Psychotherapy of functional dermatoses; its value and limitations as applied to neurodermatitis

Etiologically, neurodermatitis is interpreted as an often manifestly hereditary diathesis which is frequently complicated and exacerbated by disturbances of the patient's emotional and psychic structure. The following traits are commonly exhibited, singly or in combination: a tendency toward excitability and an exaggerated capacity for response to stimuli, polyvalent dermal hypersensitivity, a propensity to vascular disturbances, a personality somewhat obsessional in structure and evidence of deep-seated emotional conflict. Shallow psychotherapy, an indispensable adjunct to the treatment of neurodermatitis, can be successfully applied by any dermatologic physician adequately endowed with patience, sympathy and tact. This method does not achieve a cure, but, properly applied, it can immeasurably improve the patient's lot.     

A place to hide in the home-cage decreases yolk androgen levels and offspring emotional reactivity in Japanese quail

An animal''s emotional responses are the result of its cognitive appraisal of a situation. This appraisal is notably influenced by the possibility of an individual to exert control over an aversive event. Although the fact that environment controllability decreases emotional responses in animals is well established, far less is known about its potential trans-generational effects. As the levels of avian yolk hormones can vary according to the mother''s environment, we hypothesized that housing environment of mothers would modulate the quality of her eggs and in turn her offspring''s behaviour. Two groups of female Japanese quail were constituted: a group that had access to a place to hide in their home-cage (Hd, n = 20) and a group that had nowhere to hide (NoHd, n = 20) when stressed. Both groups were submitted to daily human disturbances for a twenty-day-period. Hd females produced eggs with both less testosterone and androstenedione than did NoHd females. The emotional and social reactivity of Hd females'' offspring were lower and their growth was slower than those of NoHd females'' offspring. Our results show that a minor difference in housing environment had substantial effects on eggs and offspring. The presence of a shelter probably helped quail to cope with daily human disturbances, producing less reactive offspring. This transgenerational effect caused by an opportunity to hide could lead to applications in care of laboratory animals, conservation biology and animal welfare.     

The confederation worm token.

To an increasing degree the psychiatrist is oriented to the community and general hospital either as consultant, therapist, or collaborator in overall patient management. In these new roles, he becomes a more comprehensive physician and also conveys psychiatric insights to his colleagues.Psychological factors and the patient''s personality “style” influence the development and course of every disease, complicating diagnosis and effective treatment. It is a basic requirement that a good working alliance be established between patient and physician. This is assisted by comprehensive history taking, which clarifies the lifesetting in which the illness began, the patient''s personality and his habitual reactions of emotional regression under stress. It will also point up errors introduced by the patient, omissions, and distortions in offering the subjective data which the physician must evaluate.Seven major personality types and appropriate physician responses are outlined: the dependent demanding oral patient, the orderly controlled obsessive, the dramatic seductive hysteric, the long-suffering masochist, the querulous paranoid, the overbearing narcissist and the aloof withdrawn schizoid.The non-psychiatrist can resolve complex and puzzling medical problems if he has an increased awareness of how emotional forces complicate illness and if he can exploit comprehensive history taking to the full.     

Patients in the persistent vegetative state: problems in their long term management.

Physicians responsible for the long term management of patients in the persistent vegetative state face several problems. These include deciding whether tube feeding is treatment or nutritional care, whether withdrawal of tube feeding is an appropriate form of management, what clinical advantage there is in active treatment; at what level of awareness can a patient be said to have a quality of life; and who should determine a patient''s right to die. These problems are determined more by social, legal, emotional, cultural, religious, and economic forces than by clinical facts.     

支气管哮喘患者心理特征研究进展

支气管哮喘是全球范围内影响巨大的慢性气道炎症性呼吸道疾病,近年来随着空气污染的加剧和吸烟人数的增多,其发病率呈逐年上升的趋势,引起医学界越来越多的关注。支气管哮喘是由遗传因素、生物因素、心理因素等多种发病因素综合影响所致,随着研究的深入,有关心理因素对支气管哮喘的作用取得了重大的进展,其中支气管哮喘患者存在明显的人格特征和情绪障碍,并且患者特有的人格特征以及情绪障碍会对患者的病情和生活质量产生一定的影响。鉴于此,本文就支气管哮喘患者的性格特征、情绪特征以及其对疾病的影响进行简要阐述,以供临床参考。     

Ethical conflicts in long-term care of the aged: nutritional problems and the patient-care worker relationship.

The patient-care worker relationship was analysed by observation and unstructured group discussion in four long-stay somatogeriatric wards at Saint Lars Hospital. Investigation centred on patients entering the terminal phase who could no longer be spoon-fed. The relationship was complicated and reciprocal, and failure by the care worker to interpret her role and the dying patient''s behaviour correctly led to emotional conflict and double-binding, with resultant anxiety for both herself and the patient. Infusions and tube-feeding prescribed in such cases were given not for the patient''s benefit but to relieve anxiety in care workers and relatives. Permitting the patient a natural, painless death from water deficiency may be preferable to prolonging pain and discomfort by intervening with infusion and tube-feeding.     

Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

Effects of living with and looking after survivors of a stroke.

Information from a two year, longitudinal study on a community sample of patients with acute stroke was analysed to determine the effects of the stroke on the mood of the chief carer (the person living with the patient). Increased anxiety was the most commonly reported change six months after stroke. Significant depression was seen in 11-13% of carers over the first two years after stroke. The patient''s functional disability was associated with depression in the carer over the first year but not at two years. A perceived poor recovery by the patient, a low level of general activities by the patient, and depression in the patient were also associated with depression in the carer within the first year. At two years after stroke none of the measured factors were related to a carer''s level of depression. Carers of patients who have suffered stroke showed anxiety and emotional distress unrelated to the patient''s physical disability after two years. More help from stroke support groups for carers is perhaps needed.     

口服营养补充研究进展

疾病相关营养不良是住院病人一个重要的不良预后因素,影响病人的生活质量,除去吞咽困难及消化道不健全,当患者摄入不能满足机体的需求时建议给予口服营养补充(ONS)。越来越多的证据证明口服营养补充在营养不良治疗中的重要有利作用,尤其对急性病、老年人及低营养状态的病人效果显著。口服营养补充符合人体生理特点,安全、经济、易于吸收且依从性较好,可以有效改善患者的能量及营养元素的摄取,提高患者的生活质量。ONS越来越多的在临床应用,但其应用时间,具体方法以及临床效果的评价还存在争议,本文从以下几方面对ONS的研究进行综述,介绍ONS的起源与发展,完善ONS的定义,准确评估其临床疗效,具体阐明ONS在肿瘤疾病中的应用,为ONS更好的应用于临床提供比较好的理论依据。     

Differential diagnosis in patients with disorders of the patellofemoral joint.

Anterior knee complaints are difficult diagnostic problems. It cannot be overstated that the most important information available is to be found in the patient''s history. Onset, quality, and quantity of symptoms must be assessed. This information is then synthesized to determine the specific functional disabilities resulting from the patient''s anterior knee disorder. Once a history is obtained, a consistent, methodical physical examination can be performed to narrow the differential diagnosis. Radiographic evaluation is used to further hone the differential or to confirm the most likely diagnosis. Ultimately, a specific working diagnosis is selected and treatment is tailored to changing the underlying structural or biomechanical abnormalities that led to the patient''s complaints.     

Bioethics for clinicians: 2. Disclosure.

In the context of patient consent, "disclosure" refers to the provision of relevant information by the clinician and its comprehension by the patient. Both elements are necessary for valid consent. Disclosure should inform the patient adequately about the treatment and its expected effects, relevant alternative options and their benefits and risks, and the consequences of declining or delaying treatment. The clinician''s goal is to disclose information that a reasonable person in the patient''s position would need in order to make an informed decision. Therefore, clinicians may need to consider how the proposed treatment (and other options) might affect the patient''s employment, finances, family life and other personal concerns. Clinicians may also need to be sensitive to cultural and religious beliefs that can affect disclosure.     

Aftercare of State Hospital Patients—The Role of the General Practitioner

Of all the problems facing patients released from a state hospital, the most serious one is adjustment. Failure here means a return to the hospital. The present aftercare program of the Department of Mental Hygiene does not and is not intended to meet all of the patient''s needs. It must rely upon other agencies to assist. It must rely upon the general practitioner to provide the continuity of care which is so important to successful rehabilitation.The general practitioner can often make return to a state hospital unnecessary by an accurate assessment of the patient''s problems, by effective intervention, by utilizing available consultation and by judicious referral. When services are not available, he can do much to make them available through the effective use of his professional channels.     

Drugs of abuse--opiates.

Treating opiate-dependent patients can be difficult for many physicians because the patients'' life-styles, values, and beliefs differ from those of the physicians. Primary care physicians, however, are often involved in the treatment of the medical complications of opiate abuse, and physicians must often manage a patient''s opiate dependence until appropriate referral to a drug abuse treatment program can be arranged. Treatment is guided by an understanding of the patient''s addictive disease, for which there are specific diagnostic criteria, and an understanding of the pharmacology of opiates of abuse and the medications used in treating opiate dependence. The opiate agonist, methadone, is useful for both detoxification and maintenance. The opiate antagonist, naloxone, is the treatment of choice for opiate overdose, and naltrexone, also an opiate antagonist, is a useful adjunct in subgroups of opiate-dependent patients for preventing relapse. New medications for the treatment of opiate dependence are being developed.     

Radiologic assessment in the pediatric intensive care unit.

The severely ill infant or child who requires admission to a pediatric intensive care unit (PICU) often presents with a complex set of problems necessitating multiple and frequent management decisions. Diagnostic imaging plays an important role, not only in the initial assessment of the patient''s condition and establishing a diagnosis, but also in monitoring the patient''s progress and the effects of interventional therapeutic measures. Bedside studies obtained using portable equipment are often limited but can provide much useful information when a careful and detailed approach is utilized in producing the radiograph and interpreting the examination. This article reviews some of the basic principles of radiographic interpretation and details some of the diagnostic points which, when promptly recognized, can lead to a better understanding of the patient''s condition and thus to improved patient care and management. While chest radiography is stressed, studies of other regions including the upper airway, abdomen, skull, and extremities are discussed. A brief consideration of the expanding role of new modality imaging (i.e., ultrasound, CT) is also included. Multiple illustrative examples of common and uncommon problems are shown.     

Emotional Reactions to Disfigurement from Cancer Therapy

Disfigurement not only produces current anxieties but reactivates childhood conflicts. The emotional reaction depends upon the disturbance to the patient''s major adaptations to life as well as the meaning of the organ to the patient. Fear of isolation and rejection by others may be more terrifying than fear of death. Emotional reactions include regression with marked dependency, anxiety, depression, hostility and, if severe, paranoid states, hypochondriasis, denial, counterphobic behaviour, obsessive-compulsive reactions and schizophrenic reactions. Management basically involves early establishment of a positive doctor-patient relationship. In such a relationship the physican should educate his patient, undercut guilt, accept transient regression and expression of anger, set limits on counterphobic behaviour, either support or gently question denial of reality, and support, without being overly sympathetic, a depressed patient. The nurse, social worker, psychiatrist and the patient''s family may be valuable members of the therapy team. Disfigurements of various body areas pose individual problems of management.     

Association of endodermal sinus tumour,testicular teratoma and alpha1-fetoprotein.

An endodermal sinus tumour in the retroperitoneal region was associated with the presence of alpha1-fetoprotein (AFP) in the patient''s serum. At autopsy a simple cystic teratoma of the right testicle was also found. The association of these two tumours has been reported before. The classification of these malignant germ-cell tumours and an understanding of their evolution may be aided by the discovery that AFP is often found in the patient''s serum.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Attempt to restore lymphocytes with defective T-cell function by mixing with normal cells in vitro

Blood leukocytes from a patient with T-cell immunodeficiency failed to respond to stimulation with phytohemagglutinin (PHA) in vitro although ample lymphocytes were present. Leukocytes from this patient were mixed in various proportions with normal leukocytes, and the mixtures were stimulated with PHA and cultured for three days. There was no restoration of PHA responsiveness of the patient''s cells in the presence of normal cells. This would indicate that the defect in the patient''s cell population was not due to the absence of any facilitating factor or cooperative function that could be provided by normal T cells or other blood leukocytes. Since in thymic aplasia the patient''s own cells are rapidly restored to normal PHA responsiveness by an unknown facilitating factor after thymic transplantation, we suggest that this mixed-cell culture method might differentiate between patients who need a bone marrow transplant and those who will respond to a thymus transplant.     

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient''s noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician''s own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician''s perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.