Gender and psychotherapy with traditional men

Therapists who are accustomed to operating in a world where gender roles are becoming increasingly androgynous may underestimate how foreign the experience of psychotherapy can be to "traditional" men. This paper describes the occurrence of transference and resistance encountered by female therapists when seeing male patients at a Veterans Administration (V.A.) Medical Center who identify with traditional American male gender roles. The discussion is informed by recent advances in the theory of male gender identity development and yields new insights into the typical defenses men may bring to the early phases of psychotherapy. Case examples from the authors' practices illustrate strategies for intervening with resistance and enhancing the therapeutic alliance. Common countertransference issues encountered by therapists working with "traditional" men are also discussed.     

Dual angiotensin-converting enzyme/neutral endopeptidase inhibition on cardiac and renal fibrosis and inflammation in DOCA-salt hypertensive rats

OBJECTIVES: The relative roles of angiotensin-converting enzyme (ACE) and neutral endopeptidase (NEP) inhibition on cardiac and renal fibrosis in deoxycorticosterone acetate (DOCA)-salt hypertensive rats were studied. METHODS: The ACE/NEP inhibitor omapatrilat (40 mg/kg per day), the ACE inhibitor enalapril (10 mg/kg per day) and the NEP inhibitor CGS 25462(100 mg/kg per day) were administrated for 3 weeks to DOCA rats. Collagen was stained with Sirius red, and mediators of inflammation were identified by immunolabeling (vascular cell adhesion molecule, nuclear factor-kappaB, infiltrating ED-1-positive macrophages and monocyte chemotactic protein-1) or by western blot (platelet-endothelial cell adhesion molecule-1). RESULTS: Elevated systolic blood pressure of DOCA rats was significantly reduced (P < 0.05) by omapatrilat and CGS 25462. Omapatrilat and CGS 25462 significantly (P < 0.05) decreased interstitial collagen density in the left ventricle of DOCA rats compared with untreated DOCA rats. Enalapril only decreased the subepicardial collagen of DOCA rats. Omapatrilat significantly (P < 0.05) decreased renal mesangial collagen deposition in DOCA rats. Cardiac and renal expression of surface adhesion molecules, nuclear factor-kappaB, monocyte chemotactic protein and ED-1-positive cells were decreased in omapatrilat-treated DOCA rats compared with untreated DOCA rats. Enalapril and CGS 25462 did not alter mesangial collagen of DOCA rats. CONCLUSIONS: Dual ACE/NEP inhibition was more effective than ACE or NEP inhibition in decreasing inflammatory mediators, and improving cardiac and renal fibrosis. This suggests a role for NEP inhibition added to blockade of the renin-angiotensin system that may explain the greater efficacy of omapatrilat.     

Appendicular colic and the non-inflamed appendix: fact or fiction?

AIMS: Appendicoliths cause acute appendicitis and appendicular perforation. Do appendicoliths cause acute abdominal pain in the absence of acute appendicitis? METHODS: A retrospective observational study was undertaken of histology reports of all appendicectomy specimens from children < 16 years of age between January 1995 and December 2001. Specimens were categorised as perforated or uncomplicated acute appendicitis, non-inflamed, and "incidental" (removed during abdominal surgery for other indications). The presence of an appendicolith was noted. Clinical details were supplemented by selected case note review. Specimens in which the diagnosis of appendicitis or the presence of an appendicolith were not clearly defined (n = 20) were reviewed by an experienced, independent pathologist. RESULTS: 601 consecutive appendicectomy reports were analysed. The mean age of the study population was 9 years (range 1 day - 15.9 years) and there were 357 boys. An appendicolith was identified in 31/118 (26%) cases of perforated appendicitis, 60/352 (17%) cases of uncomplicated appendicitis, 12/59 (20%) cases of non-inflamed appendices, and only 1/72 (1%) cases of incidental appendicectomies. All patients with an appendicolith in the non-inflamed appendix group had presented with acute abdominal pain mimicking acute appendicitis. The frequency of an appendicolith in perforated appendicitis was significantly greater than in uncomplicated acute appendicitis (chi (2) = 4.8, 1 df, p < 0.05). There was no significant difference in the frequency of an appendicolith between non-inflamed appendices and acute appendicitis (either perforated or intact). Appendicoliths were rarely found in incidental appendicectomies, but these patients were younger. The frequency of appendicoliths in non-inflamed appendices was much greater than that expected from published autopsy data. CONCLUSION: Appendicoliths may cause acute abdominal pain that mimics acute appendicitis.     

Reflections on clinical audit in palliative care following an attempt to audit urinary catheterization

Audit has a high profile within palliative care quality initiatives. However, there are numerous potential pitfalls to auditing. We had hoped to perform a multicentred multiprofessional audit on urinary catheterization of hospice patients. Unexpectedly, the problems encountered highlighted numerous flaws in our approach to audit. An initial standard-setting pilot study, using a prospective observational methodology, generated results for 25 patients. The audit cycle was not pursued, as the data and the process did not appear valid. Conversely there were valuable lessons from reflecting on our mistakes and reviewing historical 'wisdom'. For example, audit's interface with research can easily be misunderstood and the difficulties of audit in palliative care can be underestimated. Particularly concerning was the potential for harm from insufficient rigour within audit processes, in allowing invalid data to influence practice. Conversely, despite risks, robust studies within audit may inform the limited palliative care research base.     

X-linked inheritance of Dandy-Walker variant

We report a family in which two sisters had three male fetuses with isolated Dandy-Walker variant (DWV) diagnosed on antenatal ultrasound. DWV is one part of a spectrum of abnormalities related to Dandy-Walker malformation (DWM) which commonly occur in association with other anomalies with or without chromosome abnormalities. The majority of cases are sporadic but rare reports of recurrence in siblings exist. This is the second report suggesting that isolated DWM/DWV can be inherited as an X-linked recessive trait.     

Variability of Broca's area homologue in African great apes: implications for language evolution

The cortical circuits subserving neural processing of human language are localized to the inferior frontal operculum and the posterior perisylvian region. Functional language dominance has been related to anatomical asymmetry of Broca's area and the planum temporale. The evolutionary history of these asymmetric patterns, however, remains obscure. Although testing of hypotheses about the evolution of language areas requires comparison to homologous regions in the brains of our closest living relatives, the great apes, to date little is known about normal interindividual variation of these regions in this group. Here we focus on Brodmann's area 44 in African great apes (Pan troglodytes and Gorilla gorilla). This area corresponds to the pars opercularis of the inferior frontal gyrus (IFG), and has been shown to exhibit both gross and cytoarchitectural asymmetries in humans. We calculated frequencies of sulcal variations and mapped the distribution of cytoarchitectural area 44 to determine whether its boundaries occurred at consistent macrostructural landmarks. A considerable amount of variation was found in the distribution of the inferior frontal sulci among great ape brains. The inferior precentral sulcus in particular was often bifurcated, which made it impossible to determine the posterior boundary of the pars opercularis. In addition, the distribution of Brodmann's area 44 showed very little correspondence to surface anatomy. We conclude that gross morphologic patterns do not offer substantive landmarks for the measurement of Brodmann's area 44 in great apes. Whether or not Broca's area homologue of great apes exhibits humanlike asymmetry can only be resolved through further analyses of microstructural components.     

Dedifferentiated chondrosarcomas of the larynx: a report of two cases and review of the literature

OBJECTIVE: To analyze the long-term clinical outcome of dedifferentiated chondrosarcoma or chondrosarcoma with additional malignant mesenchymal component (CAMMC) of the larynx and compare the results with those of axial chondrosarcomas. STUDY DESIGN/METHODS: Two patients with CAMMC of the larynx (0.03%) were retrospectively identified within the archives of the Armed Forces Institute of Pathology between 1970 and 2001. We compared the clinical and histologic features of these two cases with those reported in the English literature (Medline 1966-2001) (Table I). RESULTS: Patient no. 1 was a 67-year-old man who presented with a 12-month history of hoarseness and was found to have a 4-cm mass involving the cricoid cartilage. Enucleation was performed and histologically demonstrated a dedifferentiated chondrosarcoma. Without additional intervention, the patient died after 136 months without evidence of disease. Patient no. 2 was a 41-year-old man who also presented with a 12-month history of hoarseness and dysphagia and was found to have a 5-cm mass involving the cricoid cartilage. A total laryngectomy was performed for the dedifferentiated chondrosarcoma. He is alive without evidence of disease at last contact (91 mo). CONCLUSION: CAMMC of the larynx are rare tumors but have a better prognosis than their axial counterparts (mean, 6 mo). Initial voice-sparing surgery can be followed with more aggressive surgery if recurrences develop.     

Treatment of postmastectomy lymphedema with low-level laser therapy: a double blind,placebo-controlled trial

BACKGROUND: The current study describes the results of a double blind, placebo-controlled, randomized, single crossover trial of the treatment of patients with postmastectomy lymphedema (PML) with low-level laser therapy (LLLT). METHODS: Participants received placebo or one cycle or two cycles of LLLT to the axillary region of their affected arm. They were monitored for reductions in affected limb volume, upper body extracellular tissue fluid distribution, dermal tonometry, and range of limb movement. RESULTS: There was no significant improvement reported immediately after any of the treatments. However, the mean affected limb volume was found to be significantly reduced at 1 month or 3 months of follow-up after 2 cycles of active laser treatment. Approximately 31% of subjects had a clinically significant reduction in the volume of their PML-affected arm (> 200 mLs) approximately 2-3 months after 2 cycles of treatment. There was no significant effect of placebo treatment, or one cycle of laser treatment, on affected limb volume. The extracellular fluid index of the affected and unaffected arms and torso were reported to be significantly reduced at 3 months after 2 cycles of laser therapy, and there was significant softening of the tissues in the affected upper arm. Treatment did not appear to improve range of movement of the affected arm. CONCLUSIONS: Two cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately 33% of patients with postmastectomy lymphedema at 3 months after treatment.