Coatesville Veterans Affairs Medical Center

Abstract The vibrational spectrum of a molecule is considered to be a unique physical property and is characteristic of the molecule. As such, the infrared spectrum can be used as a fingerprint for identification by the comparison of the spectrum from an “unknown” with previously recorded reference spectra. This is the basis of computer‐based spectral searching. In the absence of a suitable reference database, it is possible to effect a basic interpretation of the spectrum from first principles, leading to characterization, and possibly even identification of an unknown sample. This first principles approach is based on the fact that structural features of the molecule, whether they are the backbone of the molecule or the functional groups attached to the molecule, produce characteristic and reproducible absorptions in the spectrum. This information can indicate whether there is backbone to the structure and, if so, whether the backbone consists of linear or branched chains. Next it is possible to determine if there is unsaturation and/or aromatic rings in the structure. Finally, it is possible to deduce whether specific functional groups are present. If detected, one is also able to determine local orientation of the group and its local environment and/or location in the structure. The origins of the sample, its prehistory, and the manner in which the sample is handled all have impact on the final result. Basic rules of interpretation exist and, if followed, a simple, first‐pass interpretation leading to material characterization is possible. This article addresses these issues in a simple, logical fashion. Practical examples are included to help guide the reader through the basic concepts of infrared spectral interpretation.

1. Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary foot-care team (A-II) (table 1). The team managing these infections should include, or have ready access to, an infectious diseases specialist or a medical microbiologist (B-II). Infectious Diseases Society of America—United States Public Health Service Grading System for ranking recommendations in clinical guidelines. 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic foot infections. Patients who have chronic wounds or who have recently received antibiotic therapy may also be infected with gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inflammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Send appropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain radiography may be adequate in many cases, but MRI (in preference to isotope scanning) is more sensitive and specific, especially for detection of soft-tissue lesions (A-I). 8. Infections should be categorized by their severity on the basis of readily assessable clinical and laboratory features (B-II). Most important among these are the specific tissues involved, the adequacy of arterial perfusion, and the presence of systemic toxicity or metabolic instability. Categorization helps determine the degree of risk to the patient and the limb and, thus, the urgency and venue of management. 9. Available evidence does not support treating clinically uninfected ulcers with antibiotic therapy (D-III). Antibiotic therapy is necessary for virtually all infected wounds, but it is often insufficient without appropriate wound care. 10. Select an empirical antibiotic regimen on the basis of the severity of the infection and the likely etiologic agent(s) (B-II). Therapy aimed solely at aerobic gram-positive cocci may be sufficient for mild-to-moderate infections in patients who have not recently received antibiotic therapy (A-II). Broad-spectrum empirical therapy is not routinely required but is indicated for severe infections, pending culture results and antibiotic susceptibility data (B-III). Take into consideration any recent antibiotic therapy and local antibiotic susceptibility data, especially the prevalence of methicillin-resistant S. aureus (MRSA) or other resistant organisms. Definitive therapy should be based on both the culture results and susceptibility data and the clinical response to the empirical regimen (C-III). 11. There is only limited evidence with which to make informed choices among the various topical, oral, and parenteral antibiotic agents. Virtually all severe and some moderate infections require parenteral therapy, at least initially (C-III). Highly bioavailable oral antibiotics can be used in most mild and in many moderate infections, including some cases of osteomyelitis (A-II). Topical therapy may be used for some mild superficial infections (B-I). 12. Continue antibiotic therapy until there is evidence that the infection has resolved but not necessarily until a wound has healed. Suggestions for the duration of antibiotic therapy are as follows: for mild infections, 1–2 weeks usually suffices, but some require an additional 1–2 weeks; for moderate and severe infections, usually 2–4 weeks is sufficient, depending on the structures involved, the adequacy of debridement, the type of soft-tissue wound cover, and wound vascularity (A-II); and for osteomyelitis, generally at least 4–6 weeks is required, but a shorter duration is sufficient if the entire infected bone is removed, and probably a longer duration is needed if infected bone remains (B-II). 13. If an infection in a clinically stable patient fails to respond to ⩾1 antibiotic courses, consider discontinuing all antimicrobials and, after a few days, obtaining optimal culture specimens (C-III). 14. Seek surgical consultation and, when needed, intervention for infections accompanied by a deep abscess, extensive bone or joint involvement, crepitus, substantial necrosis or gangrene, or necrotizing fasciitis (A-II). Evaluating the limb's arterial supply and revascularizing when indicated are particularly important. Surgeons with experience and interest in the field should be recruited by the foot-care team, if possible. 15. Providing optimal wound care, in addition to appropriate antibiotic treatment of the infection, is crucial for healing (A-I). This includes proper wound cleansing, debridement of any callus and necrotic tissue, and, especially, off-loading of pressure. There is insufficient evidence to recommend use of a specific wound dressing or any type of wound healing agents or products for infected foot wounds. 16. Patients with infected wounds require early and careful follow-up observation to ensure that the selected medical and surgical treatment regimens have been appropriate and effective (B-III). 17. Studies have not adequately defined the role of most adjunctive therapies for diabetic foot infections, but systematic reviews suggest that granulocyte colony-stimulating factors and systemic hyperbaric oxygen therapy may help prevent amputations (B-I). These treatments may be useful for severe infections or for those that have not adequately responded to therapy, despite correcting for all amenable local and systemic adverse factors. 18. Spread of infection to bone (osteitis or osteomyelitis) may be difficult to distinguish from and may but bone is for the of osteomyelitis, for the and for the antibiotic of (B-II). field has is The especially that adequately studies be to and for infection, diagnosing osteomyelitis, optimal antibiotic regimens in various and the role of in treating osteomyelitis of the Foot infections in with diabetes are a and addition to severe for the of and are the most cause of amputations Diabetic foot infections require careful attention and coordinated management, preferably by a multidisciplinary foot-care team (A-II) The team managing these infections should preferably include, or have ready access to, an infectious diseases specialist or a medical microbiologist of diabetic foot infections can the of the for and duration of and the of major limb amputation these infections are This may from a of of and insufficient to the or a of effective multidisciplinary The of is to help the medical and with diabetic foot infections. The of is on managing the diabetic patient with or foot infection, other the of the diabetic foot and diabetic foot The that the of care and the of in some clinical the of some of the and that in all care is usually more difficult to or care and This should a for treating all diabetic patients who have a foot health care be to it better and of of may the and with including those related to antibiotic wound care, surgical and adjunctive it to the of lower in with the may may be by an for foot care, (especially and vascular This is of Infectious Diseases Society of with experience and interest in diabetic foot infections, many of also have experience in guidelines. are from and other their and clinical infectious diseases clinical and of the are also of the on the Diabetic which on and Diabetic Foot Infections in an extensive the the the diabetic foot and and of of and all evidence in a of and and a of that and these as a basis for the which that based on both and of the of or other evidence in most of recommendations are based on and (table to a and to an extensive for those who to the data diabetic foot infection is most defined as any infection in a with diabetes These necrotizing and The most and is the infected diabetic foot This wound results from a of risk factors which are in 2. the with disturbances of and to to or on a foot that the of is tissues are to This wound may to and, by the infection can This of can be or especially in an especially those that may some diabetic and these likely the risk and severity of foot infections factors for foot and Aerobic gram-positive cocci are the predominant that and in the S. aureus and the and but especially are the most pathogens wounds a more including various obligate and, other gram-negative surgical and, especially, or antibiotic therapy may patients to infection with or have previously been from cases are and are with in patients with diabetic foot infections S. aureus has been in the cases of S. aureus a diabetic patient with a foot infection The necrotic or bone may as and to a role infections in patients who have not recently received antimicrobials are often with an aerobic gram-positive chronic infections are often of specimens obtained from patients with infections generally including gram-positive and gram-negative and The role of in a infection is often clinical infection and the pathogens most likely in with with various clinical Diabetic patients may many of foot wounds, any of which can should be diagnosed clinically on the basis of the presence of purulent or at least of the of or and or not all ulcers are infected an infection often to, but is not defined healing of an of diabetic foot infections and the severity of infection as the basis for the appropriate to treatment (B-II). The of osteomyelitis is particularly and and is with to treating a diabetic patient with a foot wound of the infection should at as in and the patient as a the limb or and the infected The is to determine the clinical (table and the (table of the infection, the or of the any of foot to the cause of the wound thus, to any of vascular (especially and the presence of any systemic of the or experience to any of these should appropriate Evaluating the diabetic patient who has an infected of soft-tissue specimens from an infected diabetic foot for The results of the in can be used to determine the severity of the infection and to a (B-II). the of on wound and infection of The has been used for but for the is severe and all infections a is that the issues in a diabetic foot wound are (in which tissues are and the wound is by ischemia or infection (B-II). The on the Diabetic Foot recently a on a diabetic foot ulcer for The are by the infection, and The infection includes of and or and of a systemic response is to be to all it includes a of for uninfected 2–4 are to those in 6. to treating a diabetic patient with a foot if any of the are systemic toxicity and metabolic severe or or infection, substantial necrosis or gangrene, or presence of of or and to care for or of a diabetic foot infected wounds the most important is to patients who require parenteral and empirical antibiotic therapy, and consideration of and surgical have defined these infections as Infections defined as must be from clinically uninfected lesions but are to infections as the a of wounds, some of which can be and limb have used the and with mild and but to with the various that can a The moderate and severe infections has to with the of the foot with the patient to it is This is by the that of patients with a infection not systemic signs or the in as a basis for in and (B-II). antibiotics for uninfected that many uninfected diabetic foot ulcers are a of defined as of that results in and wound healing Available evidence does not support the use of antibiotics for the of clinically uninfected to wound healing or as infection antibiotic use and may cause adverse therapy of uninfected some it is difficult to a chronic wound is as when the foot is has or a has tissue, is with or or when an ulcer fails to healing these cases, a of antibiotic therapy may be appropriate (C-III). the for is the most of treating a diabetic foot infection, and on consideration of both medical and Patients with infections that are severe or by limb ischemia should generally be patients with mild infections and more patients with moderate infections may also may be for or factors are likely to their wound care or to antibiotic the of these most patients with mild or moderate infections can be as (A-II) the to the metabolic of the patient is This may of the and of and and treatment of other patients who require should usually be to the should usually not be for after to the The of may in both the infection and healing the wound the infection may be to an antibiotic of the antibiotic regimen initially the of therapy, the of to be and the specific to and the regimen and the duration of therapy is usually empirical and should be based on the severity of the infection and on any data, as recent culture results or severe infections and for chronic moderate infections, it is to therapy with agents. These should have gram-positive cocci (including in is as as gram-negative and obligate anaerobic (B-III). ensure adequate and therapy should be at least initially (C-III). some suggest empirical therapy for most infections the of many can be with agents with a as those only aerobic gram-positive cocci (A-II) anaerobic are from many severe infections are in mild-to-moderate infections and there is evidence to support the for therapy in most infections (B-III). mild-to-moderate infections in patients without and for an oral with the appropriate is oral therapy is often especially with bioavailable agents (A-II). infected wounds with limited data support the use of therapy in effective in infected diabetic foot lesions is with the of the specific and, especially, the arterial supply to the with diabetes There are few clinical of antibiotic therapy for diabetic foot antibiotic patients with various and soft-tissue infections have some patients with diabetic foot infections. a of clinical that on therapy of diabetic foot infections, or as an of a The of among these the of of regimens The of infection severity and clinical that used in these the to a for the basis of the or of agents to be to Antibiotic agents used in clinical studies of diabetic foot infections. some empirical antibiotic regimens to the clinical severity of the infection, the data not to recommend any specific antibiotic regimen for diabetic foot infections (B-II). These agents are from clinical and experience and are not to be of all agents be depending on various and antibiotic therapy when culture and susceptibility results are (C-III). choices for patients who are not to antibiotic therapy should agents that a or of The regimens in are in of the does not by the of antibiotic agents should be selected to of the and the and the experience of the and should be on the basis of any (especially and other clinical factors. empirical antibiotic based on clinical for diabetic foot infections. to a diabetic patient with a foot infection who is not to of the for infections require surgical that from and of infected and necrotic tissues to of the lower and of soft-tissue or surgical treatment of diabetic foot infections is based on evidence that for antibiotic therapy Seek surgical consultation for or infections, as those with necrotizing gangrene, extensive soft-tissue or evidence of or those in with ischemia (A-II) surgical specialist should also patients who have foot or evidence of a infection, deep or infection in the of appropriate medical care and surgical debridement, including limited or may the for amputation especially in an can cause and patients with infections, it may be appropriate to to the of medical therapy or to determine the necrotic and The must determine the adequacy of the supply to the consider infection among foot to the deep or the and a for soft-tissue secondary or The surgical should the for healing and should to the of the of the foot addition to the must have sufficient and experience to when and to The is important or of the of the the of and infection, and experience with and for the field most the should to the patient until the infection is and the wound is healing (B-III). some cases, amputation is the or only amputation is usually required only when there is extensive necrosis or infection amputation may be for the patient who has has of foot or require or care of the of amputation must into consideration and issues the should to as of the limb as possible. a amputation that results in a more if a is may be a better a foot that is to or to all or of a foot has gangrene, it may be preferable (especially for a patient for is a to the necrotic may also be to in especially on the until to be more removed, there does not to be an of infection If the infected limb to be the patient should be to a with vascular most cases, ischemia is to to the and the to be may be amenable to or vascular Patients with ischemia those with an to of can usually be without a vascular vascular disease of the many have use of in diabetic patients a patient with a infected it is usually preferable to any needed early after the infection 1–2 to in of (and antibiotic therapy the other careful debridement of necrotic infected should not be surgical may require a The wound may require additional attention after the debridement the (table The is to and tissue, wound healing and a of pathogens may limited This can usually be as a or and without especially for a debridement with or is generally preferable to or which are and and may require and There are many products that are as to healing in various but a of these is The infected wound should be in a that and a (B-III). evidence any type of and are important of from a foot wound is crucial to the healing of can the infected but it is important to that and have many of including wound factors and therapy treatment likely has some appropriate for infected wounds, evidence is insufficient to recommend use of any of these for treatment or adjunctive granulocyte colony-stimulating factors have been in diabetic foot infections of these that does not of infection but may the for and suggest that hyperbaric oxygen therapy may be of for treatment of diabetic foot wounds, and a few recent studies have results recent that hyperbaric oxygen therapy the risk of major amputation related to a diabetic foot ulcer (B-I). additional clinical can for and with these and limited be used in the treatment of diabetic foot infections. should be used as a for proper surgical debridement and observation of the response to therapy is and should be for and perhaps initially for (B-III). The of are of local and systemic symptoms and clinical signs of inflammation. including and as the and the are of limited use for is it to and cause for when to antibiotic therapy for a diabetic patient with a foot methicillin-resistant Staphylococcus a patient is ready for or an for the should and 1. Select the antibiotic the culture and susceptibility results and any adverse related to the antibiotic a antibiotic regimen (including the treatment on the basis of the results of or other and the clinical response (C-III). is not necessary to all from S. aureus and or should be but in a infection, and may be important (B-II). If the infection has not responded to the empirical agents with all a clinically stable patient who has ⩾1 of therapy, consider discontinuing antimicrobials for a few and optimal specimens for culture (C-III). 2. the the to ensure that the infection is and that the wound is If is the for surgical evidence antibiotics for the entire that the wound remains should be used for a defined by the of the infection and by the clinical as in (A-II). If clinical evidence of infection the on the with antibiotics and for adverse factors These may the of antibiotic a an deep or of osteomyelitis, or ischemia that is more severe initially and of antibiotic therapy, by clinical 3. the off-loading and wound care the and the the consultation when 4. that and other of the metabolic are adequately with osteomyelitis is perhaps the most difficult and in the of diabetic foot infections among is that the of a of the disease the of studies and there are many but often the presence of osteomyelitis the of surgical including and the required duration of antibiotic therapy osteomyelitis healing of the wound and as a for to consider the osteomyelitis as a of any deep or extensive especially that is chronic or a osteomyelitis when an ulcer does not after at least weeks of appropriate care and ulcer in which bone is or can be with a is likely to be by osteomyelitis patients with a infection, results of a may be as sufficient for but the of have not been foot in a patient with a of foot ulceration, a a or an or should also of osteomyelitis (B-II). bone an ulcer should be to osteomyelitis a diabetic patient who has osteomyelitis of the and or be or preferably after antibiotic therapy has been for 1–2 weeks to the is usually not on radiography the early of disease and can infection, diagnosing osteomyelitis at the the patient to the can be difficult on may help in cases are more sensitive for osteomyelitis the early of but are and can be The of various of but the of bone is generally MRI is the most useful of the MRI is the most for bone infection, and it also the most of deep soft-tissue infections. The of all these are with the of osteomyelitis, and are most useful for cases The for diagnosing osteomyelitis is of from a obtained of bone to with findings of and (B-II). few of the studies that have or have treatment have used MRI is usually not needed as a in cases of diabetic foot osteomyelitis is a obtaining often If these evidence of pathological findings in the patient should be for weeks for the soft-tissue If of osteomyelitis radiography 2–4 weeks If the of osteomyelitis and and and if there is of a for osteomyelitis, preferably after obtaining appropriate specimens for culture (B-III). If findings of radiography are only but not osteomyelitis, of the choices should be 1. MRI is the with preferably use or a If results of the are osteomyelitis is if results suggest osteomyelitis, consider bone is needed 2. antibiotic therapy for 2–4 weeks and to determine have suggest 3. an appropriate as defined of a of a or is if the remains in after or if osteomyelitis is likely but the etiologic or antibiotic are not also specimens of most or these are more difficult to and more often lead to a the an can the should preferably be or if possible. patients with may be of as by and and by have been specimens if at least for culture and for it may only be to a few of of foot bone and consider it to be a (B-II). of bone specimens more data those of soft-tissue specimens for patients with osteomyelitis medical and surgical have that a bone with chronic osteomyelitis for some have the for surgical Definitive surgical to osteomyelitis, as and may risk of the in and additional of and systemic of infection may make osteomyelitis for the who may for at medical management. these diabetic may also bone with or in infection, additional bone or soft-tissue and a These have some health care professionals to diabetic foot osteomyelitis with or surgical intervention on treatment with a of antibiotics have clinical in of cases these often to a of osteomyelitis, patients patients or and debridement of bone The of which patients are for as as duration of antibiotic therapy is needed, are important for there are cases in which of osteomyelitis be (B-II). 1. There is surgical of the infection cause of 2. The patient has ischemia by vascular disease but to 3. is to the and there is soft-tissue 4. The patient and health care that surgical risk or is not appropriate or therapy for osteomyelitis consider the is there necrotic or infected bone or surgical that should be or the selected antibiotic regimen likely the and adequate in and it for a sufficient the to bone infection the cause of the wound an usually in consultation with a patients may from antibiotics in or hyperbaric oxygen therapy, or may or antibiotic in some cases, an antibiotic The most appropriate duration of therapy for any type of diabetic foot infection has not been defined is important to consider the presence and of any or infected bone and the of the a infected tissue, antibiotic therapy is needed (B-II). if infected bone or despite treatment is osteomyelitis, some parenteral therapy may be especially if an with is used (C-III). therapy may be in the recommendations for duration of therapy are based on the clinical and are in 9. The of treating a diabetic foot infection are the of clinical evidence of infection and the of soft-tissue and a clinical response of clinical evidence of to appropriate therapy in of mild-to-moderate infections and in of severe infections or cases of osteomyelitis with a signs of systemic infection limb perfusion, osteomyelitis the presence of necrosis or gangrene an and of the infection in of especially in those with may be difficult to from a recent of of the Infections that the for treating diabetic foot osteomyelitis systematic of and patient treatment may be useful for and for multidisciplinary foot-care (B-II). patient who has foot infection is more likely to have a to with the patient of is the to prevent foot infections. the patient the of appropriate at all foot of the and any to health care professionals (A-II). can be in a few should these by patients foot care and their and Patients with severe substantial foot or ischemia should be to appropriate to with these (A-II). of the recommendations in are based on and adequately There are in which be particularly 1. a for infected foot lesions to studies of their and support to the for 2. there is a role for antibiotic therapy in managing clinically uninfected 3. optimal antibiotic regimens and for various of soft-tissue and bone infections. 4. a of osteomyelitis in the diabetic 5. and a for the and treatment of infections, especially 6. the of surgical and of of support or for and for for and and support from support or for and and for and support from and and for and of support from and for and and

Ainslie argues that our responses to the threat of our own inconsistency determine the basic fabric of human culture. He suggests that individuals are more like populations of bargaining agents than like the hierarchical command structures envisaged by cognitive psychologists. The forces that create and constrain these populations help us understand so much that is puzzling in human action and interaction: from addictions and other self-defeating behaviors to the experience of willfulness, from pathological over-control and self-deception to subtler forms of behavior such as altruism, sadism, gambling, and the 'social construction' of belief. This book integrates approaches from experimental psychology, philosophy of mind, microeconomics, and decision science to present one of the most profound and expert accounts of human irrationality available. It will be of great interest to philosophers and an important resource for professionals and students in psychology, economics and political science.

Preface 1. The paradox of addiction 2. In search of the two minds 3. Temporary-preference theory 4. The interaction of interests: the effects of short-range interests 5. The interaction of interests 6. Freedom and compulsion 7. Self-generated reward as the basic impulse-control problem 8. The demon at the calliope 9. The texture of experience Appendices Bibliography Indices.

Relative to individuals who do not have addictive disorders, drug abusers exhibit greater devaluation of rewards as a function of their delay ("delay discounting"). The present study sought to extend this finding to methamphetamine (MA) abusers and to help understand its neural basis. MA abusers (n = 12) and control subjects who did not use illicit drugs (n = 17) participated in tests of delay discounting with hypothetical money rewards. We then used a derived estimate of each individual's delay discounting to generate a functional magnetic resonance imaging probe task consisting of three conditions: "hard choices," requiring selections between "smaller, sooner" and "larger, later" alternatives that were similarly valued given the individual's delay discounting; "easy choices," in which alternatives differed dramatically in value; and a "no choice" control condition. MA abusers exhibited more delay discounting than control subjects (P < 0.05). Across groups, the "hard choice > no choice" contrast revealed significant effects in the ventrolateral prefrontal cortex, dorsolateral prefrontal cortex (DLPFC), dorsal anterior cingulate cortex, and areas surrounding the intraparietal sulcus (IPS). With group comparisons limited to these clusters, the "hard choice > easy choice" contrast indicated significant group differences in task-related activity within the left DLPFC and right IPS; qualitatively similar nonsignificant effects were present in the other clusters tested. Whereas control subjects showed less recruitment associated with easy than with hard choices, MA abusers generally did not. Correlational analysis did not indicate a relationship between this anomaly in frontoparietal recruitment and greater degree of delay discounting exhibited by MA abusers. Therefore, while apparent inefficiency of cortical processing related to decision-making in MA abusers may contribute to the neural basis of enhanced delay discounting by this population, other factors remain to be identified.

The Interaural Time Difference for High-Pass Filtered Noise and Its Relationship With Brainstem Dysfunction and Disability in Multiple Sclerosis,

I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. 1,2 The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. “nontrauma” hospital); access to a particular technology at the surgeon’s institution; and the surgeon’s individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT. II. PROCESS A. Identification of References A MEDLINE search was performed using the key words “abdominal injuries” and the subheading “diagnosis.” This search was limited further to (1) clinical research, (2) published in English, and (3) publication dates January 1978 through February 1998. The initial search yielded 742 citations. Case reviews, review articles, meta-analyses, editorials, letters to the editor, technologic reports, pediatric series, and studies involving a significant number of penetrating abdominal injuries were excluded before formal review. Additional references, selected by the individual subcommittee members, were then included to compile the master reference list of 197 citations. B. Quality of the References Articles were distributed among subcommittee members for formal review. A review data sheet was completed for each article reviewed that summarized the main conclusions of the study and identified any deficiencies in the study. Furthermore, reviewers classified each reference by the methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services as follows: Class I: Prospective, randomized, double-blinded study Class II: Prospective, randomized, nonblinded trial Class III: Retrospective series, meta-analysis After review by the subcommittee, references were excluded on the basis of poor design or invalid conclusions. An evidentiary table (Table 1) was constructed using the remaining 101 references: Class I, 20 references; Class II, 32 references; and Class III, 49 references. Recommendations were made on the basis of studies included in the evidentiary table (Table 1).Table 1: Euidentiary: Practice Management Guidelines for the Evaluation of Blunt Abdominal TraumaTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedTable 1: ContinuedIII. RECOMMENDATIONS A. Level I 1. Exploratory laparotomy is indicated for patients with a positive DPL. 2. FAST may be considered as the initial diagnostic modality to exclude hemoperitoneum. B. Level II 1. When DPL is used, clinical decisions should be made on the basis of the presence of gross blood on initial aspiration (i.e., 10 mL) or microscopic analysis of lavage effluent. 2. Exploratory laparotomy is indicated in hemodynamically unstable patients with a positive FAST. In hemodynamically stable patients with a positive FAST, follow-up CT scan permits nonoperative management of select injuries. 3. Surveillance studies (i.e., DPL, CT scan, repeat FAST) should be considered in hemodynamically stable patients with indeterminate FAST results. 4. CT scanning is recommended for the evaluation of hemodynamically stable patients with equivocal findings on physical examination, associated neurologic injury, or multiple extra-abdominal injuries. Under these circumstances, patients with a negative CT scan should be admitted for observation. 5. CT scanning is the diagnostic modality of choice for nonoperative management of solid visceral injuries. 6. In hemodynamically stable patients, DPL and CT scanning are complementary diagnostic modalities. C. Level III 1. Objective diagnostic testing (i.e., FAST, DPL, CT scanning) is indicated for patients with abnormal mentation, equivocal findings on physical examination, multiple injuries, concomitant chest injury, or hematuria. 2. Patients with seat belt sign should be admitted for observation and serial physical examination. The presence of intraperitoneal fluid on FAST or CT scan in a patient with seat belt sign suggests the presence of an intra-abdominal injury that may require surgery. 3. CT scanning is indicated for the evaluation of suspected renal injuries. 4. In the patient at high risk for intra-abdominal injury (e.g., multiple orthopedic injuries, severe chest wall trauma, neurologic impairment), a follow-up CT scan should be considered after a negative FAST. 5. In hemodynamically stable patients with a positive DPL, follow-up CT scan should be considered, especially in the presence of pelvic fracture or suspected injuries to the genitourinary tract, diaphragm, or pancreas. IV. SCIENTIFIC FOUNDATION A. Diagnostic Peritoneal Lavage DPL was introduced by Root et al. in 1965 as a rapid and accurate method to identify the presence of intra-abdominal hemorrhage after trauma. 3 Subsequent studies have confirmed the efficacy of DPL in diagnosing abdominal hemorrhage as well as its superiority over physical examination alone. 4 The accuracy of DPL has been reported to be between 92% and 98%. 5–10 The high sensitivity of DPL is because of the significant false-positive rate of the technique. 11–13 Several authors have highlighted the importance of interpreting DPL results in the context of the overall clinical condition of the patient. A positive DPL does not necessarily mandate immediate laparotomy in the hemodynamically stable patient. 12,14–16 DPL has been shown to be more efficient than CT scanning in identifying patients that require surgical exploration. 17 The complication rate associated with DPL is quite low. 18 The incidence of complications is lower for open DPL compared with the closed technique. However, closed DPL can be performed more rapidly. 19–22 Studies designed to examine the ability of physicians to estimate the red blood cell (RBC) count in DPL fluid have demonstrated the poor sensitivity of visual inspection. 23–25 A positive DPL, on the basis of microscopic analysis of lavage fluid, has been defined as > 105 RBCs/mm3. It has been recommended that patients with RBC counts in the equivocal range (i.e., 25,000–75,000 RBCs/mm3) undergo additional diagnostic testing, such as CT scanning. 12 The false-positive rate for DPL is increased in patients with pelvic fractures. 26,27 To avoid sampling the retroperitoneal hematoma, a supraumbilical approach has been recommended, theoretically reducing the chances of a false-positive result. 28 The advantages of DPL for detection of hollow visceral injuries have been clearly demonstrated. 29,30 Two studies that advocate analysis of DPL fluid for amylase and alkaline phosphatase consistent with enteric injuries have been disputed. 31–33 Similarly, the utility of the DPL white blood cell count has been questioned. 34–36 DPL is sensitive for mesenteric injury and, in fact, has been shown to be superior to CT scanning for the diagnosis of this injury. 37 Thus, DPL is a safe, rapid, and accurate method for determining the presence of intraperitoneal blood in victims of BAT. It is more accurate than CT scanning for the early diagnosis of hollow visceral and mesenteric injuries, but it does not reliably exclude significant injuries to retroperitoneal structures. False-positive results may occur in the presence of pelvis fractures. Hemodynamically stable patients with equivocal results are best managed by additional diagnostic testing to avoid unnecessary laparotomies. B. Computed Tomographic Scanning Routine use of CT scanning for the evaluation of BAT was not initially viewed with overwhelming enthusiasm. CT scanning requires a cooperative, hemodynamically stable patient. In addition, the patient must be transported out of the trauma resuscitation area to the radiographic suite. Specialized technicians and the availability of a radiologist for interpretation were also viewed as factors that limited the utility of CT scanning for trauma patients. CT scanners are now available in most trauma centers and, with the advent of helical scanners, scan time has been significantly reduced. As a result, CT scanning has become an accepted part of the traumatologist’s armamentarium. The accuracy of CT scanning in hemodynamically stable blunt trauma patients has been well established. Sensitivity between 92% and 97.6% and specificity as high as 98.7% have been reported in patients subjected to emergency CT scanning. 38,39 Most authors recommend admission and observation after a negative CT scan. 40,41 In a recent study of 2,774 patients, the authors concluded that the negative predictive value (99.63%) of CT scanning was sufficiently high to permit safe discharge of BAT patients after a negative CT scan. 42 CT scanning is notoriously inadequate for the diagnosis of mesenteric injuries and may also miss hollow visceral injuries. In patients at risk for mesenteric or hollow visceral injury, DPL is generally felt to be a more appropriate test. 37,43 A negative CT scan in such a patient cannot reliably exclude intra-abdominal injuries. CT scanning has the unique ability to detect clinically unsuspected injuries. In a series of 444 patients in whom CT scanning was performed to evaluate renal injuries, 525 concomitant abdominal and/or retroperitoneal injuries were diagnosed. Another advantage of CT scanning over other diagnostic modalities is its ability to evaluate the retroperitoneal structures. 40 Kane et al. performed CT scanning in 44 hemodynamically stable blunt trauma patients after DPL. In 16 patients, CT scan revealed significant intra-abdominal or retroperitoneal injuries not diagnosed by DPL. Moreover, the findings on CT scan resulted in a modification to the original treatment plan in 58% of the patients. 44 C. Focused Abdominal Sonography for Trauma In recent years, FAST has emerged as a useful diagnostic test in the evaluation of BAT. The advantages of the FAST examination have been clearly established. FAST is noninvasive, may be easily performed, and can be performed concurrently with resuscitation. In addition, the technology is portable and may be easily repeated if necessary. 45–48 In most cases, FAST may be completed within 3 or 4 minutes. 49–51 The test is especially useful for detecting intra-abdominal hemorrhage in the patient with multiple injuries or the pregnant patient. 52 A noted drawback to the FAST examination is the fact that a positive examination relies on the presence of free intraperitoneal fluid. In the hands of most operators, ultrasound will detect a minimum of 200 mL of fluid. 53 Injuries not associated with hemoperitoneum may not be detected by this modality. 49,54,55 Thus, ultrasound is not a reliable method for excluding hollow visceral injury. 47,49,56–58 In addition, the FAST examination cannot be used to reliably grade solid organ injuries. Therefore, in the hemodynamically stable patient, a follow-up CT scan should be obtained if nonoperative management is contemplated. 59 FAST compares favorably with more traditionally used diagnostic tests. In the hemodynamically stable patient with BAT, FAST offers a viable alternative to DPL. 60 DPL may also be used as a complementary examination in the hemodynamically stable patient in the presence of equivocal or negative ultrasound findings with strong clinical suspicion of visceral injury. 61,62 FAST has demonstrated utility in hemodynamically stable patients with BAT. 58,60,63 In addition, ultrasound has been shown to be more cost-effective when compared with DPL or CT scanning. 45,47,60 Overall, FAST has a sensitivity between 73% and 88% and a specificity between 98% and 100%, and is 96% to 98% accurate. 46,50,57,58,64,65 This level of accuracy is independent of the practitioner performing the study. Surgeons, emergency medicine physicians, ultrasound technicians, and radiologists have equivalent results. 46,53,64–66 D. Other Diagnostic Modalities As interest in laparoscopic procedures has increased among general surgeons, there has been speculation regarding the role of diagnostic laparoscopy (DL) in the evaluation of BAT. One of the potential benefits postulated is the reduction of nontherapeutic laparotomies. With modification of the technique to include smaller instruments, portable equipment, and local anesthesia, DL may be a useful tool in the initial evaluation of BAT. Although there are no randomized, controlled studies comparing DL to more commonly used modalities, experience at one institution using minilaparoscopy demonstrated a 25% incidence of positive findings on DL, which were successfully managed nonoperatively and would have resulted in nontherapeutic laparotomies. 67 Although its ultimate role remains unclear, another modality to be considered in the diagnostic evaluation of BAT is visceral angiography. This modality may have diagnostic value when used in conjunction with angiography of the pelvis or chest, or when other diagnostic studies are inconclusive. 68 V. SUMMARY Injury to intra-abdominal viscera must be excluded in all victims of BAT. Physical examination remains the initial step in diagnosis but has limited utility under select circumstances. Thus, various diagnostic modalities have evolved to assist the trauma surgeon in the identification of abdominal injuries. The specific tests are selected on the basis of the clinical stability of the patient, the ability to obtain a reliable physical examination, and the provider’s access to a particular modality. It is important to emphasize that many of the diagnostic tests used are complementary rather than exclusionary. On the basis of the above recommendations, a reasonable diagnostic approach to BAT is summarized in Figures 1 and 2. In hemodynamically stable patients with a reliable physical examination, clinical findings may be used to select patients who may be safely observed. In the absence of a reliable physical examination, the main diagnostic choice is between CT scanning or FAST (with CT scanning in a complementary role). Hemodynamically unstable patients may be initially evaluated with FAST or DPL.Fig. 1: Evaluation of BAT: unstable patient.Fig. 2: Evaluation of BAT: stable patient.VI. FUTURE INVESTIGATIONS Recent literature is replete with studies that emphasize the many advantages of ultrasound in the valuation of BAT. Although this technology is becoming more available to trauma surgeons, for a variety of reasons, it has not become universally available in all centers. Continued research addressing the utility of FAST, with emphasis on its advantages specific to resource use, is suggested. In addition, studies should be designed to more closely evaluate the feasibility of FAST as the sole diagnostic test in hemodynamically stable patients. Perhaps safe strategies for nonoperative management of solid visceral injuries could be developed that rely on FAST alone, such that the number of CT scans could be reduced.

CONTEXT: State medical boards discipline several thousand physicians each year. Although certain subgroups, such as those disciplined for malpractice, substance use, or sexual abuse, have been studied, little is known about disciplined physicians as a group. OBJECTIVE: To assess the offenses, contributing factors, and type of discipline of a consecutive series of disciplined physicians. DESIGN: Case-control study on publicly available data matching 375 disciplined physicians with 2 groups of control physicians, one matched solely by locale, and a second matched for sex, type of practice, and locale. SUBJECTS: All disciplined physicians publicly reported by the Medical Board of California from October 1995 through April 1997. MAIN OUTCOME MEASURES: Characteristics of disciplined physicians, offenses leading to discipline, and type of discipline. RESULTS: A total of 375 physicians licensed by the Medical Board of California (approximately 0.24% per year) were disciplined for 465 offenses. The most frequent causes for discipline were negligence or incompetence (34%), abuse of alcohol or other drugs (14%), inappropriate prescribing practices (11%), inappropriate contact with patients (10%), and fraud (9%). Discipline imposed was revocation of medical license (21%), actual suspension of license (13%), stayed suspension of license (45%), and reprimand (21%). Type of offense was significantly associated with severity of discipline (P=.03). In logistic regression models comparing disciplined physicians with controls matched by locale, board discipline was significantly associated with physicians' sex (odds ratio [OR] for women, 0.44; 95% confidence interval [CI], 0.28-0.70) and involvement in direct patient care (OR, 2.56; 95% CI, 1.75-3.75). In the regression model with additional matching criteria, disciplinary action was negatively associated with specialty board certification (OR, 0.42; 95% CI, 0.29-0.60) and positively associated with being in practice more than 20 years (OR, 2.02; 95% CI, 1.39-2.92). CONCLUSIONS: A small but substantial proportion of physicians is disciplined each year for a variety of offenses. Further study of disciplined physicians is necessary to identify physicians at high risk for offenses leading to disciplinary action and to develop effective interventions to prevent these offenses.

Behavioral science has long been puzzled by the experience of temptation, the resulting impulsiveness, and the variably successful control of this impulsiveness. In conventional theories, a governing faculty like the ego evaluates future choices consistently over time, discounting their value for delay exponentially, that is, by a constant rate; impulses arise when this ego is confronted by a conditioned appetite. Breakdown of Will (Ainslie 2001) presents evidence that contradicts this model. Both people and nonhuman animals spontaneously discount the value of expected events in a curve where value is divided approximately by expected delay, a hyperbolic form that is more bowed than the rational, exponential curve. With hyperbolic discounting, options that pay off quickly will be temporarily preferred to richer but slower-paying alternatives, a phenomenon that, over periods from minutes to days, can account for impulsive behaviors, and over periods of fractional seconds can account for involuntary behaviors. Contradictory reward-getting processes can in effect bargain with each other, and stable preferences can be established by the perception of recurrent choices as test cases (precedents) in recurrent intertemporal prisoner's dilemmas. The resulting motivational pattern resembles traditional descriptions of the will, as well as of compulsive phenomena that can now be seen as side-effects of will: over-concern with precedent, intractable but circumscribed failures of self-control, a motivated ("dynamic") unconscious, and an inability to exploit emotional rewards. Hyperbolic curves also suggest a means of reducing classical conditioning to motivated choice, the last necessary step for modeling many involuntary processes like emotion and appetite as reward-seeking behaviors; such modeling, in turn, provides a rationale for empathic reward and the "construction" of reality.

DBA/2J (D2) and C57BL/6J (B6) mice exhibit differential sensitivity to seizures induced by various chemical and physical methods, with D2 mice being relatively sensitive and B6 mice relatively resistant. We conducted studies in mature D2, B6, F1, and F2 intercross mice to investigate behavioral seizure responses to pentylenetetrazol (PTZ) and to map the location of genes that influence this trait. Mice were injected with PTZ and observed for 45 min. Seizure parameters included latencies to focal clonus, generalized clonus, and maximal seizure. Latencies were used to calculate a seizure score that was used for quantitative mapping. F2 mice (n = 511) exhibited a wide range of latencies with two-thirds of the group expressing maximal seizure. Complementary statistical analyses identified loci on proximal (near D1Mit11) and distal chromosome 1 (near D1Mit17) as having the strongest and most significant effects in this model. Another locus of significant effect was detected on chromosome 5 (near D5Mit398). Suggestive evidence for additional PTZ seizure-related loci was detected on chromosomes 3, 4, and 6. Of the seizure-related loci identified in this study, those on chromosomes 1 (distal), 4, and 5 map close to loci previously identified in a similar F2 population tested with kainic acid. Results document that the complex genetic influences controlling seizure response in B6 and D2 mice are partially independent of the nature of the chemoconvulsant stimulus with a locus on distal chromosome 1 being of fundamental importance.

Endosymbiosis of bacteria by eukaryotes is a defining feature of cellular evolution. In addition to well-known bacterial origins for mitochondria and chloroplasts, multiple origins of bacterial endosymbiosis are known within the cells of diverse animals, plants and fungi. Early-diverging lineages of terrestrial fungi harbor endosymbiotic bacteria belonging to the Burkholderiaceae. We sequenced the metagenome of the soil-inhabiting fungus Mortierella elongata and assembled the complete circular chromosome of its endosymbiont, Mycoavidus cysteinexigens, which we place within a lineage of endofungal symbionts that are sister clade to Burkholderia. The genome of M. elongata strain AG77 features a core set of primary metabolic pathways for degradation of simple carbohydrates and lipid biosynthesis, while the M. cysteinexigens (AG77) genome is reduced in size and function. Experiments using antibiotics to cure the endobacterium from the host demonstrate that the fungal host metabolism is highly modulated by presence/absence of M. cysteinexigens. Independent comparative phylogenomic analyses of fungal and bacterial genomes are consistent with an ancient origin for M. elongata - M. cysteinexigens symbiosis, most likely over 350 million years ago and concomitant with the terrestrialization of Earth and diversification of land fungi and plants.

A subjective disturbance of sleep, including the occurrence of repetitive, stereotypical anxiety dreams, is characteristic of posttraumatic stress disorder (PTSD). The phenomenology of the PTSD anxiety dream has seemed most consistent with an underlying rapid eye movement (REM) sleep dysfunction. However, motor behavior reportedly can accompany PTSD dreams, and normal REM sleep typically involves a nearly total paralysis of the body musculature. As a means of understanding this discrepancy, anterior tibialis muscle activity during sleep was studied in a group of Vietnam combat veterans with current PTSD and in an age-matched normal control group. The PTSD subjects had a higher percentage of REM sleep epochs with at least one prolonged twitch burst; they also were more likely to have periodic limb movements in sleep, during nonrapid eye movement sleep. Both these forms of muscle activation also have been observed in REM behavior disorder (RBD), a parasomnia characterized by the actual enactment of dream sequences during REM sleep. The identification of RBD-like signs in PTSD adds to the evidence for a fundamental disturbance of REM sleep phasic mechanisms in PTSD.

Although considerable research effort has been spent in documenting the beneficial effects of social support to individual well-being, little is known about the determinants of this resource or its distribution across sociocultural groups. The present study assessed the influence among college students of sex and sex role on three levels of social support resources: network characteristics, availability of several modes of support, and perceived supportiveness of family and friends. On a composite measure of overall support resources, females were superior to males, and feminine and androgynous individuals were superior to masculine and undifferentiated individuals. Only some specific social support variables differed across these groups specifically, network size and homogeneity, emotional support, and perceived supportiveness of family for sex role.

INTEREST in the action of monoamine oxidase inhibitors has focused attention on the effects that metabolites of naturally occurring amino acids may have on the function of the central nervous system. Lauer et al.1 found that combined therapy with tryptophan and iproniazid had more therapeutic effect on psychotic patients than iproniazid alone. Oates and Sjoerdsma2 showed that administration of tryptophan to subjects receiving monoamine oxidase inhibitors produced hyperreflexia, clonus and euphoria. Pollin, Cardon and Kety3 observed hyporeflexia and extensive mood changes in schizophrenic patients who received tryptophan, or methionine in addition to a monoamine oxidase inhibitor.In conjunction with preliminary . . .

In the past, addiction has been viewed as a sui generis phenomenon (Baker 1988). Recent theories of addiction, however, draw implicit or explicit parallels between addiction and a wide range of other behavioral phenomena. The “disease theory,” for example, highlights similarities between addiction and infectious disease (e.g., Frawley [1988], Vaillant [1983]). Becker and Murphy's rational-choice model of addiction draws a parallel between drug addictions and “endogenous taste” phenomena, such as listening to classical music to attempt to acquire a taste for it, in which current consumption affects the utility of future consumption (Becker and Murphy 1988). Herrnstein and Prelec's “garden path” theory sees addiction as analogous to bad habits, such as workaholism or compulsive lying, that can be acquired gradually due to a failure to notice a deterioration in one's conduct or situation (Herrnstein and Prelec 1992). In this chapter, I propose an alternative theoretical perspective that views addiction as one, albeit extreme, example of a wide range of behaviors that are influenced or controlled by “visceral factors” (Loewenstein 1996). Visceral factors include drive states such as hunger, thirst, and sexual desire, moods and emotions, physical pain, and, most importantly for addiction, craving for a drug. All visceral factors, including drug craving, are associated with regulatory mechanisms that are essential for survival, but all are also associated with behavior disorders (e.g., sleepiness and narcolepsy, hunger and overeating, fear and phobias, sexual desire and sexual compulsions, anger and spousal abuse, craving and addiction).

A number of reports suggest that schizophrenia and coeliac disease (gluten enteropathy) occur in the same individual more often than expected by chance. The latter is an hereditary disease, with marked psychic and somatic symptoms which usually improve when wheat gluten and its analogues in other cereals are not eaten. This possible relationship, and the high correlation of the per cent. changes in wheat plus rye consumption with first admissions for schizophrenia during World War II (unrelated to availability of work, hospital beds and physicians or wartime status of the country), suggest that cereals may also be involved in the pathogenesis of schizophrenia (Dohan, 1, 2).

Inhibition of mitochondrial respiratory chain function may contribute to dopaminergic neurodegeneration in the substantia nigra (SN) of patients with Parkinson disease (PD). Since large-scale structural changes (e.g. deletions and rearrangements in mitochondrial DNA [mtDNA]) have been associated with mitochondrial dysfunction, we tested the hypothesis that increased total mtDNA deletions/rearrangements are associated with neurodegeneration in PD. This study employed a well-established technique, long-extension polymerase chain reaction (LX-PCR), to detect the multiple mtDNA deletions/rearrangements in the SN of patients with PD, multiple system atrophy (MSA), dementia with Lewy bodies (DLB), Alzheimer disease (AD), and age-matched controls. We also compared the total mtDNA deletions/rearrangements in different brain regions of PD patients. The results demonstrated that both the number and variety of mtDNA deletions/rearrangements were selectively increased in the SN of PD patients compared to patients with other movement disorders as well as patients with AD and age-matched controls. In addition, increased mtDNA deletions/rearrangements were observed in other brain regions in PD patients, indicating that mitochondrial dysfunction is not just limited to the SN of PD patients. These data suggest that accumulation of total mtDNA deletions/rearrangements is a relatively specific characteristic of PD and may be one of the contributing factors leading to mitochondrial dysfunction and neurodegeneration in PD.

We compared the effectiveness and costs of day hospital (DH) versus inpatient (INP) rehabilitation for cocaine dependence. The research subjects were 111 inner city, lower socioeconomic, primarily African-American male veterans who qualified for a diagnosis of cocaine dependence and presented no acute medical or psychiatric conditions requiring inpatient treatment. Fifty-six men were randomly assigned to 1 month of DH rehabilitation (27 hours of weekday treatment weekly), and 55 were assigned to 1-month INP rehabilitation (48 hours of scheduled treatment weekly). Treatment outcome was evaluated 7 months after admission into treatment (92% of the subjects), and a cost analysis was performed. A significantly greater proportion of INP subjects (89.1%) completed treatment than did DH subjects (53.6%). Significant improvements in substance use, psychosocial functioning, and health status were found 7 months postadmission for both groups, but there was little evidence of differential improvement between groups. Urine toxicology findings were consistent with the self-report data in showing improvement from baseline, but no group differences in cocaine use. The groups did not differ significantly in post-rehabilitation aftercare participation or in relapse to additional treatment. DH treatment costs were 40% to 60% of INP treatment costs, depending upon the measure used.

OBJECTIVE: Definitive trauma team leadership, although difficult to measure, has been shown to improve trauma resuscitation performance. The purpose of this study was to evaluate the effect of an identified command-physician on resuscitation performance. In addition, the leadership capability of four physician combinations functioning as command-physician was studied. DESIGN: Retrospective review. METHODS: Videotapes of trauma resuscitations performed at a Level I trauma center over a 25-month period were reviewed. The presence of an identified command-physician was determined by multidisciplinary consensus. Resuscitation performance was measured by compliance with three objective criteria: primary survey, secondary survey, and definitive plan; and two subjective criteria: orderliness, and adherence to Advanced Trauma Life Support protocol. Performance was then analyzed (1) as a function of the presence or absence of a command-physician, and (2) between four identified physician combinations: AF (attending surgeon + trauma fellow); F (trauma fellow); ASR (attending surgeon + senior surgical resident); SR (senior surgical resident). Chi square and the Mann-Whitney U tests were applied. RESULTS: A total of 425 trauma resuscitations were reviewed. A command-physician was identified (CP[Pos]) in 365 resuscitations (85.7%); no command-physician was identified (CP[NEG]) in 60 (14.3%). Compliance with completion of secondary survey (81.4%) and formulation of a definitive plan (89.6%) was significantly higher in the CP(POS) group. Subjective scores for orderliness and adherence to Advanced Trauma Life Support protocol were significantly higher in the CP(POS) group. In the CP(POS) resuscitations, formulation of a definitive plan was lower in SR when compared with the other three physician combinations. CONCLUSIONS: An identified command-physician enhances trauma resuscitation performance. Completion of the primary and secondary survey is not affected by the physician combination. Prompt formulation of a definitive plan is facilitated by the active involvement of an attending traumatologist or a properly mentored trauma fellow.

This article presents the well established theoretical base and clinical practice of exposure therapy for trauma. Necessary requirements for positive treatment results and contraindicated procedures are reviewed. EMDR is contrasted with these requirements and procedures. By the definitions and clinical practice of exposure therapy, the classification of EMDR poses some problems. As seen from the exposure therapy paradigm, its lack of physiological habituation and use of spontaneous association should result in negligible or negative effects rather than the well researched positive outcomes. Possible reasons for the effectiveness of EMDR are discussed, ranging from the fundamental nature of trauma reactions to the nonexposure mechanisms utilized in information processing models.