Psychoanalytic application and psychoanalytic integrity

In this article, the author offers an analysis of psychoanalytic application, defined as the breaking of new conceptual ground in some field of knowledge whereby the new idea is conceived, and later articulated, with the aid of reference to analogous phenomena in psychoanalysis. It requires apt analogy based on competent understanding of the applied field and of psychoanalysis. Only when the relevant differences between the applied and psychoanalytic fields are grasped can the extent of certain parallels emerge. The thinking by analogy that comprises psychoanalytic application may be intuitive and implicit, but should be susceptible of explicit theoretical elaboration that specifies, precisely, the point(s) of correspondence between psychoanalysis and the applied field in relation to a precise specification of their relevant differences. Applied psychotherapy at the interface of the internal and external worlds (historically rooted in casework) is employed as a model. By analogy with Donnet's concept of the analytic site, the author proposes the concept of the psychodynamic (case)work site, and elaborates it for that applied field in order to elucidate the proposed principles of psychoanalytic application.

Primary Endovascular Repair of Juxtarenal Aneurysms with Fenestrated Endovascular Grafting

PURPOSE

To evaluate outcomes of an endovascular graft incorporating the visceral aortic segment with graft material in the setting of juxtarenal aneurysms.

MATERIALS AND METHODS

A prospective analysis of patients undergoing implantation of an endovascular device with graft material proximal to the renal arteries was conducted. All patients were deemed unacceptable candidates for open surgical repair and had proximal neck length=<10 mm, or =<15 mm with a compromising morphology (funnel or thrombus). Fenestrations were customized to accommodate aortic branch anatomy based upon CT and intravascular ultrasound data. Selective visceral ostia were treated with balloon expandable stents following endograft deployment. All patients were evaluated with CT, duplex ultrasound, and abdominal radiograph at discharge, 1, 6, 12 and 24 months.

RESULTS

A total of 32 patients were enrolled in the trial. Short proximal necks (3-10 mm) were present in 22, and 10 had necks 10-15 mm in length with concomitant angulation or thrombus compromising neck quality. Endograft design included bifurcated (30) and aortic tube (2) systems. A total of 83 visceral vessels were incorporated (mean of 2.6 per patient). These most commonly included both renal arteries and the SMA. All prostheses were implanted successfully without the acute loss of any visceral arteries. The mean follow-up was 9.2 months (range 0-24 months). One patient died within 30 days of device implantation and hypogastric bypass following the development of aspiration pneumonia. Three early (<30 days) and three late secondary interventions were performed. The 30-day endoleak rate was 6.5%. The aneurysm sac decreased greater than 5 mm in 58% of patients at 6 months and in 75% of patients at 12 months. One patient, with a persistent type II endoleak had 5 mm of sac growth over 12 months. Six patients had transient or permanent elevation of serum creatinine (>30% from baseline), with one requiring hemodialysis. Of the 83 vessels incorporated, three late stenoses (all successfully treated with an endovascular approach) and two renal occlusions were detected during follow-up. Three patients died of unrelated causes during the follow-up period.

CONCLUSIONS

The placement of endovascular prostheses with graft material incorporating the visceral arteries is technically feasible. The incidence of endoleaks is exceptionally low. It remains critical to follow the status of stented visceral vessels, and establish the long-term efficacy of this type of repair.

Defining the sports medicine specialist in the United Kingdom: a Delphi study

OBJECTIVE

To define the role and responsibilities of the sports medicine specialist using a recognised research technique.

METHODS

A Delphi technique was employed using anonymous postal questionnaires sent to a random sample of 300 members of the British Association of Sport and Exercise Medicine. The questionnaire of 300 putative attributes was developed in a pilot study and the Delphi technique used allowed participants to modify their responses according to the responses of other participants.

RESULTS

There was a 53% response to both rounds of the study with 75.6% of the respondents being male, 39% having a higher qualification in sports medicine, and 45.6% being general practitioners. Some 86.3% strongly agreed that sport and exercise medicine should be a recognised speciality and 90% strongly agreed that it should be available on the National Health Service (NHS). The most important specialist attributes were orthopaedic and soft tissue medicine (83.6% strongly agreed) and emergency medical management (79.7% strongly agreed). More than 75% of respondents did not agree that either research or personal playing experience were relevant.

CONCLUSION

Sports and exercise medicine is an evolving speciality in the United Kingdom. We believe this is the first systematic attempt to define the role and responsibilities of the sports medicine specialist and the findings are of relevance to the future development of a career pathway.

Unusual stab injury of the spinal cord

OBJECTIVE

To report an unusual penetrating stab injury of the spinal cord.

DESIGN

Case report of a 13-year-old boy who sustained cervical trauma following an accident while playing.

SETTING

Spinal Cord Injuries Unit, Musgrave Park Hospital, Belfast, UK.

CASE REPORT

Mechanism of injury was by a spear-like electric fence post entering the neck. Initial neurological examination revealed tetraplegia with C4 sensory level. Magnetic resonance imaging (MRI) of spinal cord demonstrates the penetrating injury.

CONCLUSION

No ligamentous instability was demonstrated. In the absence of this, the penetrating injury by a short blade thrown at speed was felt to be responsible for the subsequent injury and resulting outcome at discharge of C4 American Spinal Injury Association (ASIA) grade D tetraplegia.

Anti-arrhythmic actions of polyunsaturated fatty acids in cardiac muscle exerted via the sarcoplasmic reticulum

Cardiac arrhythmias can be triggered from ischaemic cardiac muscle due to the damage inflicted on individual myocytes. During an ischaemic episode free fatty acids accumulate in the ischaemic tissue. The importance of these fatty acids lies in the apparent ability of some classes of fatty acid to protect against cardiac arrhythmias. As cardiac sudden death is a likely cause of death in patients who have suffered an initial ischaemic insult, protection against such arrhythmias may be of crucial importance. The following review discusses how this protection may be produced, dealing specifically with changes in electrophysiological properties of cells and intracellular calcium regulation.

Quality assessment of genetic markers used for therapy stratification

PURPOSE

Therapy stratification based on genetic markers is becoming increasingly important, which makes commitment to the highest possible reliability of the involved markers mandatory. In neuroblastic tumors, amplification of the MYCN gene is an unequivocal marker that indicates aggressive tumor behavior and is consequently used for therapy stratification. To guarantee reliable and standardized quality of genetic features, a quality-assessment study was initiated by the European Neuroblastoma Quality Assessment (ENQUA; connected to International Society of Pediatric Oncology) Group.

MATERIALS AND METHODS

One hundred thirty-seven coded specimens from 17 tumors were analyzed in 11 European national/regional reference laboratories using molecular techniques, in situ hybridization, and flow and image cytometry. Tumor samples with divergent results were re-evaluated.

RESULTS

Three hundred fifty-two investigations were performed, which resulted in 23 divergent findings, 17 of which were judged as errors after re-evaluation. MYCN analyses determined by Southern blot and in situ hybridization led to 3.7% and 4% of errors, respectively. Tumor cell content was not indicated in 32% of the samples, and 11% of seemingly correct MYCN results were based on the investigation of normal cells (eg, Schwann cells). Thirty-eight investigations were considered nonassessable.

CONCLUSION

This study demonstrated the importance of revealing the difficulties and limitations for each technique and problems in interpreting results, which are crucial for therapeutic decisions. Moreover, it led to the formulation of guidelines that are applicable to all kinds of tumors and that contain the standardization of techniques, including the exact determination of the tumor cell content. Finally, the group has developed a common terminology for molecular-genetic results.

Assessing the dietetic needs of different patient groups receiving enteral tube feeding in primary care

AIM

To examine the nature of all contacts between adult tube-fed patients and the dietetic service and to refine the current dietetic protocols to reflect the findings of the study with a view to improving patient care.

METHODS

All adult patients referred to the Community Nutrition and Dietetic Service within a 6-month period were included in the study. Using a proforma developed from a retrospective case-note analysis, data were collected on the complications that prompted more frequent contacts than the department protocol. Data were analysed using the Statistical Package for the Social Sciences.

RESULTS

The most common indication for home enteral feeding in this group of adult patients was a swallowing disorder resulting from a cerebrovascular accident (59.5%) followed by cancer (21.5%). There was a trend for cancer patients to need more intervention compared with those patients with other medical conditions. A significant difference was observed in the total contacts and telephone calls given to those patients in there own homes (P=0.019) and there was a trend towards more domicilary visits with this group.

CONCLUSIONS

The department protocols have been revised to include a planned review within 2-6 weeks of initial dietetic assessment in the community for those patients who were identified to have the greatest need. More intensive dietetic monitoring has clear implications for dietetic services in the community.

Sports medicine and the accident and emergency medicine specialist

BACKGROUND

Sport and exercise related injuries are responsible for about 5% of the workload in the accident and emergency (A&E) department, yet training in sports medicine is not a compulsory part of the curriculum for Higher Specialist Training.

AIM

To determine how A&E medicine consultants and specialist trainees view their role and skill requirements in relation to sports medicine.

METHOD

A modified Delphi study, consisting of two rounds of a postal questionnaire. Participants were invited to rate the importance of statements relating to the role and training of the A&E specialist in relation to sports injuries (six statements) and the need for knowledge and understanding of defined skills of importance in sports medicine (16 statements). VALUE OF RESEARCH: This provides a consensus of opinion on issues in sport and exercise medicine that have educational implications for A&E specialists, and should be considered in the curriculum for Higher Specialist Training. There is also the potential for improving the health care provision of A&E departments, to the exercising and sporting population.

Genetic insights into the neurodevelopmental hypothesis of schizophrenia

The original neurodevelopmental hypothesis of schizophrenia presented by D.R. Weinberger in 1987 focused on pathogenesis and did not address etiology. Available evidence indicates that genetic factors are the principal cause of schizophrenia. It is imperative that any pathogenetic model for schizophrenia takes into account what is now known about genetic mechanisms of illness. Recent advances in molecular genetics can provide insights into the neurodevelopmental expression of the illness and what future genetic discoveries are likely to contribute to our understanding of schizophrenia. In this article, we propose a genetic model of etiopathogenesis that is consistent both with a modified neurodevelopmental hypothesis and our current knowledge about schizophrenia and molecular genetics.

Daughters and mothers exercising together (DAMET): a 12-week pilot project designed to improve physical self-perception and increase recreational physical activity

This paper presents the results of a 12-week single-sex, family-based physical activity intervention grounded in Social Cognitive Theory. Mother/daughter pairs and triads (n = 20) attended physical activity and classroom sessions twice weekly. Physiological data (VO2peak, height, and weight), psychological data (physical self-perception profile subscale scores), information about physical activity participation (PAP, d x wk(-1)) and qualitative impressions (QI) of the program were collected pre- and post-intervention. PAP and QI were also collected 6-months after completing the intervention. Although no significant increases in physical activity were reported, significant improvements in perceived sport competence, physical condition, and strength and muscularity were reported over time. The social cognitive theory, as used to plan this physical activity intervention, offered a promising theoretical perspective for facilitating improved physical self-perception in adolescent girls and their mothers.

Nitinol stent insertion for post-pneumonectomy syndrome

Post-pneumonectomy syndrome is an unusual condition, that can occur a variable period of time after a patient has had a pneumonectomy. Management of this syndrome has been described using a number of different techniques, often with considerable mortality. We present a case report where this condition was treated successfully by insertion of an expandable Nitinol stent. This is the first time this technique has been described to treat this condition, and we feel it may be the procedure of choice in managing these patients.

A Val193Met mutation in GPIIIa results in a GPIIb/IIIa receptor with a constitutively high affinity for a small ligand

We have identified a patient designated as (GTa) with Glanzmann's Thrombasthenia (GT) diagnosed on the basis of a prolonged bleeding time and failure of the patient's platelets to aggregate. The number of glycoprotein (GP)IIb/IIIa receptors on the platelet surface was 37% of normal and those receptors displayed a defect in soluble fibrinogen binding. Nevertheless, GTa platelets showed increased adhesion to solid-phase fibrinogen and binding affinity for the RGD-mimetic (3)H-SC52012, a non-peptide GPIIb/IIIa antagonist. Dithiothreitol (DTT) and ADP enhanced the affinity for [(3)H]-SC52012 in normal platelets, but had little effect in GTa platelets. These findings suggested that GTa platelets were locked in an altered affinity state. Genetic analysis showed that GTa was a compound heterozygote for the GPIIIa gene. One allele showed a deletion at the 3' end of exon 3 resulting in a premature stop codon. The second GPIIIa allele had a G to A transition at nucleotide 577, resulting in a Val193Met substitution. HEK 293T cells transfected with mutant GPIIb/IIIaV193M bound [(3)H]-SC52012 with a higher affinity than wild-type GPIIb/IIIa, and this was not increased by DTT. The mutant receptor distinguishes between platelet adhesion and aggregation, and demonstrates the phenotype that may be expected when platelet aggregation alone is inhibited.

Improved asthma control with budesonide/formoterol in a single inhaler, compared with budesonide alone

Budesonide/formoterol in a single inhaler was compared with budesonide alone, and with concurrent administration of budesonide and formoterol from separate inhalers, in patients with asthma, not controlled with inhaled glucocorticosteroids alone. In this 12-week, double-blind, randomized, double-dummy study, 362 adult asthmatics (forced expiratory volume in one second 73.8% of predicted, inhaled glucocorticosteroid dose 960 microg x day(-1)) received single inhaler budesonide/formoterol (Symbicort Turbuhaler) 160/4.5 microg, two inhalations b.i.d., or corresponding treatment with budesonide, or budesonide plus formoterol via separate inhalers. There was a greater increase in morning peak expiratory flow (PEF) with single-inhaler (35.7 L x min(-1)) and separate-inhaler (32.0 L x min(-1)) budesonide and formoterol, compared with budesonide alone (0.2 L x min(-1); p<0.001, both comparisons); the effect was apparent after 1 day (p<0.001 versus budesonide, both comparisons). Similarly, evening PEF, use of rescue medication, total asthma symptom scores and percentage of symptom-free days improved more with both single inhaler and separate inhaler therapy than with budesonide alone, as did asthma control days (approximately 15% more, p<0.001 versus budesonide, both comparisons, with a marked increase in the first week). All treatments were well tolerated and the adverse event profile was similar in all three treatment groups. It is concluded that single inhaler therapy with budesonide and formoterol is a clinically effective and well-tolerated treatment for patients with asthma that is not fully controlled by inhaled glucocorticosteroids alone.

Corticosteroid induced osteoporosis. Guidelines for treatment

BACKGROUND

Last year, Australian Family Physician published 'Guidelines for Management of Postmenopausal Osteoporosis', which were developed by Osteoporosis Australia. Recently, significant advances in our understanding of the treatment of corticosteroid osteoporosis have occurred.

OBJECTIVE

The following guidelines, also developed by Osteoporosis Australia, and supported by the National Asthma Campaign, are to help general practitioners identify those patients at risk of this problem and to provide information about current treatment strategies.

DISCUSSION

Corticosteroids are widely used and effective agents for the control of many inflammatory diseases. Corticosteroid osteoporosis is a common problem associated with the long term high dose use of these medications.

Comprehensive genetic and histopathologic study reveals three types of neuroblastoma tumors

PURPOSE

To determine the relationship between multiple genetic features, tumor morphology, and prognosis in neuroblastoma.

PATIENTS AND METHODS

The genetic alterations and morphologic features that underpin three histopathologic risk classifications were analyzed in 108 neuroblastoma patients. Tumors were subdivided into four groups based on the three most frequent and prognostically significant genetic alterations (17q gain, 1p deletion, and MYCN amplification), and all other genetic, morphologic, and clinical data were analyzed with respect to these groups.

RESULTS

Our analyses identify three nonoverlapping tumor types with distinct genetic and morphologic features, defined here as types 1, 2, and 3. Type 1 tumors show none of the three significant genetic alterations and have good prognosis. Both type 2 (17q gain only or 17q gain and 1p del) and type 3 (17q gain, 1p del, and MYCN amplification) tumors progress. However, these tumor types are distinguished clinically by having significantly different median age at diagnosis and median progression-free survival (PFS). Multivariate analysis indicates that 17q gain is the only independent prognostic factor among all genetic, histopathologic, and clinical factors analyzed. Among histopathologic risk systems, the International Neuroblastoma Pathology Classification was the best predictor of PFS.

CONCLUSION

Our results indicate that specific combinations of genetic changes in neuroblastoma tumors contribute to distinct morphologic and clinical features. Furthermore, the identification of two genetically and morphologically distinct types of progressing tumors suggests that possibilities for different therapeutic regimens should be investigated.

The psychotherapy of a male anorectic

The author describes the way in which a male anorexic patient came to be understood in once-weekly psychotherapy. The findings are similar to recent psychoanalytic ones about female anorectics, but add that he was preoccupied with display and that there was an erotised transference in the oral mode. Of two major themes, the first was a food obsession; the food was felt concretely to be the mother as in a symbolic equation, and the conflict about eating represented a wish for and fear of fusion with her. The second major theme concerned exhibition; the self, as seen in two screen memories, was felt to be uncomfortably on show. Meanwhile the patient was preoccupied with a self-displaying maternal object, which was prominent in the transference. This perception of the object served as a defence against envy, although the defensive aspect may have been added to by an actual experience of a mother who functioned operatively, giving food rather than loving attention. The patient employed primary-process thinking defensively against self-object differentiation, which would have excited further awareness both of envy and of the real deficiencies of his primary objects. The author raises the possibility that the anorexia functioned as a perversion, binding and organising the core complex about fusion.

Clinical governance in action. Part 9. Teamworking

Part 9 of our series on clinical governance describes how a group of people from different disciplines can be transformed into an effective working team.

Towards a safe future

Creating a 'safety culture' requires an open approach to encourage analysis of deeper, systemic factors which may be causing serious failures. The NHS is setting systems in place which will work to end the most common and preventable errors.