Safe levels of hemoglobin concentration in autologous blood transfusion

It has been generally accepted that an adequate oxygen-carrying capacity can be achieved with a hemoglobin concentration of 7 g/dl, as far as the patient's intravascular volume is sufficient to allow tissue perfusion. To guarantee patient's safety in the operating theater, patient's oxygenation, ventilation, circulation and temperature, which enable oxygen utilization in tissues, should be monitored vigilantly and ensured strictly. This is also true when taking care of anemic patients outside the operating theater, because failure of these functions in anemic patients leads directly to tissue hypoxia. Besides the standard monitoring, measuring oxygen carrying capacity/consumption parameters and gastric/sigmoidal intramucosal pH have been shown to be helpful to estimate tissue oxygenation. Therefore, safe levels of hemoglobin concentration should be determined according to the ability of doctors and nursing staffs to evaluate and to maintain patient's systemic and tissue oxygenation as well as to the patient's pathophysiological conditions.     

Milieu countertransference in treatment of borderline patients.

Describes milieu countertransference as a collective phenomenon in which the treatment staff as a group experiences regressions in functioning that, because of the operation of the patient's ego defenses, essentially mirror the level of functioning in the patient. When properly identified and treated, the milieu countertransference can benefit treatment both as a means to better understand the patient's experience and as a tool for active intervention in remediation of the patient's pathological development. A case report, involving a 14-yr-old male, is presented to illustrate the issues and interventions involved in the milieu countertransference developed in the treatment of a borderline patient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Reflections on Crohn''s disease and healing

One patient's story is recounted. Relatively asymptomatic for 20 years, the patient reflects on factors that contributed to his healing. Psychosocial and spiritual dimensions are described as well as biomedical aspects. The story concludes that dealing with Crohn's disease triggered a spiritual quest which in turn contributed to the patient's healing.     

The body in analysis: authentic movement and witnessing in analytic practice

This paper will describe a form of active imagination called authentic movement, in which attention is given to the somatic unconscious. In authentic movement, patients are encouraged to focus inward and attend to any bodily sensations, images and feelings which may arise. In the process of focusing inward on one's bodily-felt experience, images, somatic memory and the accompanying feelings which arise are then available to be explored as a communication from the patient's unconscious. Authentic movement supports the individual in linking image with affect in that the individual re-experiences the somatic aspect of symbolization. What was previously conserved on the somatic level as unmentalized experience, can now begin to be taken up into the mind, thought about, and made available for analysis. In authentic movement, the analyst acts as a silent witness to the patient's explorations. The quiet focused attention of the witness helps to create a secure containing environment in which the person moving can experience a sense of feeling held and seen. The function of the witness is to hold the patient's experience in his own mind, particularly what is not yet mentalized. The witness utilizes his somatic countertransference, including any images, feelings and bodily responses which are generated by what is being communicated non-verbally, as a means of understanding and responding to the patient's material.     

What I do with what you give me: Therapeutic action as the creation of meaning.

The thesis of this article is that the essence of analytic change lies not in what the analyst offers, but in what the patient creates from the analyst's provisions, whether these offerings are interpretations, functions, or an emotional impact. This concept of analytic change implies a clinical strategy in which interpretations are viewed as necessary preparations. The analyst's role is not only to understand, but also to facilitate the patient's creative use of interpretation by opening a therapeutic space. The inclusion of the patient's creation of new meaning in the theory of therapeutic action implies a clinical strategy in which the analyst facilitates the patient's creation, In such an analytic stance, the analyst opens therapeutic space for the patient to create new possibilities. A clinical illustration demonstrates a strategy that combines discovery and the promotion of the patient's creation of new meaning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Aspects of the therapeutic action in child analytic treatment.

Explores sources of gain in psychoanalytic work with children. Therapeutic gains are shown to be directly related to the patient's development of the capacity to empathize with self-representations as experienced and communicated by the therapist. The focus of this article is the patient's use of projective identification. Clinical material is used to illustrate a sequence that involves the projection of initially disowned self-elements, the evocation of corresponding affects and fantasies in the therapist, the patient's empathic scrutiny of the fate of these elements while contained within the therapist, and the eventual reinternalization by the patient of the now therapeutically transformed self-elements. It is argued that those elements of the therapist's self that are experienced by the patient as related to the projected material will also be reinternalized. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Conceptualizing the therapeutic alliance from a psychoanalytic perspective.

Defines the therapeutic alliance as the patient's active collaboration in the work of psychotherapy or psychoanalysis. The failure to differentiate alliance from transference has in part led to the skepticism regarding the concept of alliance. The patient's active use of the treatment process as a resource for self-understanding and constructive change constitutes his/her collaboration. The nature of collaboration varies with the type of treatment. The alliance depends significantly upon the patient's ability to maintain an observing ego; the activation of transferences significantly affects this process. The alliance is influenced by a core of object relations capacities that are essential to forming a trusting relationship. Defining alliance as patient collaboration makes a sharp distinction between technique and alliance. It is suggested that a scale devised to assess the degree of collaboration, based on this conceptualization, by the present 3rd author and colleagues (1983) provides an instrument for future research. (25 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Small-cell carcinoma of the lung presenting with paraneoplastic peripheral nerve microvasculitis and optic neuropathy

The authors report the case of a patient who developed hyperammonemia and coma during therapy with valproic acid for affective disorder. Onset of the coma was gradual and initially interpreted as a therapeutic reduction in the patient's anxiety. In a psychiatric setting, treatment of hyperammonemia may be delayed if a patient's increasing lethargy is interpreted as a therapeutic response. Staff may need to be educated about the potential for hyperammonemia, and patients whose tolerance for valproic acid is unknown may need to be monitored for liver function and blood levels of urea and ammonia.     

Musing of the feline hepatic voltage-dependent delayed-rectifier potassium channel gating

SETTING: Measures known to improve adherence such as short course chemoprophylaxis and directly observed therapy can be enhanced to a significant extent/by the use of incentives. Adherence to tuberculosis therapy is influenced by several factors, including the health care system, complexity of therapeutic regimens and patient's characteristics. Individual factors that negatively influence patient's adherence are the most difficult to counter. Preventive tuberculosis therapy is doubly challenging because the benefit of treatment is not felt, while toxicity from the medication, when it occurs, is experienced immediately. Ingenious incentives therefore have to make it worth the patient's while. During a study on preventive regimens, a request for an incentive, Sustacal, was observed to help completion of preventive regimens. Components of individual TB programs may help in patient adherence; it is important for health care staff to identify these aspects and, if they are successful, utilize these as an incentive to complete treatment.     

Evidence for a structural mutation of procollagen type I in a patient with the Ehlers-Danlos syndrome type VII

We have found that the collagen from a patient with the Ehlers-Danlos syndrome type VII contained a polypeptide chain, pN alpha 2, not present in collagen prepared from normal tissue. Fibroblasts cultured from the patient's skin produced type I procollagen in which the NH2-terminal propeptide of pro alpha 2 was cleaved to about half of normal values by chick procollagen neutral protease which removes the NH2-terminal propeptides from procollagen (N-protease). The NH2-terminal propeptide on the pro alpha 2 chain of the patient's procollagen was also more resistant than procollagen from control fibroblasts to digestion by pepsin or alpha-chymotrypsin. assays for procollagen N-protease indicated that the patient's fibroblsts contained about the same level of enzymic activity as normal fibroblasts. These results suggest that the patient's fibroblasts synthesize both an abnormal pro alpha 2 chain and a normal pro alpha 2 chain. The abnormality probably consists of a structural mutation in or near the site at which procollagen N-protease cleaves the pro alpha 2 chain. The results presented here appear to provide the first example of a mutation in a structural gene for collagen. Since equal amounts of pN alpha 2 and alpha 2 are found in the protein in neutral salt extracts of the patient's tissue, as well as in newly synthesized collagen produced by cultured skin fibroblasts, and since both parents are phenotypically normal and express exclusively normal collagen chains, the patient is likely to be a sporadic heterozygote, arisen by new mutation, with one normal and one abnormal gene coding for pro alpha 2.     

Kniest dysplasia: patient's growth progress and development--evolution of abnormalities, 30 year follow up

A case of a male patient with Kniest dysplasia is reported. The patient's growth and the development and evolution of the patient's abnormalities were tracked for a 30 year period, starting at the patient's birth. The clinical and radiographic features during this period, along with the differential diagnosis of Kniest dysplasia, are discussed. Femoral capital epiphyses and the presence of a cataract in one eye were noted from the early stages of the patient's life. The patient's final height was 165 cm. We believe this to be the first long-term follow up of this condition.     

Clinical implications of research on brief dynamic psychotherapy II. How the therapist helps or hinders therapeutic progress.

In this second of a two-part article, we describe how the therapist's interpretations promote therapeutic progress. Any therapist behavior that is in accord with the patient's plan will be helpful to the patient, but interventions that are at cross purposes with the patient's plan will not be helpful. The implications of the plan concept for brief dynamic therapy are described and contrasted with other key technical, concepts such as transference interpretations, therapeutic alliance, and interpretive activity. The importance of understanding the patient's plan and intervening in accord with it are illustrated in several case vignettes. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The right to refuse treatment is not a right to be killed

It is widely accepted now that a patient's right to refuse treatment extends to circumstances in which the exercise of that right may lead to the patient's death. However, it is also often effectively assumed, without argument, that this implies a patient's right to request another agent to intervene so as to bring about his or her death, in a way which would render that agent guilty of murder in the absence of such a request. But the right to refuse treatment can, logically, have no such implication, and the mistaken supposition that it does conflates a right to die with a right to be killed. Confusion over this issue is brought out by an examination of conflicting opinion concerning the permissible termination of ventilation for mentally competent patients. A wider lesson may be drawn regarding the need for the ethical assessment of new forms of life-sustaining medical technology.     

Cultural intersections in the psychotherapy of borderline personality disorder

Psychotherapy can be essentially considered a journey in which two individuals embark, each carrying a formidable cultural legacy. The psychotherapeutic enterprise then becomes a succession of stops and intersections as the two protagonists struggle to identify their culturally determined behaviors, using culturally determined procedures to take care of them. In this sense, cultural procedures are not a technical term but the appropriate combination of learned concepts, experiential modifiers, and common sense indicators of contemporary realities both at the individual and collective levels. The fascinating and challenging nature of BPD does have a significant cultural component encompassing explanatory, interpretive, pathogenic, pathoplastic, diagnostic/nosological, and service management aspects. It is in the psychotherapeutic arena, however, where both patient and therapist must face a multitude of culturally determined situations that may have a significant impact on the outcome of treatment. Culture can help the therapist to dispose of misleading clinical labels, with obvious advantages for the patient's well-being. Psychotherapy can correct the pathogenic elements of the patient's culture, recognize the pathoplastic clothing of the patient's symptoms, and provide culturally sanctioned and valued success experiences that may increase self-esteem, strengthen stability and, particularly, contribute to the patient's achievement of an identity with which he or she can feel comfortable. Finally, it must be remembered that it is not up to the therapist to offer infallible explanatory models of the patient's plight, but only culturally acceptable premises on which to build such explanations. On the other hand, it is up to the therapist to recognize the "idioms of distress," both physical and psychological, that the patient conveys in the psychotherapeutic context which is, as had been said many times here, totally immersed in the environment of culture. Two vignettes illustrate several of the issues under discussion.     

The first stage of treatment with the conduct disordered adolescent: Overcoming narcissistic resistance.

Presents an approach to treating the conduct-disordered adolescent (CDA) that emphasizes confronting the patient's narcissistic resistance in the early treatment stage. For CDAs, their parents have served neither as ideals for them nor as checks on their natural narcissism, and CDAs remain dominated by self-love. CDAs deny differences between adults and children; the therapist must challenge this denial of differences through a narcissistic injury. For the therapist to present himself or herself as superior to the patient and also as someone the patient can hope to emulate, there are 3 steps: identifying with the patient, challenging the patient's infantile grandiosity, and responding to the patient's anger. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment implications of past trauma in borderline personality disorder

Recent research and clinical experience have shown childhood trauma to be common in the histories of patients with borderline personality disorder. This article reviews the association between borderline personality disorder and early trauma, and how an awareness of the role of trauma may improve the treatment of patients with this disorder. Particularly when early trauma is in the form of childhood abuse, clinicians may be better able to understand the difficulties these patients experience in relational skills, affect tolerance, behavioral control, self-identity, and self-worth. Clinicians may be able to facilitate a stronger therapeutic alliance through acknowledgement of the patient's victimization and empathy with the effects of early trauma on the patient's life. Reframing the patient's experience as a consequence of childhood trauma is essential, especially when making traditional interventions such as interpretation and confrontation. The role of trauma in the development of borderline personality disorder suggests the need for modification of models of individual, family, and group psychotherapies that may allow more productive and successful treatment.     

Galvanic skin response as a measure of patient's reaction to therapist's permissiveness.

"Frequency of a patient's galvanic skin response is shown to be inversely related to the judged permissiveness of the therapist during a series of 42 hours of psychotherapy. The GSR is interpreted as a measure of the anxiety of the patient, or his 'mobilization' against any cue threatening punishment by the therapist, such as any cue which the patient has learned to perceive as evidence of low esteem. This anxiety presumably motivates varying subtle forms of resistance and defense against the feared punishment. Several alternative interpretations of the relation between permissiveness and GSR are rejected by various findings." GSR is related to the emotional significance of the patient's speech, as well as to the permissiveness of the therapist. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Functional status and depression among men and women with congestive heart failure

OBJECTIVE: The study was designed 1) to examine the prevalence of depression in patients with congestive heart failure (CHF); 2) to explore associations between the physician's rating of functional status (NYHA class) and patient's assessment of functional status (physical limitation, dyspnea) with symptoms of depression; and 3) to explore gender related differences in relation to physician's rating and patient's rating of function status, and symptoms of depression. METHOD: A sample of 119 clinically stable heart failure patients (85 males and 34 females) was recruited from an outpatient cardiology hospital practice. The patients underwent a physical examination and completed a set of questionnaires. Prevalence of depressive symptoms and the association of these symptoms with NYHA class and patient's perceived functional status was studied. RESULTS: Findings indicate that depressive symptoms were not predominant among this sample of CHF patients. Path analyses showed non-significant direct associations between NYHA class as well as patient's perception of dyspnea with depression. In contract, the subjective indicator of physical limitations was strongly associated with symptoms of depression among the males, but this relation was not significant among the females. CONCLUSIONS: Results suggest that men and women respond differently to the burden of heart failure. However, interpretation of the results from the present study should be considered as tentative and additional research is required to examine mechanisms that explain gender differences in response to heart failure.     

A note on adjustment as achievement.

Since "the degree of abnormality of any patient is always ultimately measured with reference to some observer" the community person is proposed as a composite observer. The clinical worker's main job is the assessment of the patient's achievement of relatively stable reference points and the evaluation of the patient's achievement of personal and social realities. An experiment is described which indicates that psychiatrists practicing in a common institutional setting show a higher agreement about the social world among themselves than any of the psychiatrists show with their patients. The implications of considering the concept of adjustment as achievement are considered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive therapy has been shown to be effective in panic disorder

Cognitive therapists suggest panic disorder to result from 'catastrophic' misinterpretation of bodily sensations. The patient suffering from panic disorder consistently misinterprets normal anxiety responses, such as racing heart, breathlessness or dizziness, as indicating impending disaster. Cognitive therapists, who challenge the traditional view of anxiety as 'free-floating' and irrational, argue that the patient's anxiety is an understandable response to their misinterpretations, and advocate a treatment method based on the patient's specific cognitive make-up and on the principle of collaborative empiricism. The patient is gently guided to identify and challenge idiosyncratic cognitions, and to consider alternative interpretations of danger signs. The article provides an outline of the treatment method and its empirical support.