Initial Clinical Impressions Research Articles

Multi‐family therapy for adult outpatients with obsessive‐compulsive disorder and their family members, targeting family accommodation

AbstractThis paper describes a multi‐family therapy (MFT) group for adult outpatients with obsessive‐compulsive disorder and their family members. Since family accommodation (FA) is known to maintain OCD symptoms by preventing exposure and response prevention (ERP), reduction of FA is a major focus of the treatment. Furthermore, psychoeducation, conjoint ERP and (re)discovering resources and strengths of families are also important therapeutic foci of the family group. The organisation of MFT is explained and involvement of family is illustrated with clinical vignettes. Finally, some reflections about MFT are provided. On the basis of initial clinical impressions, MFT seems a promising approach. A clinical trial is currently underway.

Implantation Mycoses and Invasive Fungal Infections with Cutaneous Involvement in Tropical Taiwan: An 11-Year Retrospective Study of a Medical Center

The rising incidence of implantation mycoses and invasive fungal infections prompts the need for studies describing the latest trends of these diseases; however, the literature remains scarce from tropical Asia in recent years. We shared our 11-year clinical experience at a tertiary center in Southern Taiwan to improve physicians' understanding of the diseases, which could help them assume appropriate management strategies. Forty cases of pathology-proven cases of implantation mycoses and invasive fungal infections with cutaneous involvement were retrospectively reviewed. The epidemiology, patients' characteristics, initial clinical impressions, fungal species, management, and outcomes were compared and reported. Fonsecaea sp. was the most commonly (14%) involved species in implantation mycoses. The percentages of immunocompromised patients with implantation mycoses and invasive fungal infections were 26% and 60%, respectively. Additionally, 46% of patients with implantation mycoses had type 2 diabetes mellitus. The lesions were commonly mistaken for skin appendage tumors, skin cancers, and hyperkeratotic dermatoses. The prognosis was favorable for the implantation mycoses (83% showed clinical improvement) but bleak for the invasive fungal infections (100% mortality). Presentations of implantation mycoses and invasive fungal infections vary widely, and immunocompromised status and diabetes mellitus are important associated factors.

Prehospital identification of ST-segment elevation myocardial infarction and mortality (ANZACS-QI 61)

BackgroundEarly recognition of ST-segment elevation myocardial infarction (STEMI) is needed for timely cardiac monitoring and reperfusion therapy.MethodsThree anonymously linked New Zealand national datasets (July 2016–November 2018) were used to assess...

Initial Clinical Impressions of the Critical Care of COVID-19 Patients in Seattle, New York City, and Chicago.

Since the first recognition of a cluster of novel respiratory viral infections in China in late December 2019, intensivists in the United States have watched with growing concern as infections with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus―now named Coronavirus Disease of 2019 (COVID-19)―have spread to hospitals in the United States. Because COVID-19 is extremely transmissible and can progress to a severe form of respiratory failure, the potential to overwhelm available critical care resources is high and critical care management of COVID-19 patients has been thrust into the spotlight. COVID-19 arrived in the United States in January and, as anticipated, has dramatically increased the usage of critical care resources. Three of the hardest-hit cities have been Seattle, New York City, and Chicago with a combined total of over 14,000 cases as of March 23, 2020.In this special article, we describe initial clinical impressions of critical care of COVID-19 in these areas, with attention to clinical presentation, laboratory values, organ system effects, treatment strategies, and resource management. We highlight clinical observations that align with or differ from already published reports. These impressions represent only the early empiric experience of the authors and are not intended to serve as recommendations or guidelines for practice, but rather as a starting point for intensivists preparing to address COVID-19 when it arrives in their community.

Primary Hand Leiomyoma: A Systematic Review.

Primary leiomyoma is a rare cause of a mass in the hand, with few reported cases to date. To our knowledge, this constitutes the most comprehensive and up-to-date systematic review of the literature of all cases of primary hand leiomyoma. We also provide an additional case recently managed in our practice of confirmed primary vascular leiomyoma of the hand in a 44-year-old woman to add to the current body of literature. We performed a comprehensive literature review of all articles published on primary leiomyoma of the hand. The PubMed database was used, with search terms leiomyoma hand, angioleiomyoma hand, and angiomyoma hand. Articles were selected for their accuracy in anatomic localization in the hand and confirmed pathology of leiomyoma. Our initial search query resulted in 216 articles. After applying the inclusion criteria, we identified 50 individual articles with 108 cases of confirmed primary leiomyoma in the hand from January 1, 1954, to July 1, 2018. Common initial clinical impressions recorded for primary hand leiomyoma included ganglion cyst, giant-cell tumor, hemangioma, and glomus tumor. Patients presenting with leiomyoma of the hand frequently describe a painful lesion, which differs from most other benign tumors of the hand at presentation. Leiomyoma is an important consideration when developing a differential diagnosis for primary benign masses in the hand. We hope that this comprehensive review can provide increased awareness of this tumor type.

Prognostic effects of doctor-associated diagnostic delays in osteosarcoma

In this retrospective study, we evaluated to what extent diagnostic delays impact prognosis in osteosarcoma. The authors identified 26 osteosarcoma patients who had undergone inappropriate procedure-associated diagnostic delays of more than 45 days after surgery, calculated overall survival rates, and analyzed clinicopathologic characteristics. Initial clinical impressions were of a benign bone tumor in 15 patients, fracture in 8, and infection in 3. After initial inappropriate procedures, primary surgeons failed to send a tissue sample to a pathologist for definite diagnosis in 12 cases, and pathologists made incorrect diagnoses in the other 14. The average doctor-associated diagnostic delay after inappropriate surgery for these 26 patients was 10.5 months. Following referral to our institute, 22 underwent both surgery and chemotherapy and the remaining 4 patients underwent chemotherapy only. Four of the 26 patients were alive at last follow-ups. Estimated 5- and 10-year overall survival rates were 26 and 10%, respectively. The present study shows that doctor-associated diagnostic delay superimposed on an inappropriate primary procedure has a significant detrimental effect on overall survival in osteosarcoma. This study demonstrates that surgeons and pathologists should spare no effort to minimize diagnostic errors and delays.

Initial clinical impressions of the UC Davis large animal lift and its use in recumbent equine patients

The U.C. Davis Large Animal Lift (LAL) is a lightweight sling developed to help lift horses in clinical and rescue situations. Here we report on its first use in 16 recumbent horses with neurologic, muscular and musculoskeletal disorders. For each horse, history, sedation, ease and time of LAL application and hoisting, standing ability, LAL tolerance and outcome were recorded. The LAL was easily and safely applied in all horses in less than five minutes and the procedure was well tolerated with minimal to no sedation. While 10 horses were able to stand in the LAL after being hoisted, 6 horses were unable to stand and were eventually euthanized due to the inability to regain weight bearing function. The LAL has shown to be a useful devise to evaluate the standing ability of recumbent horses and can be used alone or in combination with the Anderson Sling Support Devise to allow standing support of horses with a variety of debilitating problems.

The Treatment of Eating Disorder Clients in a Community-Based Partial Hospitalization Program

The provision of psychological treatment within the community is becoming increasingly important as time and resources become more scarce. Nowhere is this challenge greater than when undertaking the treatment of eating disorder clients in a community mental health setting. In this paper, we outline a multi-faceted treatment approach to eating disorders within a partial hospital program that is affiliated with a community mental health hospital. Although empirical confirmation is not currently available, initial clinical impressions indicate that the program is facilitating the recovery of these difficult-to-treat individuals.

Quality of History Taking in Patients With Aortic Dissection

Aortic dissection generally is an acute catastrophe. Rapid diagnosis is critical. We hypothesized that the quality of history taking contributes to the accuracy of diagnosis in patients with dissection. Retrospective chart review of 83 patients, whose diagnosis of aortic dissection was confirmed by autopsy, surgery, CT scan, echocardiogram, or angiogram. The quality of the initial history was reviewed using predetermined criteria. The physicians' initial clinical impressions were recorded. The examining physician correctly suspected aortic dissection after the initial clinical evaluation in 54 of 83 patients (65%). Only 33 of 78 patients with symptoms (42%) were asked about the quality, location, and onset of their pain, the three descriptors identified a priori as important. In 19 patients (24%), only zero or one descriptor was recorded. When all three questions were asked, dissection was suspected in 30 of 33 patients (91%); when zero, one, or two questions were asked, dissection was suspected in 22 of 45 patients (49%). Despite important advances in diagnostic imaging, accurate diagnosis of aortic dissection requires an accurate history. In our series, the quality of initial history was associated with the accuracy of the initial clinical impression in patients with aortic dissection.

Efficacy of cytotoxic agents for the prevention of laparoscopic port-site metastases.

Recent experimental studies support initial clinical impressions that laparoscopic surgery for malignant neoplasms may be associated with an increased incidence of metastases to port sites. This study investigated in an experimental model the influence of cytotoxic agents (administered intraperitoneally or intramuscularly) on the development of port-site metastases following laparoscopic surgery. Seven days after the implantation of an adenocarcinoma in the left abdominal flank, 72 Dark Agouti rats underwent laparoscopy with carbon dioxide insufflation, instillation of an intraperitoneal agent, and intraperitoneal tumor laceration within the following study groups (12 rats in each group): (1) control (no intraperitoneal instillation); (2) intraperitoneal instillation of isotonic sodium chloride solution (0.9%); (3) intraperitoneal instillation of povodine-iodine (1:10 dilution of povidine-iodine and isotonic sodium chloride solution); (4) intraperitoneal instillation of methotrexate (0.125 mg of methotrexate in 3 mL of isotonic sodium chloride solution); and (5) intraperitoneal instillation of aqueous chlorhexidine acetate. Twelve additional rats underwent laparoscopic tumor laceration following intramuscular injection of 0.125 mg of methotrexate (no intraperitoneal agent). Rats were killed 7 days after the procedure, and the wounds were examined histologically by a blinded histopathologist for the presence of tumor metastases. No tumor was found in any port site following the intraperitoneal administration of povidine-iodine (P=.04). In contrast, port-site metastases developed in the control group (5 [41.7%] of 12), the isotonic sodium chloride solution group (4 [33.3%] of 12), the chlorhexdine group (4 [33.3%] of 12), the intraperitoneal methotrexate group (2 [16.7%] of 12), and the parenteral methotrexate group (5 [41.7%] of 12). The results of this study suggest that the development of metastases to port sites following laparoscopic surgery may be prevented by the intraperitoneal instillation of diluted povodine-iodine. Other agents failed to influence the incidence of port-site metastases. Further studies are needed to determine if these findings can be applied to humans.

Therapists' Initial Clinical Impressions of 145 Maltreated Children and Adolescents Referred for Therapy

Therapists' Initial Clinical Impressions of 145 Maltreated Children and Adolescents Referred for Therapy

Putting the illness in its place: discussion groups for families with chronic medical illnesses.

A new psychosocial intervention for families and patients experiencing the chronic phase of a disabling medical illness is described. The intervention, a short-term, highly structured, psychoeducationally oriented, multiple-family discussion group (MFDG), was developed within the context of a clinical research program and has been successfully applied to a heterogeneous range of disabling medical illnesses. This report includes a detailed description of the treatment model, the format and content of group meetings, and initial clinical impressions regarding MFDG efficacy.

Interobserver agreement in the diagnosis of stroke type.

Interobserver agreement is essential to the reliability of clinical data from cooperative studies and provides the foundation for applying research results to clinical practice. In the Stroke Data Bank, a large cooperative study of stroke, we sought to establish the reliability of a key aspect of stroke diagnosis: the mechanism of stroke. Seventeen patients were evaluated by six neurologists. Interobserver agreement was measured when diagnosis was based on patient history and neurologic examination only, as well as when it was based on results of a completed workup, including a computed tomographic scan. Initial clinical impressions, based solely on history and one neurologic examination, were fairly reliable in establishing the mechanism of stroke (ie, distinguishing among infarcts, subarachnoid hemorrhages, and parenchymatous hemorrhages). Classification into one of nine stroke subtypes was substantially reliable when diagnoses were based on a completed workup. Compared with previous findings for the same physicians and patients, the diagnosis of stroke type was generally more reliable than individual signs and symptoms. These results suggest that multicentered studies can rely on the independent diagnostic choices of several physicians when common definitions are employed and data from a completed workup are available. Furthermore, reliability may be less for individual measurements such as signs or symptoms than for more-complex judgments such as diagnoses.

Autonomic Hyper-reflexia Modulated by Percutaneous Epidural Neurostimulation

Our clinical experience in the management of five paraplegic or quadriplegic patients with subjective complaints and objective findings of autonomic hyper-reflexia is presented. These five patients had epidural neurostimulation systems implanted percutaneously to regulate intractable spasticity. During a follow-up period varying from 2 months to almost 2 years, four of the five patients experienced no episodes of autonomic dysfunction with the use of a low frequency, low voltage, square wave pulse output. From their responses and from recent neurophysiological evidence, the potential benefit of percutaneous epidural neurostimulation in the modulation of autonomic hyper-reflexia without antihypertensive medication is suggested. Further follow-up of these patients and additional clinical research should be performed to confirm our initial clinical impressions.

Autonomic hyper-reflexia modulated by percutaneous epidural neurostimulation

Our clinical experience in the management of five paraplegic or quadriplegic patients with subjective complaints and objective findings of autonomic hyper-reflexia is presented. These five patients had epidural neurostimulation systems implanted percutaneously to regulate intractable spasticity. During a follow-up period varying from 2 months to almost 2 years, four of the five patients experienced no episodes of autonomic dysfunction with the use of a low frequency, low voltage, square wave pulse output. From their responses and from recent neurophysiological evidence, the potential benefit of percutaneous epidural neurostimulation in the modulation of autonomic hyper-reflexia without antihypertensive medication is suggested. Further follow-up of these patients and additional clinical research should be performed to confirm our initial clinical impressions.

Mild pulmonary valvular stenosis studied functionally and anatomically.

Mild pulmonary valvular stenosis with an intact ventricular septum (also termed ‘isolated’, ‘solitary’, and ‘with normal aortic root’) has received little attention in the roentgenologic literature (KJELLBERG et coll. 1955, 1959, and GAY & FRANCH 1960). We have had twenty cases in which the diagnosis has been established by cardiac catheterization; in sixteen of these selective angiocardiography was also performed. Five of these cases were previously reported by KJELLBERG et coll. For purposes of this investigation mild solitary pulmonary stenosis was defined as : valvular stenosis by which at catheterization a peak right ventricular pressure no greater than 50 mm Hg with the patient at rest was demonstrated, and no evidence of a left-to-right shunt by oximetry. Methods and Material. The initial clinical impressions, conventional roentgenograms, cardiac catheterization data and selective angiocardiograms were studied in these 20 cases and contrasted with 15 ‘normal’ cases and 19 verified cases of moderate and marked stenosis. The ‘normal’ cases consisted of 9 cases - .~~_