Psychotherapy of the chronically suicidal patient

A major issue in the psychotherapy of the chronically suicidal is the patient's avoidance of his responsibility. If the patient is not helped to recognize this avoidance, the therapist's efforts may be consigned to future attempts to either assume responsibility for the patient or to rescue him.     

Effect of chronically infused adrenomedullin in two-kidney, one-clip hypertensive rats

The hypotensive effect of chronically infused adrenomedullin, a potent vasodilator peptide, was examined in conscious two-kidney, one-clip (2K-1C) hypertensive and sham-operated rats. They were infused with 1.0 microgram/h of synthetic human adrenomedullin for 14 days by means of osmotic minipumps. Control groups were infused on the same schedule with 0.9% saline. Systolic blood pressure was measured before and during the infusion. Plasma renin activity, aldosterone and human adrenomedullin concentrations were determined at day 14 of the infusion. A significant reduction of systolic blood pressure was observed in the adrenomedullin-infused 2K-1C rats at day 4, and systolic blood pressure remained significantly lower throughout the experiment compared to that of the control 2K-1C. A similar hypotensive effect was seen in the adrenomedullin-infused sham-operated rats. Both the plasma renin activity and aldosterone concentrations of the adrenomedullin-infused 2K-1C and sham groups were significantly reduced compared to those of the respective control, whereas, the plasma human adrenomedullin concentration in the adrenomedullin-infused groups was found to be within the physiological range. These findings demonstrated that chronically infused adrenomedullin had a hypotensive effect accompanied by significant reductions of plasma renin activity and plasma aldosterone concentration in 2K-1C hypertensive and sham-operated rats.     

Aging and regression of cardiac hypertrophy in the hypertensive patient

OBJECTIVE: This study was aimed at determining factors acting on the regression of left ventricular hypertrophy due to essential hypertension. METHODS: It was a non-randomized, echocardiographic study of 60 previously untreated hypertensive subjects (20 to 75 years of age). RESULTS: Following a 5-year therapy, the decrease in the left ventricular mass was 14%. Normalization of blood pressure and reversal of left ventricular hypertrophy were obtained in 50% and 58% of patients, respectively. Patients of the non-responder group (non-response being defined as a less than 10% decrease in the left ventricular mass) were older and had a longer history of high blood pressure. A positive correlation was observed between age and decrease in the left ventricular mass, the latter being less marked in older patients. Antihypertensive drugs classes had no influence on reversal of left ventricular hypertrophy. CONCLUSION: Ageing may be a factor of resistance to the decrease in left ventricular mass with therapy. These results suggest that early screening and management of hypertension are essential.     

Disturbance of consciousness associated with hypophosphatemia in a chronically alcoholic patient

A 69-year-old man with chronic alcoholism was admitted to our hospital due to disturbance of consciousness and oliguria. Emergency laboratory examination revealed metabolic acidosis, hypoglycemia, hyponatremia, mild liver dysfunction, acute renal failure and rhabdomyolysis. After administration of fluids and nutrients and continuous hemodiafiltration, he recovered from all signs and symptoms except for disturbance of consciousness after 7 days. Since severe hypophosphatemia persisted, we administered adequate phosphates, and then his level of consciousness normalized. We discuss the relationships among alcohol abuse, hypophosphatemia and disturbance of consciousness, and recommend that hypophosphatemia be considered a potential cause of disturbance of consciousness in alcoholic patients.     

Blood pressure measurement and assessment of the hypertensive patient

The aim of this study was to evaluate concentrations of monocyte chemotactic and activating factor (MCAF/MCP1) in bronchoalveolar lavage fluid (BAL) from patients with chronic bronchitis. 32 patients (aged 46 +/- 2 years) with chronic bronchitis and 14 patients (aged 30.5 +/- 3.4 years) of control group took part in this study. ELISA test (kits from R&D, USA) was used to measure concentrations of this chemokine in BALF. The results indicate for significant increase of MCAF/MCP1 in BALF from patients with chronic bronchitis (mean +/- SEM = 393 +/- 105.9 pg/ml) as compared from those of control group (middle +/- SEM = 36.4 +/- 10.9 pg/ml). CONCLUSION: MCAF/MCP1 may participate in creation of inflammatory changes of airways in patients with chronic bronchitis.     

Managing the elderly hypertensive patient beyond blood pressure reduction

ANTIHYPERTENSIVE TREATMENT OF THE ELDERLY: Several prospective, randomized, long-term trials on antihypertensive drug treatment have shown that elderly patients with systolic and diastolic or isolated systolic hypertension benefit from a reduction in blood pressure. Antihypertensive treatment reduces the overall mortality by 20%, cardiovascular mortality by 33%, the incidence of fatal and non-fatal cerebrovascular events by 40% and the complications of coronary heart disease by 15%. In addition, elderly patients have a high risk of overt or latent and asymptomatic cardiovascular diseases. For this reason, not only antihypertensive treatment, but also risk factor modification (such as cholesterol reduction therapy) is, in absolute terms, more beneficial in elderly patients than in middle-aged patients, particularly in patients with concomitant cardiovascular diseases and other risk factors. QUALITY OF LIFE: Although the randomized trials have focused on mortality and morbidity as main endpoints, it is questionable whether longevity is a worthwhile social objective in itself. Quality of life is an important aspect of antihypertensive treatment, since hypertension is generally symptomless while drug therapy may have adverse effects on the quality of life. The frequency of adverse effects is similar in both middle-aged and elderly hypertensive patients, with about 2% of patients per year in both age groups withdrawing from randomized treatment due to objectively assessed adverse effects. The rate of subjectively assessed adverse effects during treatment is also similar in younger and elderly patients. In general, clinical studies have suggested that a blood pressure reduction does not influence the well-being of elderly patients, whether measured in physical, emotional or social terms. Both calcium antagonists and diuretics have shown an age-dependent effect in comparative trials, with a higher blood pressure reduction in elderly than in younger patients. CONCLUSION: Antihypertensive therapy in elderly hypertensives adds longevity and need not compromise quality of life. Although the reduction and normalization of blood pressure is the primary goal, the increased availability of antihypertensive preparations and drugs for treating concomitant diseases and risk factors allows the physician to tailor treatment of the elderly to the needs of the individual patient.     

Management of the hypertensive patient: a case report

Hypertension is a potentially life-threatening condition that can lead to heart failure, stroke, and kidney disease. Most patients with hypertension can be treated and controlled if they are diagnosed in a timely manner. This case report exemplifies how the dentist can play a key role in the detection of hypertension by simply taking vital signs on all patients. It is incumbent upon us as health-care professionals to understand the causes of hypertension, the therapeutic drugs used and associated side effects, and the potential for drug interactions. The dentist's ability to recognize and appropriately manage hypertension will greatly enhance the health and safety of our patients.     

Time on my hands: The dilemma of the chronically late patient.

In this article the author discusses the problems and dilemmas created by patients who are chronically late for analytic hours or frequently absent from them. The discussion focuses on a single case study, in which this phenomenon was a predominant feature of the analytic process. The author explores some of the issues, dynamic and defensive, underlying such behavior as well as motivational components involving unresolved oedipal issues and powerful unsatisfied narcissistic needs. The temporal difficulties of patients such as this one demonstrate the role of time as a point of conjunction of aspects of the analytic relation involving the temporal dimension of the real structure of the analytic situation and its intersection with transferential and alliance considerations. The analytic task is to balance the temporal requirements of the analytic process against the array of the patient's infantile and narcissistic needs on one hand and legitimate claims for autonomy and freedom on the other. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of i.v. enalaprilat in chronically treated hypertensive patients during cardiac surgery

In areas where hepatitis B virus (HBV) is prevalent, HBV carriers negative for hepatitis B surface antigen (HbsAg) by enzyme-linked immunosorbent assay (ELISA) have been reported. Moreover, even after screening donor blood for HbsAg and hepatitis B core antibody (HBcAb), post-transfusion hepatitis B continues to occur, though with a decreasing frequency. Therefore, screening tests far more sensitive for detecting HBsAg than those currently available are needed. We developed a highly sensitive method for HBsAg detection. It is based on the recognition of peroxidase activity through measuring the formation of stable nitroxide radical with electron spin resonance (ESR) spectroscopy in the presence of hydrogen peroxide, p-acetamidophenol (p-AP), and 4-hydrazonomethyl-1-hydroxy-2,2,5,5,-tetramethyl-3-imidazoline-3-o xide (HHTIO). A cut-off value was established by testing of 186 healthy adults and 50 HBsAg-positive individuals. The signal to noise (S/N) ratio of less than 1.488 obtained by ESR spectroscopy was considered to be negative and more than 2.181, positive. The p-AP/HHTIO method was found to be 10 times more sensitive than the standard ELISA and reproducibility was excellent. Additional investigations were made on the HBsAg levels in the serum from 26 healthy subjects, in whom cut-off index levels on ELISA were negative but relatively high (range: 0.6 to 1.0); and on 15 patients with non B non C hepatitis. Three of 26 cases and 3 of 15 with non B non C hepatitis were judged to be HBsAg positive. Of these, 5 were found to be positive for HBV DNA by polymerase chain reaction (PCR). It was shown in this study that the p-AP/HHTIO method is practical and useful in screening HBV carriers because of the sensitivity in HBsAg detection, which is comparable to PCR analysis.     

Diastolic dysfunction as a cause of heart failure in the hypertensive patient

A study was undertaken to investigate physical work load, physical capacity, physical strain and perceived health among elderly aides in home-care service. A secondary aim was to compare the work load and strain between the two main types of home-care service available in Sweden today. Work tasks and their distribution among 20 elderly aides (aged 45-65 years), working in open home-care service (clients living in their original flats or houses) and at service apartment houses (clients living in private flats constructed for the elderly and handicapped with service functions) were observed during whole work days. Heart rate and number of steps taken were also measured continuously during the whole work day. Oxygen consumption and work postures for upper arm and back were measured during parts of the work day. The results showed that home-care work is characterised by long periods of standing and walking and that postures potentially harmful for the low back and shoulders occurred frequently. Average physiological strain measured as relative oxygen consumption and heart rate during the work day did not exceed present recommendations. Average physical work load and strain in open home-care service slightly exceeded those in service apartment houses because of more frequent cleaning and walking outdoors. Many aides in this study showed slightly reduced physical capacity, and musculoskeletal problems were common. Many elderly aides in home-care service are probably exposed at work to high risks of overexertion and impaired health as a result of high postural loads in combination with other known important factors, such as time stress and lack of equipment.     

Mathematical modeling of platelet survival with implications for optimal transfusion practice in the chronically platelet transfusion-dependent patient

Even now 50% of the world population are still living in malaria endemic areas and every year 200 million new cases with 2 million deaths are reported. Most of the malaria deaths are children under 5 years old. Although malaria endemicity currently exists mainly in tropics, before the human started its efforts to eradicate malaria in large scale in 1950s, malaria was more widely distributed in the world. At this time Japan and malaria together with North America and European countries. However some areas were precluded from malaria endemicity: i.e., high mountains and deserts. Also Polynesian islands in the Pacific have never been malarious, even though Melanesian Papua New Guinea, Solomon, and Vanuatu are highly malarious even now. Human disease malaria is caused by Plasmodium parasites and transmitted by Anopheles mosquitoes. Human is classified into the malaria donor and recipient. The environment is supporting this system: for example, temperature and rainfall are important factors together with vegetation, or housing, health infrastructure, war situation, and poverty status. In 1950s, the WHO malaria eradication program focused its efforts on vector control, using DDT-residual spraying. But the program completely failed with mainly operational reasons and we already learned it is almost impossible to control malaria only killing mosquitoes. In 1992 the new Global Malaria Control Strategy adopted by Malaria Summit at Amsterdam says the primary objective is early diagnosis and treatment to prevent malaria death. In this context malaria chemotherapy is a key issue. Also we understand more and more the environmental management is very important. Malaria vaccine may be a conceptually important tool, but may be available soon.     

Pregnancy after transposition and repositioning of the ovaries in a patient with clear-cell adenocarcinoma

A young woman with a history of in utero exposure to distilbestrol was diagnosed with vaginal clear-cell adenocarcinoma. Management consisted of limited excision of the tumor followed by brachytherapy after transposition of the ovaries. The patient had a successful pregnancy after reimplantation of the ovaries in their normal position and right adnexectomy for Chlamydia infection. The child was delivered by cesarean section. This is probably the first case with a pregnancy after repositioning of the ovaries in Europe and perhaps even in the world.     

Training students in education of the hypertensive patient: enhanced performance after a simulated patient instructor (SPI)-based exercise

The process whereby a physician explains to the ill patient what has gone wrong and what can be done about it can be taught and evaluated by simulated patients (SPIs). This study was designed to determine whether a training experience in educating a diabetic SPI improves subsequent performance with a hypertensive SPI. Competence in educating a hypertensive SPI by students who had no prior training experience (n = 26) was compared to that of an experimental group (n = 20) that had a prior training session. Performance was assessed with a counseling skills scale and a case-specific content checklist (1 = poor to 5 = excellent). Students in the experimental group performed better than controls in both counseling skills (4.46 v 3.86, P < .01) and completeness of coverage of content (3.28 v 2.65, P < .01). Students in both groups focused more on clinical features and treatment than on laboratory testing and follow-up. The ability to counsel "patients" with hypertension can be enhanced by a prior learning experience with a diabetic SPI. Clinical application of knowledge about hypertension can be assessed by SPIs.     

Screen time: Clinical notes regarding Meissner's (2006) chronically late patient.

This communication is a commentary on William W. Meissner's presentation (see record 2006-20697-003) of a patient who chronically came late for sessions. The time duration of analytic work-relatively restricted per hour yet potentially limitless in overall duration-represents an existential paradox that is fundamental to the basic representational qualities of mental experience, and inherent in a mute way in the analytic frame. It is to be expected that the latent temporal elements of the patient's conflicts will inevitably challenge this aspect of the frame, subtly coercing patient and analyst to recreate these novel dimensions. If the analyst is too cautious regarding the inevitability of countertransference reactions to such a patient, important developmental opportunities may be missed. I suspect that the chronic lateness and absence that characterized the work with this patient screened an early, nonmentalized trauma that had torn a hole in the foundations of the patient's sense of time, and was inadvertently expressed by Meissner in an entirely atypical manner. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pregnancy following thyroid hormone treatment in a patient with amenorrhea-galactorrhea due to primary hypothyroidism

A 32-year-old female with amenorrhea-galactorrhea due to primary hypothyroidism was treated with thyroid hormones, and serum levels of thyrotropin (TSH), prolactin (PRL), triiodothyronine (T3), thyroxin (T4), and T3 resin sponge uptake (RT3U) were measured throughout the course of treatment. The elevated serum levels of TSH and PRL fell into the normal range following T3 treatment. Subsequently, the menstrual cycle was restored within 1 month, and galactorrhea completely ceased and conception was achieved within 3 months. Desiccated thyroid was administered during pregnancy, and the patient gave birth to a female infant. Impaired secretion of PRL during pregnancy and poor milk secretion with blunted response of PRL to the suckling stimulus during the puerperium were noted.     

The chronically ill child in the school.

Focuses on the school attendance and performance problems encountered by chronically ill children (CIC), from the point of their re-entry after diagnosis or treatment. CIC exhibit school related problems, reflected in psychological well being, interaction with peers, academic performance, and higher absenteeism. Inability to attend school may lead to decreased self esteem and hopelessness about the future. Specific aspects of the illness or its treatment, the child's emotional response to the illness, prolonged absence, and learning problems may influence school functioning. Attitudes of parents, teachers, other school personnel and the health care team, and inability of the school to provide necessary daily health care services seriously affect successful school re-entry. School psychologists play an important role in maximizing CIC's success in school, as they prospectively monitor their educational functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)