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We present 2 cases of advanced juvenile nasopharyngeal angiofibroma (JNA) to illustrate the advantages of endoscopic Coblation-assisted resection of intranasal extensions of these masses. Both patients-an 11-year-old boy and a 14-year-old boy-presented with a large, extensive mass (Radkowski stage IIIb and Fisch stage IVb in both cases). After embolization was performed on each patient, his JNA was partially ablated via an endoscopic approach with the Coblator II Surgery System with an EVac Xtra Plasma Wand in conjunction with an image-guided navigation system. Both patients experienced resolution of their nasal obstruction with removal of the intranasal extension of the tumor. Coblation allowed for a controlled debulking of the tumors with less blood loss and without the need for multiple instruments. To the best of our knowledge, our report is one of the first to describe image-guided endoscopic Coblation of advanced JNA tumors. Future studies in adequately sized populations are needed to determine the safety and effectiveness of Coblation-assisted endoscopic removal of both advanced and lower-stage JNAs.

We report a technique for isolation and solubilization of intermediate filament (IF) proteins from colonic biopsies compatible with both gel electrophoresis and liquid chromatography "shotgun" proteomics using mass spectrometry (MS). This is important because changes in the IF proteome, particularly in keratin expression and modification, are noted in colonic mucosa of patients with colorectal cancer. Though keratins have traditionally been dissolved in high concentration of urea, the latter solvent precludes efficient proteolytic digestion by trypsin prior to gel-free LC-MS/MS approaches. The extraction of cytoskeletal proteins was initially evaluated using MCF-7 cancer cell lines using a published, differential detergent solubilization protocol. IF proteins were extracted from colonic biopsies using a combination of homogenization and sonication. Since comparable efficiency of solubilization was noted on the extracted IF from cell lines between urea and guanidine hydrochloride (GuHCl) in triethylammonium bicarbonate buffer, isolated proteins from endoscopic biopsies were solubilized in GuHCl. Using immunoblotting techniques, we successfully demonstrated isolation of keratins and preservation of posttranslational modifications (phosphorylation, acetylation). Dissolved proteins were tryptically digested and peptides analyzed by MS, showing the functionality of the workflow in shotgun proteomic applications, specifically compatibility of the workflow for isobaric tagging relative and absolute quantification based quantitation approaches., (© 2012 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.)

Objective: To determine the clinical and polysomnography outcomes in infants with laryngomalacia undergoing supraglottoplasty., Methods: Infants (<1 year old) who underwent polysomnography pre- and post-supraglottoplasty at our tertiary referral center between 2003 and 2009 were reviewed retrospectively. Outcome measures included changes in stridor, sleep disordered breathing, swallowing, and polysomnography parameters before and after surgery. Pre- and postoperative distributions were compared using a Wilcoxon signed-rank test., Results: 20 children met inclusion criteria. Statistically significant improvements were found in pre- to postoperative median values for apnea-hypopnea index (AHI) (median change: -6.4 points, p=0.02) and obstructive apnea index (median change: -2.9 points, p=0.01) values. Obstructive AHI, O₂ saturation nadir, and percentage of sleep spent with <90% O₂ saturation improved, although not significantly. Postoperative AHI scores correlated with improvements in stridor in 80% of patients. Stratification showed similar improvements in AHI after supraglottoplasty regardless of reflux treatment, secondary airway lesions, age at supraglottoplasty, or time lag between supraglottoplasty and postoperative polysomnography. Secondary airway lesions are the only potential confounders shown to have significantly better improvements in O₂ nadir. While the sleep study improved in patients with AHI >5, infants with AHI <5 had worse polysomnography parameter values postoperatively. Five patients had dysphagia that resolved within one month postoperatively; otherwise, supraglottoplasty resulted in no complications., Conclusion: Supraglottoplasty may be an effective and safe option to improve moderate to severe obstructive sleep apnea in infants with laryngomalacia. In addition, polysomnography may be useful in infants with laryngomalacia to identify obstructive sleep apnea and/or to objectively measure outcomes after supraglottoplasty. This pilot study warrants a larger, prospective, and controlled study to validate these findings., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To determine the endotracheal tube (ETT) size and presence of subglottic narrowing in children less than 1 year old with Pierre Robin Sequence (PRS)., Materials and Methods: We performed a retrospective review from 2005 to 2009 of infants with PRS who underwent diagnostic laryngoscopy (DL) and intubation., Results: Fifteen children with a median age of 25 days were reviewed. All patients, except one, were born full term. Subglottic narrowing was visualized in 5 patients (33%). 73% of all patients required an ETT size smaller than what is recommended by intubation guidelines in the literature in regards to normative data based on age and weight., Conclusion: Infants with PRS may have a higher incidence of subglottic stenosis and require a smaller ETT compared to the normal population. This pilot study warrants a larger prospective investigation to validate these findings., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objectives: The "neurotrophin hypothesis" of depression posits a role of brain-derived neurotrophic factor (BDNF) in depression, although it is unknown whether BDNF is more involved in the etiology of depression or in the mechanism of action of antidepressants. It is also unknown whether pre-treatment serum BDNF levels predict antidepressant response., Methods: Thirty un-medicated depressed subjects were treated with escitalopram (N=16) or sertraline (N=14) for 8 weeks. Twenty-five of the depressed subjects completed 8 weeks of antidepressant treatment and had analyzable data. Twenty-eight healthy controls were also studied. Serum for BDNF assay was obtained at baseline in all subjects and after 8 weeks of treatment in the depressed subjects. Depression ratings were obtained at baseline and after 8 weeks of treatment in the depressed subjects., Results: Pre-treatment BDNF levels were lower in the depressed subjects than the controls (p=0.001) but were not significantly correlated with pre-treatment depression severity. Depression ratings improved with SSRI treatment (p<0.001), and BDNF levels increased with treatment (p=0.005). Changes in BDNF levels were not significantly correlated with changes in depression ratings. However, pre-treatment BDNF levels were directly correlated with antidepressant responses (p<0.01), and "Responders" to treatment (≥ 50% improvement in depression ratings) had higher pre-treatment BDNF levels than did "Non-responders" (p<0.05)., Conclusions: These results confirm low serum BDNF levels in un-medicated depressed subjects and confirm antidepressant-induced increases in BDNF levels, but they suggest that antidepressants do not work simply by correcting BDNF insufficiency. Rather, these findings are consistent with a permissive or facilitatory role of BDNF in the mechanism of action of antidepressants., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Depression is associated with an unusually high rate of aging-related illnesses and early mortality. One aspect of "accelerated aging" in depression may be shortened leukocyte telomeres. When telomeres critically shorten, as often occurs with repeated mitoses or in response to oxidation and inflammation, cells may die. Indeed, leukocyte telomere shortening predicts early mortality and medical illnesses in non-depressed populations. We sought to determine if leukocyte telomeres are shortened in Major Depressive Disorder (MDD), whether this is a function of lifetime depression exposure and whether this is related to putative mediators, oxidation and inflammation., Methodology: Leukocyte telomere length was compared between 18 unmedicated MDD subjects and 17 controls and was correlated with lifetime depression chronicity and peripheral markers of oxidation (F2-isoprostane/Vitamin C ratio) and inflammation (IL-6). Analyses were controlled for age and sex., Principal Findings: The depressed group, as a whole, did not differ from the controls in telomere length. However, telomere length was significantly inversely correlated with lifetime depression exposure, even after controlling for age (p<0.05). Average telomere length in the depressed subjects who were above the median of lifetime depression exposure (≥9.2 years' cumulative duration) was 281 base pairs shorter than that in controls (p<0.05), corresponding to approximately seven years of "accelerated cell aging." Telomere length was inversely correlated with oxidative stress in the depressed subjects (p<0.01) and in the controls (p<0.05) and with inflammation in the depressed subjects (p<0.05)., Conclusions: These preliminary data indicate that accelerated aging at the level of leukocyte telomeres is proportional to lifetime exposure to MDD. This might be related to cumulative exposure to oxidative stress and inflammation in MDD. This suggest that telomere shortening does not antedate depression and is not an intrinsic feature. Rather, telomere shortening may progress in proportion to lifetime depression exposure.

Objectives: The objective was to review the clinicopathologic features of carotid blowout syndrome (CBS) in patients with head and neck cancer (HNC) and present a management algorithm., Methods: We reviewed all HNC patients with a diagnosis of CBS seen at our tertiary cancer hospital from 1994 to 2009 and performed a retrospective review of all English-language studies documenting CBS cases within the past 15 years., Results: Eight patients with HNC developed CBS at our institution, and another 132 HNC patients were presented in 21 studies. Patients with CBS typically have a history of radiotherapy (89%), nodal metastasis (69%), and neck dissection (63%). This disease usually occurs proximal to the carotid bifurcation and is commonly associated with soft tissue necrosis in the neck (55%) and mucocutaneous fistulas (40%). Half of CBS patients present with sentinel bleeding, but 60% of patients will develop a life-threatening hemorrhage requiring emergent intervention. Over 90% of patients with CBS were treated with endovascular therapy, and surgical ligation was rarely indicated. The morbidity and mortality rates of patients with CBS are significant; only 23% have survived without evidence of disease., Conclusions: Carotid blowout syndrome is uncommon and can be rapidly fatal without prompt diagnosis and intervention. Although endovascular treatment within the carotid system can have a significant risk of mortality and neurologic morbidity, it has become the treatment of choice for CBS.

Elevated circulating pro-inflammatory cytokines are associated with symptoms of depression, and disorders involving chronic inflammation are often co-morbid with major depression. Since healthy immune regulation is accomplished through counter-balancing effects of pro- and anti-inflammatory cytokines, we hypothesized that depressed subjects (compared to controls) would express lower concentrations of the anti-inflammatory/immunoregulatory cytokine interleukin (IL)-10, and a higher IL-6/IL-10 ratio. We also examined the possibility that depressed subjects may exhibit a deficiency in the regulatory loop involving IL-6 induced secretion of IL-10. Therefore, we hypothesized that circulating IL-6 and IL-10 would be positively correlated in controls, while the correlation would be weaker in depressed subjects. Resting state serum cytokine concentrations were quantified in 12 unmedicated depressed subjects, and 11 age, gender, and ethnicity-matched controls. Depressed subjects showed significantly lower IL-10 (p=0.03, Cohen's d=-0.96), non-significantly higher IL-6, and significantly higher IL-6/IL-10 ratios (p=0.05, Cohen's d=0.50). Across all participants, higher scores on the self-rated Inventory of Depressive Symptoms were associated with lower IL-10 (r(21)=-0.57, p=0.005) and non-significantly higher IL-6/IL-10 ratios (r(21)=0.38, p=0.07), but not related to IL-6 concentrations. As hypothesized, IL-6 and IL-10 concentrations were strongly and positively correlated in controls (r(9)=0.81, p=0.003), but were completely dissociated in depressed subjects (r(10)=0.01, p=0.98). These results suggest that lower IL-10 levels, a higher IL-6/IL-10 ratio, and the apparent absence of a counter-balancing, immunoregulatory increase in IL-10 in response to elevated IL-6 concentrations contribute to the pro-inflammatory physiological milieu that is known to be associated with major depression. Therefore, reduced induction/availability of IL-10, that would normally inhibit pro-inflammatory cytokine actions and resolve inflammation, may contribute to the depressogenic as well as the inflammatory disease-promoting effects of chronic, low-level elevations in pro-inflammatory cytokines.

Objectives: The objective was to review the presentation, diagnosis, treatment, and prognosis of patients with laryngeal liposarcoma (LLS). A case is reported, and a retrospective review of the English-language literature is presented., Methods: All published cases of LLS with adequate histopathologic documentation and clinical information were included for review., Results: Thirty cases of LLS have been reported. A majority of these patients are men between 40 and 70 years of age. The most common location of the tumor is the supraglottis, and the presenting complaints are similar to those of other laryngeal neoplasms. Although these neoplasms recur often and can cause significant morbidity, they are typically of low grade and rarely metastasize. The outcomes of this disease are generally good when it is treated with wide surgical excision., Conclusions: Cases of LLS are extremely rare. Because the histologic changes are frequently subtle, LLS can be easily mistaken for a benign tumor. As a result, the diagnosis requires a high index of suspicion and diligence in examining biopsy specimens. Computed tomography and magnetic resonance imaging can assist in the diagnosis and surgical approach. Genetic and immunostaining analysis techniques may also prove to have valuable prognostic, diagnostic, and therapeutic implications for this disease. Wide surgical excision is the mainstay of treatment. The use of radiotherapy and chemotherapy in treating this cancer remains experimental, but might be considered on a case-to-case basis for palliation or to treat aggressive variants of the disease.

Purpose: Elective cosmetic surgery is expanding in the UK in both the public and private sectors. Because resources are constrained, many cosmetic procedures are being excluded within the National Health Service. If guidelines on who can receive such surgery are to be evidence-based, information is needed about the level of dysfunction in patients referred for elective surgery and whether this is related to their degree of physical abnormality., Method: Consecutive patients referred to a regional plastic surgery and burns unit for assessment for elective cosmetic surgery completed standardised measures of physical and psychosocial dysfunction, and indicated their perception of the degree of their abnormality and their preoccupation with it. We distinguished between patients referred for physical reasons or appearance reasons only, and compared levels of physical and psychosocial dysfunction in each with published values for community and clinical samples. Surgeons indicated patients' degree of objective abnormality, and we identified the relationship of dysfunction with perceived and objective abnormality and preoccupation., Results: Whether patients sought surgery for physical or appearance reasons, physical function was normal. Those seeking surgery for appearance reasons only had moderate psychosocial dysfunction, but were not as impaired as clinical groups with psychological problems. Patients seeking the correction of minor skin lesions for purely appearance reasons reported excellent physical and psychosocial function. Level of function was related (negatively) to patients' preoccupation with abnormality rather than to their perceived or objective abnormality., Conclusions: In general, patients referred for elective cosmetic surgery did not present with significant levels of dysfunction. Moreover, levels of functioning were related to preoccupation rather than to objective abnormality. Therefore, for most patients, whether surgical treatment is generally appropriate is questionable. Future guidelines must seek to identify the small minority who do have a clinical need for surgery.

Purpose: Elective cosmetic surgery (ECS) in the absence of physical indications is often performed to improve psychosocial function. Third-party funders need evidence of its effectiveness if they are to respond in an evidence-based way to increasing demand in the context of constrained resources. Our first aim was to review recent evidence of psychosocial outcome in a way that was systematic with respect to study inclusion and methodological evaluation. Our second aim was to review evidence for the validity of currently used selection criteria., Method: Electronic and manual literature and database search identified prospective cohort or controlled studies of psychosocial outcomes of surgery performed for appearance reasons reported in English from 1992 to 2004. Data were extracted to describe outcomes and evaluate methodological quality., Results: Twenty-three reports of 22 separate studies were reviewed. All were prospective observational studies and most provided low standards of evidence because of the absence of comparison groups, short follow-up periods and loss to follow-up. The evidence suggests that breast reduction improves health-related quality of life, but does not indicate enduring improvement in quality of life after other procedures, or enduring improvement in mental health, self-esteem or body image after any procedure. Similarly, there was insufficient evidence for the validity of criteria for patient selection. The negative conclusions reflect, not the existence of negative evidence, but methodological limitations of published research., Conclusion: The problem for third-party funders is that, although evidence does not justify the continued general provision of ECS in the absence of physical need, it is not strong enough to justify withholding such treatment. Even though randomised controlled trials are probably impractical, we identify several improvements in design whereby future prospective cohort studies could provide higher standards of evidence.

This article describes two experiments on awareness in recognition memory for novel faces. Two kinds of awareness, recollective experience and feelings of familiarity in the absence of recollective experience, were measured by "remember" and "know" responses. Experiment 1 showed that "remember" but not "know" responses were reduced by divided attention at study. Experiment 2 showed that massed versus spaced repetition of faces in the study list had opposite effects on "remember" and "know" responses. Massed repetition increased "know" responses and reduced "remember" responses. Spaced repetition increased "remember" responses and reduced "know" responses. The results of both experiments replicate previous findings from the verbal domain in the domain of face recognition, and hence they increase the ecological validity of this experimental approach to memory and awareness and the generality of its database. These findings are discussed from a rehearsal perspective on factors influencing the two states of awareness and in relation to the alternative "process dissociation" procedure.

We conducted a microstudy to elicit health state descriptions and utility values, using the EuroQol instrument, from a sample of acutely ill inpatients on 5 wards at University College London Medical School. Most current work to date has elicited such descriptive and valuation data from random surveys of the general population. One problem with this is that most responders from the general population have not actually experienced the states being valued. Our goal was to ascertain whether there were any differences between the values given by inpatients and those of the general population. However, the small sample size of patients included in our feasibility study means our conclusions must remain tentative. Nevertheless, the results suggest that patients give higher values than the general population. We suggest that more research needs to be done eliciting values from patients.

The psychological reactions of 50 survivors of the King's Cross fire, which hit London's underground railway system on the 18th day of November 1987, are described. Results are presented for the Impact of Event scale, the General Health Questionnaire (28-item version), the Eysenck Personality Questionnaire and a King's Cross Event Schedule. These are investigated in relation to (a) validity measures, (b) relationships between exposure and personality, and (c) spontaneous de-briefing. Two thirds of the sample had significant levels of psychological distress (meeting the "caseness" criterion on the GHQ). Both personality (neuroticism and L-scale) and degree of trauma exposure were related to subsequent reaction. Spontaneous debriefing was associated with subjective benefit. Transportation disasters present particular problems in relation to research and service delivery.

The psychological after-effects on 27 survivors of the Marchioness riverboat disaster of 20 August 1989 are described. On measures of intrusive memories and psychological difficulties these subjects are significantly higher than population norms, and somewhat higher than psychiatric in-patient populations. Personality measures taken after the disaster show that neuroticism scores are very much higher than population norms, but personality measures were not correlated with distress.

During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.

A method of content analysis has been designed for application in brief focal psychotherapy with physically ill patients. The method is being used to study the process of therapy with patients with chronic obstructive airways disease. This paper discusses its reliability and validity in this context and suggests that it may illuminate the relevance of environmental factors to the development of the transference.

We examined children's ability to anticipate the appearance of transformed multicomponents using visual stimuli with variations of a mental rotation task. We hypothesized that (a) performance would depend on the presence, location, and spatial relationship of specific stimulus features, and that (b) younger children would use a single component to make their predictions, whereas older children would be more likely to use multiple components. In Study 1, 40 first-, and fifth-grade subjects were presented with 32 rotation problems consisting of varied stimulus characteristics; subjects selected the correct option from a field where foils were indicative of the strategy used. Analyses of variance and log linear analyses revealed the hypothesized stimulus effect differentially associated with the children's ages. In Study 2, sixty 5-, 7-, and 9-year olds confronted 64 mental rotation problems with multicomponent stimuli and a construction task. Results and implications confirmed those of Study 1.

Diazepam, in moderate doses, has been used in a placebo controlled, single blind study to treat dyspnoea in four patients severely disabled from chronic airflow obstruction. The subjects had the 'pink puffer syndrome', usually associated with emphysema and were not hypercapnoeic nor severely hypoxic at rest. With diazepam, they experienced a striking reduction in dyspnoea, and an improvement in effort tolerance; in addition the slope of the ventilation/CO2 response curve was reduced. There were no changes in resting blood gases. Psychiatric examination at the end of the study did not reveal prominent anxiety, although three patients were depressed. The use of diazepam to treat dyspnoea in this syndrome is safe in the absence of any acute infection

A difficult task in designing indices of health and measures of health output is deriving a scale of valuations of a set of defined states of health or illness. A scale derived by structured interview of 70 subjects and tested on a further 50 subjects is described. The method aims for a ratio scale and the extent to which this has actually been achieved is discussed. Scale values appear to be independent of the sex, age, socio-economic group, religious belief and past medical history of the subject, but have some association with current experience of illness. There is agreement between scale values obtained from medical nurses and patients and agreement between the different values obtained from psychiatric nurses and patients.

Two cases are presented in which treatment with lithium was complicated by thyrotoxicosis. The underlying physiological mechanisms are discussed. Lithium suppresses thyroid function, so the early stages of thyrotoxicosis may be clinically undetectable. The symptoms and signs of thyrotoxicosis may be confused with the side effects of lithium, and if lithium is withdrawn severe rebound thyrotoxicity may occur. Furthermore, some of the side effects of lithium may be aggravated by thyrotoxicity. These cases provide further evidence of the importance of routine screening of thyroid function before starting treatment with lithium.

Single oral dose kinetics of nortriptyline and of tis two major metabolites, conjugated and unconjugated 20-hydroxynortriptyline, were studied in eight healthy subjects and 15 patients with chronic renal failure, five of whom were being treated with hemodialysis. Nortriptyline kinetics were unaltered, but the elimination of the metabolites was reduced in both groups of patients. In chronic renal failure the excretion of nortriptyline metabolites appeared to be the rate-limiting step in nortriptyline elimination. Three depressed hemodialysis patients were treated with nortriptyline (75 mg at night) for 6 wk. The ratios of the steady-state plasma concentrations of unconjugated 10-hydroxynortriptyline to nortriptyline (0.74 to 2.30) were in the same range as those in a control group of depressed patients with adequate renal function (0.53 to 4.08) who were also receiving nortriptyline. Conjugated 10-hydroxynortriptyline in renal failure patients was slow to reach steady-state concentrations and these were 10 to 20 times as high as those of the control depressed patients. Conjugated 10-hydroxynortriptyline in dialysis fluid during treatment showed that a mean 43 +/- 7% (SD) of the dose was removed by a 10-hr dialysis. Dialysis clearance of conjugated 10-hydroxynortriptyline was 58 +/- 8 (SD) ml min-1, but nortriptyline and unconjugated 10-hydroxynortriptyline were not appreciably removed by dialysis. Hemodialysis is not likely to be of value in the management of acute nortriptyline poisoning.

Twenty-two adults with myotonic dystrophy were assessed for evidence of intellectual impairment and cranial CT abnormalities. Psychometric evaluation demonstrated significantly lower verbal and performance IQs in the MD subjects than in matched normal controls. The reduced performance IQ was not simply related to loss of fine motor skills. No significant differences were found in memory and personality assessments between the MD and control groups. Lateral ventricular surface area was measured on CT scans using a semiautomated image analysis technique and was found to have a positive correlation with age in a control group of 45 normal scans (r = 0.833, P less than 0.001). This correlation was lacking in the MD group of subjects (r = 0.345, P greater than 0.05), in eight of whom the ventricular surface area was above the upper limit for age found in the control group. Asymptomatic areas of focal atrophy were found in two subjects. There was no correlation between ventricular size and severity or duration of the disease or verbal or performance IQ.

A toroidal relay optic has been used to overcome the problem of damage caused by debris that has limited previous attempts at soft x-ray lithography and contact microscopy using laser-produced plasma sources. Not only is the specimen preserved, but it is now possible to have a vacuum retaining soft x-ray transparent Si(3)N(4) window as a permanent part of the apparatus, greatly simplifying specimen handling. The exposure times are ~2 ns.

The serum protein binding of maprotiline and phenytoin has been compared in a group of 22 uraemic patients receiving haemodialysis. Determination of protein binding was carried out in vitro using equilibrium dialysis at 37 degrees C and 14C-labelled drug. The mean percentage unbound maprotiline found in patients (10.0%, SD 2.5) was not significantly different from that obtained in healthy volunteers (mean 10.5%, SD 1.0). However, there was a significantly increased variability in binding in patients compared with healthy subjects. The mean percentage unbound phenytoin in the same patients (22.2%, SD 3.3) was significantly greater than that obtained in healthy control subjects (12.5%, SD 0.6). Although there was no correlation between maprotiline and phenytoin binding and serum concentrations of alpha 1-acid glycoprotein, there was a significant correlation between percentage unbound maprotiline and serum albumin concentrations. The findings indicate that the binding of this tricyclic antidepressant is essentially normal in uraemia, although there may be increased interindividual variability in the free fraction of drug.

Soft x-ray contact images have been obtained of diatom skeletons using laser-generated plasmas of low energy (2 J IR). These images have a resolution of less than 60 nm, which is superior to that reported previously for biological specimens, using this technique.

This paper describes a study of the outcome of psychotherapy with patients disabled by chronic obstructive airways disease giving rise to dyspnoea. Forty-three men and 22 women with severe COAD were randomly allocated for 8 weeks to one of three types of psychotherapy or to an untreated control group, and were followed up six months later. The group treated by a medical nurse without training in psychotherapy experienced sustained relief of dyspnoea but tended to undergo less psychodynamic change; psychiatric symptoms were reduced in those receiving supportive, but not analytical, psychotherapy. The psychosomatic mechanisms involved and the implications for medical and nursing practice and for liaison psychotherapy are discussed.

A technique is described which circumvents the difficulty in obtaining reliable judgments by clinicians on cases of inappropriate use of hospital beds. By application of the Delphi method of measuring group expert opinion, convergence was achieved in the estimate, by four physicians, of the total number of bed days wasted on a medical ward during a period of two weeks. Cases of possible misutilization were identified by the author and a second study was designed to measure the effect on the physicans' behavior of her presence on the ward (Hawthorne effect). It is suggested that review of cases of misutilization by the Delphi method could be used in the continuing education of physicians.

120 children between ages 4 and 8 were administered a set of 4 visual perspective-taking tasks similar to ones employed in previous investigations. It was hypothesized that children's competence with the tasks would be a function of the number and type of spatial relationships embedded in the stimulus displays. 2 kinds of spatial relationships were described: (1) internal relationships--those between objects within a display; and (2) external relationships--those between the display and a frame of reference. Of the 4 task types, type A tasks necessitated awareness of possible variations in external relations, types B and C tasks required both awareness and computation of changes in those external relationships, and type D tasks required simultaneous coordination of internal and external spatial relationships. It was predicted that the tasks would sequence in terms of difficulty level as A less than B, B = C, and C less than D. Analysis of variance results on the obtained data revealed a good fit with the hypothesized predictions. The findings were discussed in terms of an information-processing analysis of children's performance on perspective-taking tasks.

Children's ability to discriminate reflections and rotations of visual stimuli was examined using a kinetic imagery task. It was hypothesized that success would be related to the number and placement of orientation markers on the stimuli, as well as whether or not reflections had to be discriminated from simple rotations. 40 4- and 5-year-old children were directed to imagine how a stimulus would look if rotated to a specified location and asked to indicate the appearance of the reoriented stimulus by selecting the correct option from a number of foils. 48 of the items required only discrimination of a reoriented stimulus. The other 48 also required discrimination of a reflection of the reoriented stimulus. Stimuli differed in the number of orientation cues on the edges of the figures. Results revealed that prediction accuracy was associated with the existence of orientation markers on the stimuli, as well as age, sex, type of discrimination, and several interactions among the variables. Findings were discussed in comparison to a priori predictions based on an analysis of how children might use orientation information when performing mental rotation tasks.

The storage and loss shear moduli, G' and G'', have been measured for dilute solutions of paramyosin from the clam Mercenaria mercenaria in water and glycerol--water mixtures containing potassium chloride and phosphate buffer. The Birnboim--Schrag multiple-lumped resonator was used in the frequency range from 150 to 8100 Hz; the concentration range was 0.7 to 2 X 10(-3) g/mL and the temperature range was 0.0 to 6.0 degrees C. The intrinsic moduli were obtained by extrapolation to infinite dilution. When compared with predictions of Yamakawa for a rigid cylindrical molecule, they agreed at low frequencies but diverged at high frequencies. Excellent agreement was obtained with calculations for a hybrid model whose relaxation times are attributed to rigid-body end-over-end rotation together with some internal modes of motion, probably flexural. The rotational relaxation time agreed rather well with that determined by DeLaney and Krause from electrical birefringence measurements. From the ratio of the rotational to the longest flexural relaxation time, the flexural rigidity and Young's modulus of the paramyosin molecule were estimated by relations derived by Wada and collaborators; the modulus was 1.2 X 10(10) dyn/cm2.

To assess the differential salience of geometric features embedded in spatial displays, 60 preschool children, 3 to 5 years old, were required to reconstruct a series of geometric displays. Each arrangement included the depiction of a topological feature, unconnectedness; a Euclidean feature, linearity; and a projective feature, orientation. Children built their reconstructions under two demand conditions. The reconstructions were scored for the number that preserved each of the different geometric features. Results from a mixed-design analysis of variance revealed main effects for age, demand condition, and geometric feature, as well as for several first-order interactions. Data indicated that the Euclidean feature was the most salient and most frequently preserved characteristic and that the topological and projective ones were more problematic. The findings were discussed as a contrast to Piagetian predictions.

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow-up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

The gross and microscopic appearance of the hearts from eight patients with Duchenne's progressive muscular dystrophy are described. Seven hearts had gross evidence of myocardial fibrosis, five of these demonstrating distinctive fibrosis of the epimyocardial portion of the free wall of the left ventricle, often with a striking band-like appearance. On the basis of mapping studies of the myocardial fibrosis, a theory regarding the progression of myocardial fibrosis in Duchenne's progressive muscular dystrophy is presented. Correlation of the pathologic anatomy, electrocardiograms, and vectorcardiograms in these patients and the family studies of others suggests that Duchenne's progressive muscular dystrophy represents a generalized cardiomyopathy that has its gravest and most distinctive effect on the epimyocardial portion of the free wall of the left ventricle.

Measurements of small oscillatory deformations of a fibrin clot by axial motion of a rod in a closed tube reveal an anomalous mechanical loss due to permeation of fluid through the clot structure. The Darcy constant for permeation can be calculated from data at the frequency where the apparent storage and loss shear moduli are equal, without the necessity of measurements at much lower frequencies as previously employed. From the Darcy constant, the average number of fibrin monomer units (v) per cross-section of a fibrous element of the clot can be calculated; it ranges from 4 to several hundred. In the range of fibrin concentration(c) from 3 to 14 milligrams, v is approximately proportional to c-2 for clots of coarse structure and to c-0.5 for clots of fine structure.

This paper describes the process and technique of brief analytic psychotherapy with a 22-year-old schizophrenic man who was treated twice weekly for ten months and then followed up for two years. During therapy, re-integration occurred in his affective and cognitive processes. Despite his subjective experience of loss of the capacity for thought and for verbal and non-verbal communication, he had an unusual ability for conveying the stages by which he moved from total confusion and thought disorder to normal intellectual functioning, and for understanding the connections between his various experiences. Four phases of therapy are defined: a phase of disintegration and undifferentiation lasting six weeks, a phase of depression lasting for five weeks, a phase of multiple feelings lasting for fourt thought disorder to normal intellectual functioning, and for understanding the connections between his various experiences. Four phases of therapy are defined: a phase of disintegration and undifferentiation lasting six weeks, a phase of depression lasting for five weeks, a phase of multiple feelings lasting for fourt thought disorder to normal intellectual functioning, and for understanding the connections between his various experiences. Four phases of therapy are defined: a phase of disintegration and undifferentiation lasting six weeks, a phase of depression lasting for five weeks, a phase of multiple feelings lasting for fourteen weeks, and a phase of self-sustained development, starting in the twenty-fifth week and continuing beyond the end of therapy. The patient identified two major types of divisions between thinking, feeling and acting parts of himself and between masculine and feminine parts. Insight into these divisions helped him to understand disorders in his perception of time, and in thinking, remembering and using words and other symbols. His descriptions are presented here in the hope that they may throw light on the difficulties of similar, but less articulate, patients.