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The psychodynamic therapist is both aware of and open to phenomena arising in their relationship with the patient. This paper compares two different phenomena and expands on how processing these phenomena aids the therapeutic pair: Bion's container-contained relationship and Jung's concept of the collective unconscious, which could be thought of as containing the therapeutic relationship. The two concepts will be described and elucidated using a clinical example of a therapist's dream from the collective unconscious following sudden termination in therapy. This supports a synthesis of the two concepts in a developmental context and within the wider scholarship of both thinkers. Finally, their relationships to embodied processes will be explored. Copyright © 2022 BPF and John Wiley & Sons Ltd.
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In complex systems such as a food supply chain, where integrated flows of materials and information take place beyond the boundaries of individual companies, a substantial degree of inherent uncertainty cannot be avoided. That uncertainty may increase significantly when unexpected disruptions occur. Evidence of this is given by the recent - and still ongoing - crisis due to the coronavirus pandemic (commonly known as COVID-19), which is expected to create an economic depression even more severe than the 2008 financial crisis. This has been already observed in some economic sectors such as travel and tourism, food and agriculture, retail, healthcare systems and academic institutions. This paper grounds on a bibliographic analysis of articles and studies that have already been conducted about the impact of COVID-19 on supply chains and logistics processes, with a specific focus on the food systems, with the purpose of gaining a better understanding of this topic and of finding out how it may develop in the coming years. From the literature, a questionnaire was delineated as used as the basis for carrying out an empirical analysis on this topic, by means of an interview with a company working in the food sector. During the interview, the (medium-term) consequences of the pandemic on the food supply chains are investigated, focusing on logistics processes, whose stability has been challenged by numerous factors. The findings of the interview are presented and discussed, with the ultimate aim to highlight how COVID-19 has contaminated the logistics functions, definitely changing the way of approaching and acting within a supply chain. A series of reflections about the results obtained from the various research studies carried out, providing suggestions for possible future developments are finally presented. © 2022 The Authors.
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The prevalence of heart failure in the population and the COVID pandemic have rendered increasingly necessary the integration of remote monitoring with cardiology teleconsultation. A patient with dilated cardimiopathy was subjected to ICD implantation (Boston Scientific Perciva DR) with remote monitoring (LatitudeTM). One month after implant, remote monitoring recorded an increase in the HeartLogicTM heart failure index, a decrease of right ventricular and atrial sensing, contextually to fluctuations of the impedance values of the two leads (Fig. 1). The patient reported having performed shoulder's rehabilitation therapy with probable manipulation of the ICD pocket. Chest X-ray showed dislocation of both leads with distal end of right atrial catheter in superior vena cava and distal end of right ventricular catheter in right atrium (Fig. 2A) and kinking of proximal segments (Fig. 2B), a picture compatible with diagnosis of Twiddler's syndrome. Implant revision confirmed lead kinking in the subcutaneous pocket (Fig. 3A). The atrial catheter, given the amount of tissue deposited at its distal end (Fig.3B) which prevented its active fixation, was replaced. Following discharge, an increase in the HeartLogicTM Heart Failure Index was detected. The outpatient visit showed the presence of pleural effusion and medical therapy was therefore optimized. In order to avoid frequent ambulatory visits to the patient, a cardiology teleconsultation was planned, which enabled to verify the clinical benefit of therapy's variation. Remote device monitoring confirmed HeartLogicTM Heart Failure Index normalization. In conclusion, the integration of remote monitoring with cardiology teleconsultation, enables to timely detect device malfunctions and prevent episodes of heart failure, avoiding further hospitalizations. This integration is even more useful and necessary in geographically disadvantaged areas, strengthening the link between the territory and the hospital, improving patients compliance and therapeutic adherence and thus allowing a progressive improvement of the symptoms and quality of life of heart failure patients.
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Background: Left Atrial Appendage Occlusion (LAAO) with the Watchman device is considered an elective procedure, and thus often deferred during outbreak peaks associated with the COVID-19 pandemic. Patients with bleeding issues on anticoagulation may require additional hospitalization for bleeding episodes or suffering increased risk of stroke by postponing occlusion while anticoagulation is discontinued. We chose to develop a protocol for screening, same day discharge, and follow up of selected LAAO patients and continuing to provide quality clinical outcomes while accounting for decreased bed and staff capacity due to the pandemic. Methods: Utilizing Knowledge to Action (KTA) nursing framework, a protocol was developed and reviewed with key stakeholders. Criteria for Same Day Discharge (SDD) includes: support at home, stable vitals and access site hemostasis prior to DC, agreeable to SDD, tolerant of oral intake, ability to urinate and safely ambulate prior to DC. Exclusion for SDD includes: Liver disease, Plt count <70,000, ESRD or CKD IV or any site or procedure complications. With Perclose usage patients must have 3 hours of bedrest, with manual pressure closure must have bedrest for 6 hours and purse string suture removed. This is followed by a next day phone call to ensure the patient is taking appropriate medicines and have no medical issues. Results: 38 out of 113 patients were screened as SDD candidates from January 2021-October 2021. Average patient age was 76, 31% female, with average CHA2DS2-VASc of 5. One patient required overnight hospitalization due to underlying asthma and need for nebulizer. One patient presented to an outpatient ED on a weekend with chest pain and underwent heart catheterization due to elevated troponin and did not require intervention. There were no access site complications. No patients contracted SARS-Cov-2 within 6 weeks post procedurally, compared with 2 of the overnight stays during the same period (75 patients). Conclusion: SDD in a carefully selected patient population is a feasible and safe strategy for LAAO patients. These patients had a clinically significant, though underpowered decrease in incidence of COVID-19 diagnosis within 6 weeks post implant.
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Background: During the CoViD-19 pandemic in type 2 diabetic patients (T2DM pts) present in our Medicine wards we administered a big amount of s.c. insulin through the basal bolus regimen in order to obtain a good metabolic control;often difficult to reach both for the septic state and steroid therapy. Since we administered almost 60 to 80 units/insulin per day (TDD), not always obtaining a good metabolic control, we thought to switch some of our in-patients treated with basal bolus insulin regimen to a bolus plus a fixed ratio combination of GLP1-RA/basal insulin trying to take advantage of both the antiinflammatory and slimming effect of GLP1-RA. Results: Between October and December 2020 we evaluated 54 T2DM in-patients with CoViD-19 pneumonia.They were 41 males and 13 females aged 70±5 yrs, BMI 31±3kg/sm with an average HbA1c 8.3±1.2 and an insulin TDD of 70±11 s.c. compared to 40 matched (for sex, age, BMI and insulin TDD) control pts treated with basal bolus regimen. Conclusions:We detected in the fixed ratio combination of GLP1- RA/basal insulin a faster and stable good metabolic control vs the basal bolus treated pts. We reduced the average amount of insulin TDD of 34% with great satisfaction of pts and nurses.
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Online learning became one of the most discussed topics during the COVID-19 pandemic. The educational world had to implement and deliver online courses for their students, and millions of students found themselves behind their laptop rather than in class in a matter of weeks. This article introduces a specific piece of software, Interactive Document, tailored to higher education to allow heightened interaction and active participation with study materials. This article explains the main elements of the tool, including how instructors can benefit from using Interactive Document integrated with Microsoft Teams. Characteristics of the software such as in-line comments, practice questions, anti-skimming features, comment sorting, and the ability to attach files are discussed, with references to use cases where these features were applied. Finally, a case study from Texas A&M International University is presented, highlighting how Interactive Document enhances students' critical skills and structural understanding, while allowing instructors to have a deeper overview on student performance and interaction with the study material.
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Background: Mitral valve repair (MVR) represents the gold standard for severe regurgitation in degenerative mitral valve disease. Trans-ventricular beating heart off- pump MVR is a micro-invasive surgical technique to treat mitral valve prolapse, which does not require cardiopulmonary bypass, nor cardioplegic arrest or sternotomy. Indications, however, have to date been restricted to elective cases. We report the first patient emergently treated with this technique. Clinical Case: A 64-year-old man presented to the emergency department with dyspnoea, chest pain and pulmonary edema. Echocardiography showed severe mitral regurgitation caused by acute posterior leaflet chordal ruptures. Ejection fraction was 60%. The patient rapidly developed cardiogenic shock requiring mechanical ventilation. Decision-making: Refractory heart failure mandated emergent MVR. In view of the chest radiograph and the suspicion of COVID-19 (swab not yet available), the micro- invasive beating heart approach was considered with the aim to reduce inflammatory response and lung injury related to cardiopulmonary bypass. Feasibility was confirmed by transesophageal echocardiography, which showed a P2 flail and good predicted coaptation. Three polytetrafluoroethylene neochords were attached to the free edge of the prolapsing P2 segment through a left minithoracotomy. Skin-to-skin duration of the operation was 80 minutes. Residual regurgitation was less than mild. The patient was soon discharged home. The two months follow-up confirmed a good result of the valvuloplasty. Conclusion: This case demonstrates the safety and efficacy of the beating heart off- pump MVR, even in emergent situation. Considering the current pandemic situation, with overwhelmed health care systems, the possibility to shorten and unburden the patient's in-hospital stay with micro-invasive procedures should be routinely considered.
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Purpose : Patients affected by Coronavirus disease 2019 (Covid-19) suffer from a hypercoagulable state that may potentially affect the retinal and choroidal circulation. The aim of this study was to determine whether retinal and choriocapillaris vessel density (VD) as measured by optical coherence tomography angiography (OCTA) resulted abnormal in patients previously affected by Covid-19 Methods : The right eye of sixty patients who tested positive for Sars-CoV-2 in a reverse transcription PCR assay were examined with structural optical coherence tomography (OCT) and OCTA. A control group of age-matched healthy subjects was selected for statistical comparisons. Raw OCT and OCTA images, acquired with TOPCON DRI OCT Triton, were exported using Topcon IMAGENET 6.0 software. 3D datasets were analysed to determine retinal thickness and VD in the 5 sectors of Early Treatment Diabetic Retinopathy Study (ETDRS). Results : The images were gradable in 54 eyes (88%) on which the final analysis was conducted. The study and control group did not differed significantly for sex, intraocular pressure (IOP) and refractive error. Vessel density of the superficial capillary plexus did not differ between groups whereas VD of the deep capillary plexus (DCP) and choriocapillaris in the foveal ETDRS sector was significantly lower in the Covid-19 group compared to controls (P < 0.01). No significant difference was found in the VD's recorded in any of the other 4 ETDRS sectors between groups. Within the COVID-19 group, subgroups were identified for therapies, underlying diseases and hospitalization. Based on therapies the lowest VD was recorded among patients treated with antiviral therapy compared to antiplatelet therapy (P < 0.01). No significant difference was found between patients affected by hypertension, diabetes or thyroid disease. A significantly reduced VD value was registered in patients admitted in ICU compared to asymptomatic (P < 0.01). Conclusions : In patients with previous COVID, the VD of the retinal DCP and choriocapillaris measured with OCTA resulted decreased. The lowest values of VD were recorded in the eyes of patients who had undergone antiviral therapy and ICU-setting. Future studies are needed to further support our preliminary data that individuals with previous COVID might develop abnormalities of the retinal and choriocapillaris vasculature.
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Introduction and Aim of the study: Hydroxychloroquine has beenauthorized in the therapy of patients with COVID-19. Many publications have not clarified the real efficacy of the drug. Really, thedrug was widely used during the pandemic. A single-center observational cohort study was conducted to evaluate the effectiveness of hydroxychloroquine therapy in a group of subjects admittedin the sub-intensive therapy of the COVID Unit Hospital F. Miulli(Acquaviva delle Fonti, Bari, Italy) from 17 march to 17 may 2020.Materials and Methods: The data contained in the medicalrecords were studied. The sample was divided into two groups withrespect to therapy with or without hydroxychloroquine'. Clinicaland laboratory data were analyzed.Results: A total of 174 patients hospitalized (60.4% males),mean age 68 yrs, with diagnosis of SARS-CoV2, were analyzed.118 patients were treated with hydroxychloroquine. The treatment group consisted of 66.1% males, mean age 63 years. Thetwo groups were homogeneous in comorbidity and in the severityof clinical presentation of SARS-CoV2 infection. The death ratewas significantly higher in the group of untreated than in thosereceiving hydroxychloroquine, 40% vs 2.6% respectively. Therewere no significant differences on QTc prolongation between thetwo groups (467+47 ms control group, 446 + 35 ms, treatmentgroup).Discussion and Conclusions: The data of our study, although referring to a reduced sample, show the effectiveness of hydroxychloroquine in reducing mortality in subjects suffering fromSARS-CoV2 infection.
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Background and Aim of the study: In the course of the epidemic,COVID 19 disease first appeared severely and then with a gradualreduction in symptoms. Aim of the study was to compare the clinical characteristics of patients hospitalized in two different periodsfrom March to May.Materials and Methods: 174 patients, 161 subjects admitted inthe period March 17 / April 17 and 13 subjects admitted in theperiod April 17 / May 17, at the Covid Unit of F. Miulli Hospital inAcquaviva delle Fonti (Ba), were studied.Results: From the comparison of the two periods, there is a clearreduction in hospitalizations (161 vs 13). The number of asymptomatic or mildly complicated patients is significantly greater inthe second group. The rate of patients hospitalized with severepneumonia (19.9%) or ARDS (6.8%) in the first period is higherthan the patients of the second period (7.7% and 0%). In March/ April, 3.1% of patients needed ICU admission while no patientwas admitted to ICU in the past thirty days. The length of stay wasalso significantly higher in the first period (21 ± 8 days vs 8 ± 2days) as well as mortality (14% vs 11%). IL 6, d-dimers and fibrinogen values were lower (but not statistically significant) in theApril / May period.Discussion and Conclusions: Our sample, although of limitedsize, shows a significant difference in the clinical evolution of theCOVID 19 infection in the two study periods. The reduction inlength of stay, severe respiratory failure and mortality indicate alikely attenuation in coronavirus virulence in the last month of thepandemic spread.
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Background and Aim of the study: Tocilizumab (TCZ), a monoclonal antibody against IL-6 receptor, has been recently employedas a treatment for SARS-Cov2-associated pneumonia (COVID),due to the central role of IL-6 on the citokyne-storm associatedhyperinflammatory syndrome. Aim of this observational retrospective study was to evaluate effectiveness and safety of TCZ for thetreatment of COVID.Materials and Methods: We retrospectively evaluated, from 16thMarch 2020 to 7th April 2020, outcomes of 16 patients affected bynasopharyngeal swab-confirmed SARS-COV-2 Pneumonia who received TCZ i.v. treatment (8 mg/kg once or twice in 12 hours). Weevaluated clinical features, Arterial Blood Gas Test (ABG), laboratoryfindings collected at baseline and after consecutive two days. Results: We analyzed 16 patients (M/F: 12/4) with mean age (±SD) 69±9 years and mean disease duration 15±5 days. At baseline, mean CRP level was 14±10 mg/dl and IL-6 249±264 pg/ml.To evaluate respiratory improvement after treatment, we collectedABG data at 6,24 and 48 hours;we observed a rapid improvement of P/F ratio to 165,6±55,4 mmHg (p=0,01). We also observed a significant reduction of CRP levels to 6±6 mg/dl(p=0,0002) and a rapid increase of IL-6 serum levels to941±1317 pg/ml (p=0,05). Clinically we observed a global improvement in ten patients, while six died for infective complications. No adverse event was detected following TCZ administration.Conclusions: In our real-life experience TCZ treatment was effective and safe in a group of patients affected by SARS COV2-associated pneumonia.
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Background and Aim of the study: Partial or complete ageusiaand anosmia have been observed as initial and sometimes uniquesymptoms of COVID-19 infection, especially in paucisymptomaticpatients. A single-center observational cohort study was conductedto evaluate taste and smell in a group of subjects admitted in thesub-intensive therapy of the COVID UNIT Hospital F. Miulli (Acquaviva delle Fonti, Bari, Italy) from 8 april to 11 may 2020.Materials e Methods: A questionnaire was administered to agroup of patients, with normal cognitive system. The laboratoryand clinical data contained in the medical records were studied.Results: 53 patients, 35 male and 18 female aged between 23and 82 replied to the questionnaire. 19 patients reported no loss,3 reported only loss of smell and 31 loss of taste;of these, 23also reported an associated loss of smell (9 partial loss and 14total loss). Patients with olfactory deficits complained of nasalcongestion and the need to breathe through the mouth in 23% ofcases and rhinorrhea in 15%. The loss of taste was rarely associated with a decrease in appetite (3%) and in 65% this deficit wastotal. The division of patients into 4 phenotype groups (based onthe severity of the clinical presentation) did not reveal significantdifferences between the groups.Conclusions: The data of our study, although referring to a reducedsample, show that olfactory and gustatory deficits are associatedwith SARS-CoV2 infection in a high percentage of patients. The phenotype did not show a role in the development of these symptoms.
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Background and Aim of the study: From March 2020 to May2020 we treated 133 SARS-CoV-2 patients in our COVID Unit at'F. Miulli' Hospital, 15 of these were also affected by severe acuterespiratory syndrome that needed CPAP support. The aim of thestudy was to evaluate the clinical features of patients with severerespiratory failure treated with CPAP compared to those with milderone that didn't require it.Materials and Methods: A retrospective observational study on133 patients was performed. Patients have been divided into twogroups: those who needed CPAP (15) and those who didn't (118)to compare comorbidities and the supportive medical therapy.Results: 80% of the patients treated with CPAP were males (age71 ± 12). Only 13% were smokers;the most frequent comorbidities were heart failure (20%) and renal failure (40%);pre-existentrespiratory diseases, high blood pressure and diabetes mellitusdidn't show a significant impact on the respiratory outcome. Comparing the 2 groups we found a significant difference about theprobability to be transferred in Intensive Care Unit, higher in CPAPtreated patients (p 0,034). We also found differences between thetwo groups about the medical therapy support, in particular theuse of diuretics, resulted significantly higher (p 0,002) in CPAPtreated patients.Conclusions: A severe respiratory failure related to COVID 19 ap pears to be more frequently associated with kidney and heart disease rather than pre-existing worst respiratory situation and so requires in association with C-PAP support also a more substantialmedical therapy.