Cardiac remodeling as a consequence and cause of progressive heart failure

Natural history studies in heart failure have shown that increases in left ventricular (LV) volume and LV mass are directly related to future deterioration in LV performance and a less favorable clinical course. Despite the recognized importance of remodeling in heart failure, very little is known about the basic mechanisms that lead to cardiac remodeling. In this review, we will summarize recent clinical and experimental studies that highlight the importance of the remodeling process during the progression of heart failure. The intent of this review is to provide an integrated view of the mechanisms that contribute to LV remodeling at the cellular level, the myocardial level, and the level of the chamber.

Psychosocial aspects of the organ transplant experience: what has been established and what we need for the future

This article briefly describes the current status and limitations of the organ transplant process that has now become a routine medical procedure. The article discusses how transplantation is not a cure for end-stage organ disease but an alternative form of treatment with both potential medical and psychosocial problems. Both transplant candidates and recipients encounter psychosocial problems. The article examines how these psychosocial problems affect transplant patients prior to transplant, immediately following surgery, and posttransplant. The psychosocial problems include psychiatric diagnoses, individual and family adjustment and relationship problems, sexual dysfunction, return-to-work (RTW) difficulties, and compliance problems and variables related to noncompliance. The article also reviews the special problems of pediatric and adolescent transplant recipients. The need for empirically supported interventions is noted in each of the problem areas. The author outlines problems with previous research studies that hamper solid interpretations of the data, and discusses literature suggesting that the psychosocial problems of transplant candidates and recipients are likely to be underreported. The article concludes with recommendations about the need to switch research efforts toward intervention studies in the problem areas already solidly identified by the literature.

The intensification and resolution of blocked affect in an experiential psychotherapy

Focused Expressive Psychotherapy is a Gestalt-based method of psychotherapy which is designed to facilitate the resolution of constricted emotion in patients. This form of therapy is described as a five-step process. The present article addresses the steps of that process which relate specifically to the intensification and resolution of emotions. The importance and rationale for intensification are discussed and related to the concept of restructured schematic memories. Markers of resolution are identified as changes in 'benchmarks', changes in patient behaviour or attitude, and/or a reevaluated stance towards past events. We conclude by citing one of our recent research efforts that demonstrates a relationship between the intensification of emotion and positive therapy outcome.

Milwaukee Prehospital Chest Pain Project--phase I: feasibility and accuracy of prehospital thrombolytic candidate selection

This study prospectively determined the feasibility and accuracy of prehospital thrombolytic therapy candidate selection by base station emergency physicians. During a 6-month period, paramedics acquired and transmitted prehospital 12-lead electrocardiograms (ECGs) and then applied a thrombolytic therapy contraindication checklist. Emergency physicians interpreted prehospital ECGs and prospectively selected candidates for thrombolytic therapy. A safety committee of cardiologists reviewed prehospital ECGs, checklists and hospital records to determine accuracy independently. Six hundred-eighty stable adult prehospital patients with a chief complaint of nontraumatic chest pain were initially evaluated. Two hundred forty-one patients were excluded because of (1) unsuccessful electrocardiographic transmission (149), (2) transport to nonparticipating facilities (72), and (3) unavailable medical records (20). No prehospital thrombolytic therapy was administered in this study. Of 439 cases, 91 (21%) had the final diagnosis of acute myocardial infarction, 38 (8.7%) had diagnostic prehospital ECGs, and 12 (2.7%) were selected by emergency physicians as candidates for thrombolytic therapy. Seventy percent of patients with myocardial infarction had checklist exclusions for thrombolytic therapy. Prehospital evaluation increased mean scene time (paramedic arrival on scene to scene departure) by 4 minutes. The median time from chest pain onset to paramedic arrival in patients with myocardial infarction was 60 minutes. The estimated average time saved if prehospital thrombolytic therapy had been available was 101 +/- 81 minutes. The safety committee concluded that acceptable accuracy of emergency physician prehospital electrocardiographic interpretation, checklist and case selection was achieved. It is concluded that emergency physicians can accurately identify candidates for prehospital thrombolytic therapy.

Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures

Group cognitive therapy (CT), focused expressive psychotherapy (FEP; a form of group experiential psychotherapy), and supportive, self-directed therapy (S/SD) were compared among 63 patients with major depressive disorder (MDD). Variation among patients' coping styles (externalization) and defensiveness (resistance potential) was used in a prospective test of hypothesized differential treatment-patient interactions. Results suggest that patient characteristics can be used differentially to assign psychotherapy types. Externalizing depressed patients improved more than nonexternalizing depressed patients in CT, whereas nonexternalizing (internalizing) patients improved most in S/SD. Conversely, high defensive (resistant) patients improved more in S/SD than in either FEP or CT, whereas low defensive patients improved more in CT than in S/SD.

Predictors of differential response to cognitive, experiential, and self-directed psychotherapeutic procedures

Group cognitive therapy (CT), focused expressive psychotherapy (FEP; a form of group experiential psychotherapy), and supportive, self-directed therapy (S/SD) were compared among 63 patients with major depressive disorder (MDD). Variation among patients' coping styles (externalization) and defensiveness (resistance potential) was used in a prospective test of hypothesized differential treatment-patient interactions. Results suggest that patient characteristics can be used differentially to assign psychotherapy types. Externalizing depressed patients improved more than nonexternalizing depressed patients in CT, whereas nonexternalizing (internalizing) patients improved most in S/SD. Conversely, high defensive (resistant) patients improved more in S/SD than in either FEP or CT, whereas low defensive patients improved more in CT than in S/SD.

Identification of patients at risk for nonresponse and negative outcome in psychotherapy

This study evaluated the use of pretherapy patient variables as correlates of 3 categorical types of outcome: negative response (negative change of more than 1 normative SEest on depression measure); nonresponse (change within +/- 1 SEest on depression measure); and positive response (positive change of more than 1 SEest on depression measure) to psychotherapy among 62 patients with major depressive disorder. By using 4 scales from the Brief Symptom Inventory, the Inventory of Interpersonal Problems, age, and sex, 75.8% of the Ss were correctly classified into the 3 groups. Negative responders were characterized by high levels of interpersonal difficulty and low levels of subjective distress. Nonresponders displayed moderate levels of both interpersonal difficulties and subjective distress. Positive responders displayed high levels of both interpersonal difficulties and subjective distress.

Behavior, affect, and cognition among psychogenic pain patients in group expressive psychotherapy

In an exploratory study, the authors examined the cognitions, affect, and behaviors reported by eight female depressed chronic pain patients during experiential therapy sessions that focused on anger and depression. Subjects appeared to fit previously developed psychologic profiles of patients with chronic pain disorder: they presented as conscientious, compliant, passive, and rule-bound, viewing life and emotional expression as dangerous, avoiding conflict and risk, denying their own emotional needs. Their reports were compared with the self-reported affect behavior and cognitions of eight depressed female patients without chronic pain, under similar therapeutic conditions. Considerable differences in style and content were found. Implications of these findings for clinical practice are discussed.

Identification of patients at risk for nonresponse and negative outcome in psychotherapy

This study evaluated the use of pretherapy patient variables as correlates of 3 categorical types of outcome: negative response (negative change of more than 1 normative SEest on depression measure); nonresponse (change within +/- 1 SEest on depression measure); and positive response (positive change of more than 1 SEest on depression measure) to psychotherapy among 62 patients with major depressive disorder. By using 4 scales from the Brief Symptom Inventory, the Inventory of Interpersonal Problems, age, and sex, 75.8% of the Ss were correctly classified into the 3 groups. Negative responders were characterized by high levels of interpersonal difficulty and low levels of subjective distress. Nonresponders displayed moderate levels of both interpersonal difficulties and subjective distress. Positive responders displayed high levels of both interpersonal difficulties and subjective distress.