An Illustration of SARS-CoV-2 Dissemination Within a Skilled Nursing Facility Using Heat Maps.

OBJECTIVES: To illustrate dissemination and asymptomatic transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during a skilled nursing facility (SNF) outbreak. DESIGN: Case report. SETTING AND PARTICIPANTS: Residents of a 150-bed SNF. MEASUREMENTS: Heat maps generated by the SNF's infection prevention team to track staff and resident symptoms and SARS-CoV-2 test results to identify infection patterns. RESULTS: The SNF experienced a severe outbreak of SARS-CoV-2 early in the pandemic. The initial cluster of residents with symptoms and the first confirmed case occurred on the SNF's dementia care unit. The insufficient availability and prolonged turnaround time of testing for both residents and staff at the outset of the outbreak prevented timely and accurate identification and cohorting of cases. Despite extensive other infection control measures being in place, SARS-CoV-2 disseminated widely through the facility within 3 weeks of the first confirmed case, resulting in significant morbidity and mortality. CONCLUSION: Early, rapid, universal SARS-CoV-2 testing of both SNF residents and staff at the outset of an outbreak and then repeatedly thereafter is critical to mitigate viral transmission. This will become even more important as states relax stay-at-home orders and SNF staff intermingle with communities that are increasingly mobile. Increased testing will inevitably result in more staff testing positive and having to self-quarantine at home, meaning that states must partner with SNFs and other long-term care providers to coordinate and support strategic staffing reserves that can supplement current frontline staff. J Am Geriatr Soc 68:2174-2178, 2020.

My Patient, My Stalker Empathy as a Dual-Edged Sword: A Cautionary Tale.

Success in psychotherapy is correlated with the "fit" between patient and therapist, a factor related to attachment. For psychotherapists of any orientation, empathy and building the bond of attachment is our stock-in-trade. When empathy builds the bond of attachment with someone starved for connection, a therapist may inadvertently set him- or herself up to become a victim of a stalker. Because individuals who stalk others suffer from severe attachment disorders, their hunger for attachment motivates them to shadow psychotherapists, which makes being stalked a very real occupational hazard for psychotherapists. This was a painful discovery for me. I was stalked for 11 months, leaving me with post-traumatic stress disorder. After recovering, I deconstructed the experience to understand how and why it happened, and discovered that it was my empathy and compassion that contributed to and maintained the stalking. What I learned from the forensic literature provided the knowledge and confidence needed to end the stalking. In this paper recommendations are made about how to prevent stalking and to halt it if it does happens.

To PEG or not to PEG: a review of evidence for placing feeding tubes in advanced dementia and the decision-making process.

Percutaneous endoscopic gastrostomy (PEG) has evolved into a common low-risk procedure in current medical practice. Clinical evidence supporting the use of tube feedings in patients with advanced dementia is clearly lacking, yet PEG procedures continue to be performed in a large number of these cases. In fact, multiple studies have shown that feeding tubes seldom are effective in improving nutrition, maintaining skin integrity by increased protein intake, preventing aspiration pneumonia, minimizing suffering, improving functional status, or extending life. The decision-making process is complicated, however, and involves the clinician considering such issues as advance directives, ethical considerations, legal/financial concerns, emotional factors, cultural background, religious beliefs, and the need for a family meeting incorporating all of these principles.

Free association reconsidered: the talking cure, the writing cure.

It has not been fully appreciated that psychoanalysis, in its origins, was both a talking and a writing cure. When Freud instructed his patients to say whatever came to mind, using words to verbalize that which was preconscious replaced the hypnotic technique as the "talking cure" and was the beginning of the psychoanalytic method. Freud used writing to an internal other in his self-analysis, and his free association writing has had an enormous influence on psychoanalysis. This author has introduced writing into the treatment of some patients and has found it invaluable with psychosomatic patients, including those who suffer from eating disorders and self-injury, because they tend to use their bodies rather than words to express emotions. Today's "widening scope" evokes a need to develop newer techniques, especially with patients who are unusually resistant to free associating or whose thinking is presymbolic. Caution must be taken that writing eases the resistance to free association and does not serve as a source of resistance itself, and that it serves creative rather than destructive aims. A little-known event in psychoanalytic history is instructive: E. Pickworth Farrow, a former psychoanalytic patient, devised a self-analytic process through writing down his free associations.

Ecstatic stigmatics and Holy anorexics: medieval and contemporary.

As has been shown and explained, the stigmata and other mortifications of the flesh can serve as survival tools for someone who has been severely traumatized, devout Christian or unbeliever alike. When Diana, Princess of Wales, was killed, this nonreligious woman came to be regarded by her admirers as a popular saint who wanted nothing more than to help and serve others. Despite her wealth, she became a waif in the popular imagination, and like many others who suffered great psychic pain, she too inflicted further pain and suffering on herself through starving herself, binging and purging, and cutting herself. This suffering was her visible stigmata, inspiring great popular devotion. When she died, millions cried, carrying candles in the streets as they listened to Elton John's song to this suffering woman whose light flickered "like a candle in the wind".

When deep venous thrombosis fails to respond to therapy.

BACKGROUND: Deep venous thrombosis in primary care is usually treated with rest, analgesics, intravenous or low-molecular-weight heparin, and coumadin. In some cases, however, a less familiar course of diagnosis and management is required. METHODS: We describe the case of a 53-year-old truck driver who had an acute deep venous thrombosis of his right lower extremity, which failed to respond to routine therapy with heparin and warfarin. A literature search was undertaken to research the differential diagnosis and management of deep venous thrombosis and to review specifically the role of venal caval filters and inherited thrombotic disorders and occult cancer in this context. RESULTS AND CONCLUSION: The ultimate diagnosis in our patient appeared to be signet ring cell cancer of the colon that had metastasized to the right thigh. This case is an example of the inherent limitations of even an aggressive diagnostic and therapeutic approach to the entity of refractory deep venous thrombosis.