Stress-induced ST-segment elevation in patients without prior Q-wave myocardial infarction

Background

Stress-induced ST-segment elevation is an uncommon finding that usually occurs in patients with prior myocardial infarction (MI). Our purpose was to assess the angiographic and clinical significance of this finding in patients without prior MI.

Methods

Of the 29 002 consecutive ambulatory patients who underwent stress myocardial perfusion imaging over a 5-year period, 205 (0.7%) developed stress-induced ST-segment elevation, of whom 39 (19%) had no Q-wave MI in leads showing ST-segment elevation during either exercise (n = 31) or dipyridamole (n = 8) stress myocardial perfusion imaging. All 39 patients were hospitalized and underwent coronary angiography.

Results

Significant coronary artery disease was found in all 39 patients: 87% had critical (≥90%) stenosis, and 59% had multiple vessel disease. During hospitalization, 37 patients (95%) underwent revascularization.

Conclusions

In patients without prior Q-wave MI, stress-induced ST-segment elevation is associated with critical coronary artery disease. Therefore, these patients should be considered for early coronary investigation.     

Timing of aspirin administration as a determinant of survival of patients with acute myocardial infarction treated with thrombolysis

Unlike thrombolytic agents, there are conflicting data regarding the time-dependent effect of aspirin treatment on outcome in acute myocardial infarction (AMI). We sought to evaluate the impact of timing of aspirin administration (before vs after thrombolysis) on mortality of patients with AMI. Our study included 1,200 patients with ST elevation AMI treated with thrombolysis. Early (n = 364) versus late (n = 836) users were defined as those receiving emergency aspirin before versus after initiation of thrombolysis, respectively. Time (median) from symptom onset to initiation of aspirin treatment was significantly shorter in early versus late users (1.6 vs 3.5 hours; p <0.001). There were no significant differences between the 2 groups with respect to baseline clinical characteristics. Early aspirin users were more likely to develop reischemia, to be treated with beta blockers, to be referred to coronary angiography, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery. Early users experienced lower mortality at 7 days (2.5% vs 6.0%, p = 0.01), 30 days (3.3% vs 7.3%, p = 0.008), and 1 year (5.0% vs 10.6%, p = 0.002) than late users. This survival benefit persisted for patients with and without previous aspirin therapy or revascularization and after adjustment for baseline characteristics and therapies at 7 days (odds ratio 0.36, 95% confidence interval 0.15 to 0.79), at 30 days (odds ratio 0.39, 95% confidence interval 0.17 to 0.82), and at 1 year (odds ratio 0.41, 95% confidence interval 0.21 to 0.74). Our study proposes a time-dependent benefit from aspirin in patients with AMI treated with thrombolysis.     

Increased risk of depression in patients with rheumatoid arthritis: a seven-year population-based cohort study

OBJECTIVE:

Rheumatoid arthritis (RA) is a costly and crippling autoimmune disease that can lead to the development of depression, contributing to suboptimal clinical outcomes. However, no longitudinal studies have identified an association between rheumatoid arthritis and subsequent depression. This study aimed to investigate the incidence and risk factors of depression among RA patients in Taiwan.

METHODS:

Using Taiwan''s National Health Insurance Research Database, we identified 3,698 newly diagnosed RA patients aged 18 years or older, together with 7,396 subjects without RA matched by sex, age and index date, between 2000 and 2004. The incidence of depression and the risk factors among RA cases were evaluated using Cox proportional-hazard regression.

RESULTS:

The incidence of depression was 1.74-fold greater in the RA cohort than in the non-RA cohort (11.80 versus 6.89 per 1,000 person-years; p<0.01). Multivariate analysis showed that RA subjects who were female, were older, or had comorbidities such as stroke, chronic kidney disease, or cancer had a significantly greater risk of depression compared with those without these conditions.

CONCLUSION:

This population-based cohort study showed a strong relationship between RA and a subsequent risk of depression. The findings could be beneficial to healthcare providers for identifying individuals with a higher predisposition for depression, thereby possibly facilitating the provision of an appropriate rehabilitation intervention after RA onset to support the patient''s adaptation.     

Authentic Voices in Supervision

Analytic thinkers incorporated the significance of authenticity for human development and therapeutic processes into their theories. I suggest that, consequently, supervisors search for the supervisees’ authentic voices, often masked by unconscious rhetorical devices, and for the patients’ authentic voices hidden in the supervisees’ voices. Assuming a poetic stance for listening, which highlights the speakers’ unique use of language, beyond the lexical and the prosaic, enables supervisors to perceive and construct implicit musical patterns and symbols woven into the supervisees’ communications. This stance allows the supervisors to perceive the supervisees’ authentic voices, free from their distracting rhetoric, and to imagine the patients’ voices in the supervisees’ heads. When supervisors differentiate and integrate various perceiving and reflective modes that characterize the poetic stance, they function as identification models for the supervisees in their development as analytic therapists.     

The Shared Regressive State and Understanding-without-Reflection in Supervision

One of the transformational therapeutic experiences is the therapeutic dyad's immersion in and recovery from shared regressive states that are often provoked by an awakened childhood fear of breakdown. I suggest that the supervisory dyad has parallel transformational experiences – the shared regressive states that follow continuous incomprehension of the unfolding therapeutic reality. Moreover, when the supervisory partners immerse themselves in a shared regressive state, a unique, inclusive, embodied, unsymbolized, and procedural understanding-without-reflection emerges spontaneously. Analytic writers describe such an understanding as an unconscious knowledge, and existentialist writers describe it as prereflective consciousness. Before translating this unique understanding into a therapeutic narrative, the supervisor needs to recover from the regressive state and organize it according to discursive and logical analytic principles. From this perspective, the already existing experiential and analytic theoretical knowledge serves as a platform for creating new perceptions and analytic discourses.     

On the Supervisee's Future Orientation

While exploring the supervisee's implicit contribution to therapeutic interactions, the supervisor can focus on the supervisee's future orientation instead of exploring transference manifestations that might arouse the supervisee's anxiety. I suggest that future orientation is shaped by an implicit urge described in the analytic literature as an unconscious hope to elicit yearned-for psychological nutrients from the environment. In parallel, existentialist literature describes an urge to exercise the freedom to live an authentic life and actualize fundamental personal projects, sometimes against cultural and societal convictions and conventions. Furthermore, frustrating the urge that shapes future orientation might lead to a limited situational crisis described differently by the two schools of thought. While reconstructing the supervisee's therapeutic experiences, the supervisor can discern this urge in the components or response patterns of the supervisee's situational crisis. I will suggest that the supervisory dyad's capacity to formulate the implicit urge that shapes the supervisee's future orientation creates a continuous temporality and enlivens the supervisory and therapeutic processes.