Patient, therapist, and supervisor in a psychiatric institution: inner freedom and inner structure

The authors discuss issues concerning the psychotherapeutic process in a psychiatric institution. They develop the concept of the institution as an internalized object in addition to its being an objective object. As such, it has an effect on the inner freedom and the internal structure of the patient, the therapist, and the supervisor. It is claimed that it is crucial for the development of an identity as a psychotherapist that the supervisor be aware of the institution as an inner and real object. The authors raise questions about what kind of "space" is possible in a psychiatric institution and what influence that may have on the therapeutic process. The impact on the therapist's professional identity is discussed. They point to the process of becoming a therapist via supervision and examine some relevant dilemmas. The authors conclude by discussing the duality of inner freedom and internal structure, and their specific manifestations within an institution.     

Mechanisms of gonadotropin desensitization

The gonadotropic hormones, FSH and LH exert a major effect on ovarian and testicular function through interaction with specific seven-transmembrane domain glycoprotein receptors. Desensitization to the hormones, which can occur both in vivo and in vitro, is essential for prevention of overstimulation of the gonadal cells. The long-term process of desensitization to the gonadotropic hormones is probably mediated, in part, by extensive clustering and internalization of the hormone-receptor complex. Short-term desensitization may occur as a result of phosphorylation of serine or threonine residues on the receptor molecules, although a specific receptor kinase has not yet been identified. Recently, we have discovered a novel mechanism of gonadotropin desensitization, which is exerted by down-regulation of StAR expression and steroidogenesis mediated by MAPK activation as a result of hormone-receptor interaction, cAMP accumulation and PKA activation. Thus, PKA not only mediates gonadotropin-induced steroidogenesis, it also activates the down-regulation mechanism that can silence steroidogenesis under certain conditions. Moreover, our findings raise the possibility that activation or inhibition of ERK by other pathways could be an important mechanism for diminution or amplification of gonadotropin-stimulated steroidogenesis. This could contribute to functional luteolysis, a process in which luteinized granulosa cells show reduced sensitivity to LH despite maintenance of LH receptors, or to up-regulation of the steroidogenic machinery during luteinization of granulosa cells.     

The prognostic significance of circulating neuroendocrine markers chromogranin a, pro-gastrin-releasing peptide and neuron-specific enolase in patients with advanced non-small-cell lung cancer.

BACKGROUND: Chromogranin A (CGA), Pro-gastrin-releasing peptide (ProGRP) and neuron-specific enolase (NSE) are known as immunohistochemical tissue markers closely associated with neuroendocrine differentiation in non-small-cell lung carcinoma (NSCLC). The aim of the present study was to assess the value of serum levels of these markers in predicting response to chemotherapy and survival of patients with unresectable NSCLC. METHODS: The study included 67 patients with advanced NSCLC treated with chemotherapy. Before treatment, serum levels of CGA, ProGRP and NSE were measured with commercial kits. RESULTS: No association was found between serum NSE and age, gender, histology, performance status or extent of the disease. Distribution of serum CGA differed significantly according to gender and histology, with higher levels being found in men (p = 0.01) and in squamous cell carcinoma (p = 0.01). Serum ProGRP levels correlated with disease extent, being higher in patients with metastatic disease (M1) than in those with locoregional disease (M0; p = 0.02). The association of NSE, CGA and ProGRP levels with response to chemotherapy was not significant. While NSE had no impact on survival, the median survival was shorter for patients with elevated serum CGA and longer for patients with high ProGRP levels. Association with survival was significant when the Classification and Regression Tree (CART)-derived or median cutoff points were explored. On inclusion in multivariate Cox models, both CGA and ProGRP retained significance with high levels showing an opposite effect on survival [CART-derived cutoff points: CGA, relative risk (RR) -4.0; p < 0.001, and ProGRP, RR -0.4; p = 0.006, and median cutoff points: CGA, RR -1.8; p = 0.04, and ProGRP, RR -0.5; p = 0.03]. The combined use of CGA, ProGRP and NSE allowed for definition of two sets of patients with significantly different median survival times (25.2 vs. 8.8 months, p = 0.0001). CONCLUSIONS: In the circulation, CGA and Pro-GRP appear to bear important information related to the prognosis for NSCLC patients before chemotherapy. While a high CGA before treatment was found as an unfavorable prognostic determinant, a high ProGRP conferred a survival advantage. The combined use of serum CGA, ProGRP and NSE may supply additional information to prognosis.     

Amplitude spectra of natural images

Several studies have suggested that the amplitude spectra of photographs of natural scenes are remarkably similar and have the form: amplitude varies; is directly proportional to spatial frequency-1.0. This is, of course, a straight line with slope of -1.0 when plotted on double logarithmic coordinates. We have examined the amplitude spectra of 135 digitized photographs of natural scenes and have found that relatively few images conform exactly to the suggestion. About 25% of the images in our sample have spectra which show significant curvature when plotted on log-log coordinates. The best-fitting regression lines have slopes that range from -0.8 to -1.5; the average slope is -1.2, rather steeper than previously suggested.     

Computed tomography of the orbit with special emphasis on coronal sections: Part II. Pathological anatomy

Visualization of orbital soft tissue structures by computed tomography in direct coronal and axial studies is extremely useful in diagnosis. Direct enlargement viewing of scans has disclosed minute anatomical details. This study reviews some of our experiences in the investigation of a variety of lesions within the orbit and attempts, in particular, to illustrate the value of direct coronal studies.     

Clinical applications and future trends in cardiac CTA

The new 64-slice multi-detector computed tomographic scanners with improved temporal and special resolution are well suited to cardiac scanning allowing large area coverage and very short scan time. Current applications include plaque and stenosis assessment, evaluation of bypass graft patency and stenosis, coronary artery anomalies and recently, assessment of implanted coronary stents. Possible fields of utilization include emergency room triage of chest pain, and screening prior to invasive angiography in order to reduce the load of invasive studies. The future holds the prospect of automatic analysis of coronary plaque and luminal stenosis possibly opening up a new vista for non-invasive risk assessment.     

Testing the effectiveness of an innovative information package on practitioner reported behaviour and beliefs: The UK Chiropractors,Osteopaths and Musculoskeletal Physiotherapists Low back pain ManagemENT (COMPLeMENT) trial [ISRCTN77245761]

Background  

Low back pain (LBP) is a common and costly problem. Initiatives designed to assist practitioner and patient decisions about appropriate healthcare for LBP include printed evidence-based clinical guidelines. The three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy in the UK share common ground with their approaches to managing LBP and are amongst those targeted by LBP guidelines. Even so, many seem unaware that such guidelines exist. Furthermore, the behaviour of at least some of these practitioners differs from that recommended in these guidelines.     

Repair of pig dura in vivo using temperature controlled CO(2) laser soldering

BACKGROUND AND OBJECTIVES: The purpose of this study was to demonstrate that laser soldering might be successfully used for closing holes or cuts in the dura layer, which encapsulates the brain. STUDY DESIGN/MATERIALS AND METHODS: A temperature controlled fiberoptic CO(2) laser system and albumin solder were used for spot soldering of fascia patches to holes in the dura of farm pigs, in vitro and in vivo. RESULTS: The mean burst pressure of the soldered patches in the in vitro experiments was 190 +/- 88 mm Hg-significantly higher than typical maximum CSF pressure of 15 mm Hg. In the in vivo experiments the pigs showed no postoperative complications. Histopathological studies exhibited an accepted level of inflammatory reaction and showed no thermal damage to the underlying brain tissue. CONCLUSIONS: It has been clearly demonstrated that temperature controlled laser soldering is a very useful technique for the repair of the dura. It provides significant advantages over standard closure techniques: it is easy to apply, the bond is strong and watertight and the procedure is likely to be much faster than suturing. This research work will lead to clinical trials.     

Colovesical Fistula: Not a Contraindication to Elective Laparoscopic Colectomy

PURPOSE Traditionally, diverticular fistula was thought to be a contraindication for laparoscopic colectomy. The advent of hand-assisted laparoscopy has allowed repair of a diverticular fistula to be technically feasible laparoscopically. We present our experience with laparoscopic colectomy in patients with diverticular fistulas.METHODS Patients with colovesical or colovaginal fistulas secondary to diverticular disease were consecutively entered into a database over a five-year period. All operations were electively performed by a single group of colorectal surgeons. Patient demographics, American Society of Anesthesiologists classification, type of surgery, operating time, hospital length of stay, and early and late complications were recovered by chart review. These results were then compared to results from a group of patients who had undergone elective laparoscopic colectomy for recurrent diverticulitis during the same period by the same group of surgeons.RESULTS Altogether, 40 consecutive operations for diverticular fistulas were performed, 36 of which were started laparoscopically (90 percent). The average patient age was 65 years and the average American Society of Anesthesiologists class was 2. Patient demographics were similar among the group with recurrent diverticulitis (n = 149). The average hospital stay was 6.2 days for the fistula group and 4.4 days in the recurrent diverticulitis group. The average operating time was 220 minutes for the fistula group vs. 176 minutes for the uncomplicated group (P < 0.002). The conversion rate was significantly higher in the fistula group (25 percent vs. 5 percent, P < 0.001). There were no postoperative anastomotic leaks or bleeding episodes requiring reoperation in the fistula group.CONCLUSIONS Diverticular fistula should no longer be considered a contraindication for laparoscopic colectomy. These cases are more complex, as evidenced by the longer operating times and higher conversion rates when compared with resections for uncomplicated recurrent diverticulitis. Although the length of hospital stay was longer for patients who underwent laparoscopic colectomy for diverticular fistula, those whose operations were completed laparoscopically had the same outcome as patients with uncomplicated disease. We anticipate that minimally invasive surgery will become the standard of care for colovesical fistula, as it now is for uncomplicated diverticular disease.Read at the meeting of The American Society of Colon and Rectal Surgeons, Dallas, Texas, May 8 to 13, 2004.