity was satisfactorily established in 14 cases on the basis of rechallenge, predictability from known pharmacology, or the unique nature of the reaction. Of the remaining 19 reports, further verification still has not been satisfactorily established in 12. Seven of these possible false alarms were haematological reactions.Although 35 of the 47 anecdotal reports were clearly correct, of the 19 reports that were not reasonably validated at the time of the report, only seven were subsequently verified. This suggests that agencies monitoring adverse drug reactions should adopt criteria for assessing the validity of first reports of suspected adverse reactions. Such criteria should include: reactions on rechallenge, a pharmacological basis for the adverse reaction, immediate acute reactions, local reactions at the site of administration, reactions with a new route of administration of a drug known to provoke such reactions by another route, and the repeated occurrence of very rare events.