Intraoperative bypass flow measurement reduces the incidence of postoperative ventricular fibrillation and myocardial markers after coronary revascularisation.

OBJECTIVE: Sudden ventricular fibrillation (VF) and myocardial infarction (MI) are life-threatening complications after coronary artery bypass grafting (CABG). We prospectively analysed the impact of intraoperative bypass flow measurement with the transit time flow Doppler method (TTFD) on the incidence and outcome of postoperative VF and MI. METHODS: In 1995 a standardized algorithm for the treatment of postoperative VF was introduced in our institution. The rate of postoperative VF was therefore exactly registered. In 1998 the TTFD method was implemented as a standard in all CABG cases. Whenever insufficient bypass graft flow was detected, anastomoses were redone and technical problems affecting the grafts were excluded. The incidence of postoperative VF and CK/CK-MB fraction was observed prospectively and the new data was compared to the data from 1995 to 1998. RESULTS: From 1/95 to 7/98 a total of 4321 patients (group A) were operated on with isolated CABG procedures using extracorporeal circulation. In the period from 8/98 to 10/02 a total of 3421 patients (group B) was operated on with isolated CABG procedures under the same conditions, except that the TTFD method was used in every case. The treatment of VF was standardised in both groups according to the algorithm. The most striking effect was the significant reduction of VF from 0.66% to 0.44% when TTFD was introduced and the steep decrease in mortality from 30% to 12.2% in patients with VF when the algorithm and TTFD were routinely applied. Furthermore the rate of insufficient bypass flow detected by angiography was reduced by 66%. CONCLUSION: Routinely the use of TTFD significantly reduced the incidence of postoperative VF, postoperative CK/CK-MB fraction, and angiographically detected bypass malfunction. A simultaneously implemented algorithm reduced the mortality with VF after CABG. The consequent use of TTFD intraoperatively reduced the incidence of postoperative anastomosis and technically related complications of bypass surgery and led to a significant reduction of postoperative mortality in CABG procedures.

Oedipus again: a critical study of Charles Laughton's The Night of the Hunter.

In this paper the Oedipus complex is reexamined through a film, The Night of the Hunter. Study reveals a concealed fairy tale structure, a structure that, when presented against a mythic backdrop, is ideal for presenting a certain kind of oedipal situation, that of a vulnerable damaged father and couple (indeed, couples), revealing a skewed oedipal situation. The film, produced in 1954 and looked at forty years later in the context of psychoanalytic writings of the last decade (Bergmann, Feldman, Herman, Simon), provides a matrix with which to reexamine a fundamental psychoanalytic concept, the Oedipus complex. It is the mutual enrichment of art and psychoanalysis that this paper addresses.

Infusion of oxidized glutathione enhances postischemic segment-shortening in dog hearts.

Oxidized glutathione (GSSG) but not its reduced form (GSH) is taken up by intact myocardial cells, and is rapidly converted into GSH. Reduced glutathione is an important intracellular defense against oxygen-derived free radicals and has been found to enhance calcium sensitivity in skinned cardiac fibers. We have investigated the effects of intravenous GSSG on left ventricular systolic pressure, maximal rate of rise of pressure and regional segment-shortening in dogs subjected to occlusion of the left anterior descending artery for 30 minutes, followed by 45 minutes reperfusion. Starting 10 minutes before reperfusion, the dogs were randomly treated with either GSSG (100 mM, 5 ml/min, n = 5) or Ringer's solution (5 ml/min, n = 5) until 30 minutes of reperfusion. Myocardial blood flow was measured by radioactive microspheres. Infusion of GSSG increased total glutathione content in both ischemic (47 +/- 16 mumol/g protein) and nonischemic myocardium (71 +/- 17 mumol/g protein) as compared to controls (23 +/- 2 mumol/g protein, p < 0.05). In both groups paradoxical wall motion occurred in the ischemic region during occlusion. On reperfusion, regional dyskinesia persisted in controls; while, in glutathione-treated dogs, systolic segment-shortening reached half the baseline values (p < 0.05, treated vs controls, at 15, 30, 45 minutes reperfusion). During ischemia the area of pressure-length loops, obtained from simultaneous recordings of left ventricular pressure and regional segment length, decreased to 30 +/- 7% of baseline in controls and to 40 +/- 18% of baseline in GSSG-treated animals. After 45 minutes reperfusion it was restored to 78 +/- 22% baseline in treated hearts but was still 36 +/- 16 of baseline in controls (p < 0.05). We conclude that infusion of GSSG increases the intracellular stores of glutathione and improves the contractile state of postischemic myocardium.

Specialized extended hospital treatment for borderline patients.

The intensive psychoanalytically oriented hospital treatment described by the authors was developed specifically for borderline patients. This unique treatment, an integrated multimodal approach, is based on the theory that the disturbed behaviors and relationships of borderline patients are manifestations of intrapsychic impairment. The authors use a detailed case report to illustrate how the theory is transformed into technical precepts and applied to all aspects of the treatment.

Glutathione alters calcium responsiveness of cardiac skinned fibers.

The glutathione status of cardiac muscle, that is the ratio of reduced glutathione (GSH) to oxidized glutathione (GSSG) changes in certain forms of cardiomyopathy and during reperfusion of ischemic heart. Here we show that it also affects the sensitivity of contractile proteins to calcium. GSH (4 mM) increased the pCa50 for force development in skinned fibers by 0.2 pCa units and increased force by 44% +/- 5.4% at pCa 5.6 whereas GSSG (4 mM) decreased it by 54% +/- 17.8% at pCa 5.6. Half maximal activations and inhibitions were seen with 4 mM GSH or GSSG, respectively. In contrast to GSH, the reducing agent dithiothreitol at 5 mM had no activating effect. Our results suggest that the loss of contractility observed after a reperfusion of the ischemic heart may, at least in part, be due to a decreased responsiveness of the contractile proteins due to an altered glutathione status.

Long-term hospital treatment of borderline patients: a descriptive outcome study.

The authors report a prospective 2-year outcome study of 40 inpatients with severe personality disorders who were treated on a specialized long-term unit for patients with "borderline conditions." Treatment goals included improving interpersonal relationships and facilitating a lasting discharge from the hospital. Data were collected at admission, discharge, and 1 and 2 years after discharge. The data reflect change from admission to follow-up in impulsivity, psychotherapy, and social adjustment. Mediating effects of length of stay on outcome are discussed.

Diagnosing borderline personality. A pilot study using multiple diagnostic methods.

The research described in this paper stemmed from the hypothesis that borderline personality organization can be differentiated from neurotic and psychotic levels of personality organization by means of three structural criteria: degree of identity integration, level of defensive operations, and capacity for reality testing. In order to elicit these criteria, the "structural" interview has been developed that focuses on the "here-and-now" patient-interviewer interaction. The patient's responses to the interviewer's attempts to clarify, confront, and interpret various aspects of the patient's interview behavior provide the basis for judgments as to the patient's structural diagnosis. Specifically, the paper reports a study of the differential diagnosis of 48 hospitalized patients in which structural diagnoses of borderline or psychotic personality organization were made according to this diagnostic interview approach. These diagnoses were compared with ones obtained from Gunderson's Diagnostic Interview for Borderlines, with psychological test diagnoses, and with clinical diagnoses based on past history and current illness. Results show substantial convergent agreement among all of the diagnostic methods and support the utility of the structural interview. In most discrepant cases, other methods reflected disagreement among themselves despite the diagnoses obtained from the structural interview, suggesting that there are some cases difficult to classify by any means. Further analysis suggests that the structural interview may be eliciting a different dimension of personality functioning in arriving at borderline diagnoses than do the other methods studied. The results also indicate that borderline structural diagnoses refer to patients described clinically as having severe character pathology, and do not overlap with patients described as having schizophrenic disorders. The structural interview appears to warrant further study, and, at the same time, shows promise as a research tool in further studies of structural diagnosis and its relevance for prognosis and treatment.

The role of the hospital milieu in structural diagnosis.

The authors have found the structural approach to diagnosis to be a valuable tool in classifying ill-defined mental illnesses. That approach presumes there are discrete levels of mental functioning: neurotic, borderline, and psychotic. Each can be differentiated by identifying the degree of identity integration, the level of defensive operations, and the degree of reality testing. Two case illustrations are used to describe how the dynamic role of the hospital milieu can be used in conjunction with individual treatment to make an accurate diagnosis. The application of this approach to the diagnosis of adolescents is emphasized.

Borderline personality organization, structural diagnosis and the structural interview. A pilot study of interview analysis.

Kernberg has related the level of integration of the personality to the level of integration (and "structuring") of internalized object relations. He has designated three levels of personality organization: neurotic, borderline, and psychotic, and has developed a specially focused clinical interview designed to reveal intrapsychic structural characteristics--a "structural interview"--as a diagnostic instrument to differentiate the three types of personality organization. This study presents a method of analysis of the structural interview. Interviews of ten hospitalized psychiatric patients were studied to determine whether indicators could be retrieved from the typescripts of the interviews consonant with the diagnoses made by clinicians utilizing Kernberg's structural theory. Results indicate that scores generated from the typescripts are consistent with the hypothesis that the interviews did contain the indicators called for by structural theory and differentiate borderline from psychotic structures better than chance. In addition, this method of analysis of contingencies of interaction in the interview may have broader application to the study of psychotherapy and psychoanalysis.