The prisoner's dilemma: game theory and the therapeutic alliance

My aim in this paper is to describe how the therapeutic alliance evolves during psychoanalytic treatment. Lindgren has shown that a coevolutionary process can optimize the level of cooperation by the players in the game of prisoner's dilemma. This level is reached when strategies for recognizing reliable patterns in the sequence of moves by the other player have evolved. These are multiple memory strategies. Lindgren's work suggests that the analytic process must have sufficient time for multiple memory strategies to emerge if it is to achieve the necessary level of trust for an effective therapeutic alliance to develop.     

Adenosine in wide-complex tachycardia

The use of adenosine as a therapeutic and diagnostic tool in wide-complex tachycardia is suggested in the current Advanced Cardiac Life Support (ACLS) guidelines. The ACLS guidelines are now 4 years old, and new information on the safety and efficiency of adenosine in wide-complex tachycardia is available. We review the ACLS recommendations in light of the current available literature. In general, the ACLS recommendations remain reasonable with some important caveats.     

Aging and the dendritic morphology of the rat laterodorsal and pedunculopontine tegmental nuclei

This study is based on interviews with 37 persons fulfilling the DSM-IV criteria for kleptomania recruited through newspaper advertisements, and on 50 shoplifters interviewed directly after apprehension. Our hypothesis was that there are no absolute borders between 'pure' kleptomania according to DSM-IV and other forms of shoplifting. When asked about the latest case of shoplifting, one fifth of the shoplifters reported not having stolen the item for personal use and had later discarded it. A quarter of the kleptomaniacs reported ambivalence when asked if they needed the item in question. The degree of reported impulsivity and a feeling of not being oneself at the time of the theft was the same in the two groups. The two groups also estimated their degree of impulsivity, planning, thrill, relief, vengeance, need, pleasure on a Visual Analogue Scale (VAS) as well as the degree of psychiatric imbalance on the latest theft occasion. These estimates showed that there were no differences between the groups concerning the degree of planning, psychological imbalance and the need for the stolen item in question. The kleptomaniacs rated a feeling of inner tension before the theft higher than the shoplifters. The same was true concerning a feeling of relief during the theft and impulsivity. However, the shoplifters also rated high on all these items. Altogether, these findings support our hypothesis that many shoplifters, even if they do not fulfill all DSM criteria for kleptomania, may constitute a significant medical problem and should be offered support and treatment. Anti-depressants as well as the educational programmes developed by the Shoplifters Alternatives may be effective not only in cases of kleptomania but also for more unselected groups of non-professional shoplifters.     

The incidence, morbidity, and mortality of surgical procedures after orthotopic heart transplantation

OBJECTIVE: The authors present their experience with patients having undergone orthotopic heart transplantation (OHT) in whom surgical conditions subsequently developed that required operative intervention. The incidence, morbidity, and mortality of these procedures are reported. SUMMARY BACKGROUND DATA: Several studies have evaluated the management options of biliary tract disease after OHT. Multiple reports of patients having undergone OHT who subsequently underwent peripheral vascular reconstructions, plastic reconstructive, and thoracic procedures also have been published. METHODS: A chart review of 349 patients who underwent OHT between 1985 and 1996 was conducted to identify surgical procedures that were required in the post-transplant period. Their outcomes are reported. RESULTS: Of 349 patients who underwent OHT, conditions requiring 94 surgical procedures developed in 54 patients (15%). Biliary tract disease developed in 17 patients (5%) who required cholecystectomy, 2 of the 5 patients with acute cholecystitis died. Eight patients (2%) underwent orthopedic procedures with no operative mortality. Flap advancements for sternal wound infections were performed in five patients and four deaths occurred. Seventeen thoracic procedures were performed in 11 patients with an overall mortality of 45%. Twenty-one vascular procedures were performed on 17 patients with 1 delayed death due to a malignancy. Seven patients underwent procedures of the colon and rectum with no mortality. Seven patients underwent repair of inguinal or incisional hernias with no mortality. Various infections occurred with one resultant death after operative intervention. Six procedures were performed for diseases of the small intestine with no resultant mortalities. CONCLUSIONS: Patients having undergone OHT and chronic immunosuppression are at increased risk of having complications develop from infection. Acute cholecystitis and sternal wound infection caused an inordinate risk of complications and death. Malignancies developed in four patients who required surgical intervention. A heightened awareness of coexisting peripheral vascular disease in patients transplanted for ischemic cardiomyopathy should exist. Close screening before surgery and surveillance after surgery to identify risk factors for infection and vascular disease and to screen for malignancies are essential.     

Experimental model of pudendal nerve innervation of a skeletal muscle neosphincter for faecal incontinence

BACKGROUND: Faecal incontinence is difficult to treat. A variety of reconstructive procedures has been described, but none is entirely satisfactory. This study evaluated the feasibility of cross-innervating a skeletal muscle neosphincter with the pudendal nerve in a canine model. METHODS: Thirty dogs were rendered surgically incontinent (the pudendal nerve was cut and the external sphincter was partially excised). A neosphincter was then created using the semitendinosus muscle. In ten dogs pudendal nerve transposition (PNT) to the nerve to the semitendinosus muscle was performed. Ten dogs were given a dynamic neosphincter by inserting a pulse generator at 6 weeks. The remaining ten dogs served as controls with passive semitendinosus wraps. Anal manometry was performed before operation and monthly for 5 months. Muscle biopsies, performed at the initial operation and at 5 months, were stained for slow- and fast-twitch fibres, and were examined histologically. RESULTS: At 1 month, mean sphincter function was 32 per cent of the preoperative value in the control animals, 34 per cent in the PNT group and 27 per cent in the electrostimulation group; all dogs were incontinent. At 5 months the mean recovery of sphincter function was 42 per cent of the preoperative value in controls, 100 per cent in dogs with PNT (P < 0.001) and 63 per cent in dogs having electrostimulation (stimulator on) (P = 0.02). Six dogs with PNT had squeeze pressures equal to or greater than preoperative levels. At 5 months the ratio of slow to fast fibres was significantly greater in all dogs (control P = 0.01, PNT P < 0.005, electrostimulation P < 0.001). CONCLUSION: Use of the pudendal nerve to innervate a canine skeletal muscle anal wrap produced a functional anal sphincter that was superior to electrically stimulated and passive wraps.     

Improved osseointeraction of calcium phosphate-coated external fixation pins. Studies in calves

The analysis of health state of drivers sent for an extra health examination for the estimation of driving capability for the driving of motor vehicle in alcoholic state was presented. The study included 380 drivers who were found driving drunk by traffic police (studied group) and 180 drivers of control group sent for an extra health examination for some other reason. The disorders in psychomotor sphere were noticed in the drivers of studied group and it was determined that they had caused significantly larger number of traffic accidents in last five-year period compared to the drivers of control group. The alcohol consumption in driving population represents significant medical, social, economic and traffic problem. The control of driver's alcoholism, the sending of alcoholic drivers to an extra health examination for the repeated estimation of driving capability and including in therapeutic and health-educational program can present significant measure of the primary prevention of road traffic traumatism which is on the constant increase.     

Consistent improvement in sphincterotome orientation with manual grooming

AIMS: To determine the prevalence of lymphoid follicles in Helicobacter pylori positive and negative gastritis in antral and body type gastric mucosa in patients with non-ulcer dyspepsia (NUD), duodenal ulcer, or gastric ulcer; to correlate follicle presence with patient age; to evaluate the correlation between the prevalence of lymphoid follicles and active and inactive gastritis and its severity; and to assess the positive predictive value of lymphoid follicle prevalence with respect to H pylori infection. METHODS: Gastric biopsy specimens, graded according to the Sydney system, from 337 patients were studied. RESULTS: Lymphoid follicles occurred more often in antral mucosa (78%) than in body type mucosa (41%) and were observed in 85% of patients with H pylori positive gastritis. There was no significant difference between NUD and gastric and duodenal ulcer disease with regard to the presence of lymphoid follicles. The positive predictive value of the presence of lymphoid follicles in H pylori infection was 96%. Lymphoid follicles were more commonly observed in patients aged between 10 and 29 years. Lymphoid follicles were more frequently found in pangastritis of all subtypes than in antral gastritis and also in active gastritis than in inactive gastritis. The presence of lymphoid follicles correlated strongly with the degree and severity of gastritis. CONCLUSION: Lymphoid follicles are a constant morphological feature of H pylori associated gastritis.     

Pharmacologic control of a humanized gene therapy system implanted into nude mice

Systemic delivery of specific therapeutic proteins by a parenteral route of administration is a recognized practice in the management of several gene defects and acquired diseases. As an alternative to repetitive parenteral administration, gene therapy may provide a novel means for systemic delivery of therapeutic proteins while improving patient compliance and therapeutic efficacy. However, for gene therapy to be an efficacious and safe approach to the clinical management of such diseases, gene expression must be tightly regulated. These investigations demonstrate precise in vivo control of protein expression from cells that are engineered to secrete human growth hormone (hGH) in response to stimulation by rapamycin. The cells were implanted intramuscularly into nu/nu mice and stimulated by intravenous or oral administration of rapamycin. In vivo experiments demonstrate that the activity and pharmacokinetics of rapamycin determine the level of serum hGH that result from the engineered cells. In addition, responsiveness of the cells to rapamycin, number of cells implanted, hGH expression kinetics, and the pharmacokinetics of hGH itself, also influence the circulating levels of hGH after rapamycin stimulation. Controlled manipulation of several of these parameters, either independently or in combination, allows for precise regulation of circulating hGH concentration in vivo.