The boy in the iron mask: superego issues in the analysis of a two-year-old encopretic.

The paucity of psychoanalytic literature on encopresis is surprising given its frequency as a presenting symptom. Vignettes from the analysis of a two-year-old encopretic boy are presented to demonstrate the prominence of superego determinants, even in a child so young. The implications of this finding for understanding encopresis are subsequently discussed, including the common feature of depression. Technical issues arising from a sensitivity to these superego contributors are demonstrated, and the importance of addressing a child's sadistic superego directly in order to facilitate insight is emphasized.

Evaluation of dose-intense Ifosfamide, with and without edatrexate, in adults with sarcoma.

Purpose. To define the maximally tolerated dose (MTD) of ifosfamide when given with G-CSF on an every other week schedule, and to define the MTD of edatrexate that can be given every two weeks with an intense schedule of ifosfamide.Patients and Methods. Forty-one patients with metastatic or unresectable, locally advanced sarcoma participated in this 2-step phase I trial.The starting dose of ifosfamide was 10 gm/m(2) given by continuous intravenous infusion over 4 days every 2 weeks.When the MTD was defined, edatrexate, beginning at a dose of 40 mg/m(2) intravenously every 2 weeks was added in subsequent cohorts of patients.Results. Myelosuppression was the most prominent toxicity. Fatigue, nausea, and vomiting were observed in the majority of patients. Ifosfamide 12 gm/m(2) given every 2 weeks approached or exceeded the MTD. Edatrexate 100 mg/m(2) could be given safety as an intravenous bolus with ifosfamide 10 gm/m(2) every 2 weeks. Therapeutic responses were observed in patients with measurable disease.Conclusions. This study demonstrates the feasibility of administering a dose-intense schedule of ifosfamide alone or ifosfamide with edatrexate that might be applied in the adjuvant or neo-adjuvant setting.

Phase II trial of paclitaxel in patients with soft-tissue sarcoma.

The response rate (RR) to single-agent chemotherapy with doxorubicin or ifosfamide in patients with advanced soft-tissue sarcoma (STS) is in the range of 20%. Paclitaxel is clinically useful in treating several solid tumors and has demonstrated activity in a series of human sarcoma cell lines. Twenty-eight patients with measurable advanced STS participated in this phase II trial of paclitaxel at 250 mg/m2 administered as a 3-hr i.v. infusion once every 3 weeks. All patients received granulocyte colony-stimulating factor (G-CSF) beginning on the day after paclitaxel and lasting until recovery from neutropenia. No prior chemotherapy had been used in 17 patients; 10 patients had had prior doxorubicin-based therapy; and 1 patient had had intraperitoneal therapy with edatrexate. Two partial responses (PRs) (7%; 95% confidence interval [CI] = 1-23%) were observed. The responding patients included a patient with angiosarcoma of the scalp who had complete regression of cutaneous lesions and improvement of nonmeasurable pulmonary disease lasting 6 months. The other PR occurred in a woman with metastatic uterine leiomyosarcoma and lasted 9 months. Seven patients had stable disease for 3-4 months. Median time to progression for all patients was 3.5 months (range: 2.5-9 months). The mean nadir in the white-blood-cell (WBC) count was 3.8 x 10(3)/microliter (range: [0.2-16.2] x 10(3)/microliter), with a mean nadir in the absolute neutrophil count (ANC) of 2.4 x 10(3)/microliter (range: [0.0-7.1] x 10(3)/microliter). Three patients died while in the study. Two patients with angiosarcoma of the scalp who did not qualify for this study were treated with paclitaxel off protocol, and experienced dramatic tumor regression. The overall response to paclitaxel observed in this heterogeneous group of patients was disappointing. However, the activity seen in angiosarcoma of the scalp suggests that further evaluation is warranted in patients with STS.

Attrition in the treatment of childhood anxiety disorders.

The present study explored the differences between completers and terminators (including both refusers and dropouts) of an individual cognitive-behavioral treatment for childhood anxiety. Participants were 190 children with anxiety disorders and their parents: 146 completed treatment and 44 terminated. Terminators were more likely to live in a single-parent household, be ethnic minorities, and self-report less anxious symptomatology. Follow-up interviews indicated that identifiable child factors were influential in terminators' decisions to discontinue treatment. Among terminators, differences between refusers and dropouts were also investigated.

Implementation of a radiology electronic imaging network: the community teaching hospital experience.

Because of their typically small in-house computer and network staff, non-university hospitals often hesitate to consider picture archiving and communication system (PACS) as a solution to the very demanding financial, clinical, and technological needs of today's Radiology Department. This article presents the experiences of the 3-year process for the design and implementation of the Radiology Electronic Imaging Network (REIN) in the Department of Radiology at The Western Pennsylvania Hospital (WPH). WPH embarked on this project in late 1994 to find a solution to the very pressing demands to reduce operating costs and improve service to primary care clinicians, both on-site and at WPH-affiliated clinics. A five-member committee consisting of in-house medical, administrative, information services, and medical physics staff was formed to design a network that would satisfy specific needs of WPH by using a phased mini-PACS approach and to select the various vendors to implement it. Suppliers for individual mini-PACS were selected to provide modality-specific solutions. For the backbone network, vendors were evaluated based on their technological progress, competence and resources, the commitment of the company to the imaging network business, and their willingness to embark on a mid-sized PACS project such as this. Based on patient volume, workflow patterns, and image quality requirements, the committee produced proposals detailing number and location of workstations, short- and long-term memory requirements, and so on. Computed tomography/magnetic resonance imaging, computer radiography, ultrasound, nuclear medicine, digital fluoroscopy, and angiography mini-PACS have been implemented over the past 2 years, and most of these are already integrated into the main REIN. This article presents detailed information concerning the design, selection and implementation processes, including storage requirement calculations. This indicates that PACS implementation is achievable for community hospitals with small computer, networking, and physics departments. Also presented are recommendations concerning design and vendor selection, that may be helpful for similar institutions.

Phase I trial of dose-intense liposome-encapsulated doxorubicin in patients with advanced sarcoma.

PURPOSE: To define the maximum-tolerated dose (MTD) of liposome-encapsulated doxorubicin (LED) when used every 2 weeks with granulocyte colony-stimulating factor (G-CSF) in patients with advanced soft tissue sarcoma. PATIENTS AND METHODS: Doxorubicin encapsulated in egg phosphatidylcholine/cholesterol liposomes was given to patients with sarcoma in a disease-specific phase I trial. The initial dose was 75 mg/m2 with G-CSF 5 micrograms/kg. The MTD was defined as the highest dose that could be given every 2 weeks. RESULTS: Twenty-nine patients participated in this study. Major toxicities included myelosuppression, nausea and vomiting, fatigue, and mucositis. Eight patients were hospitalized for nadir fever. No cardiotoxicity was seen. The MTD was LED 105 mg/m2 with G-CSF 5 micrograms/kg. LED 120 mg/m2 resulted in tolerable, albeit prominent, acute toxicity, but did not permit recycling of therapy on day 15. Among 26 patients with soft tissue sarcoma, 23 had measurable disease, of whom three achieved a partial response (13%; 95% confidence interval, 2% to 34%). CONCLUSION: LED can be administered every 2 weeks at a dose of 105 mg/m2 with G-CSF support, which provides a dose-intensity of 52.5 mg/m2/wk. To exceed this intensity, the dose of LED that would have to be administered every 3 weeks would be greater than 157.5 mg/m2. A formal phase II trial is needed to estimate better the true response rate.

Dynamic underpinnings of father hunger as illuminated in the analysis of an adolescent boy.

Growing sensitivity to the importance of the father in child development has contributed to research demonstrating the existence of "father hunger" in children who have lost their fathers (Herzog, 1982), manifested in serious problems modulating aggression. Vignettes from a five-year analysis of an adolescent boy who lost his father at age five are presented to demonstrate the complex psychodynamic underpinnings of father hunger. These clinical data lead to the conclusion that father hunger should be considered an ego state involving highly complex compromise formations manifested in fantasies. These are affected by the child's personal history with each parent, his or her developmental stage when the loss occurred, constitutional endowment, and the reaction of the mother to the father's death. The case material presented highlights the primarily defensive nature of the aggression characterizing father hunger. This essay also briefly discusses technical complications of analyzing such cases, including the patient's denial of mourning, management of the patient's aggression, transference-countertransference interactions, and a vulnerability to premature separation.

Developmental antecedents of masochism: vignettes from the analysis of a 3-year-old girl.

This paper suggests that masochism be understood as an organizing concept which involves drives, defence mechanisms, superego elements, self and object representations as well as environmentally based interpersonal relationships. Vignettes from the analysis of a 3-year-old girl who presented with protomasochistic provocativeness are offered to illustrate the multiple functions served by such behaviour. The opportunity to study such developmental antecedents of masochism demonstrates that such symptoms have intrapsychic meanings even at such an early age. The role of external reality must be considered in regard to its structuring and stimulating influences on intrapsychic factors rather than regarded as the sole cause of masochism. Finally, it is important to realize that masochism has forerunners at all developmental stages rather than to try to reduce its origins to any one developmental epoch.

Where's the beef? Putting personality back into personality assessment.

This article attempts to demonstrate the value of using a psychoanalytic theory of personality for psychological testing. This approach has more clinical utility than a solely research-based one. It recasts test data into conceptually related constructs that have internal consistency to each other and are directly relevant to psychotherapeutic treatment. Such theoretical recasting serves an organizing function, an integrative function, a clarification function, and a predictive function for the clinical inference process. Furthermore, a psychoanalytically oriented approach to testing allows for the expansion in sources of data that one considers in the testing situation. Five different sources of data emerge from the testing situation once one refocuses on theoretical constructs rather than test signs. These include test scores, test content, the patient-examiner interaction, patient behavior, and examiner countertransference.

The role of aldosterone in potassium tolerance: studies in anephric humans.

Since the role of aldosterone in mediating extrarenal potassium transport remains uncertain, the effect of mineralocorticoid on potassium metabolism was assessed in anephric patients. Seven anephric patients underwent three identical 72-hour periods between hemodialyses during which treatment with either 10 mg/day deoxycorticosterone acetate (DOCA) intramuscularly or 300 mg/day spironolactone orally was compared to a baseline control period. The serum potassium rise, plasma aldosterone, salivary and stool electrolytes were measured in response to potassium loading over 48 hours with a metabolic diet containing 38 mEq/day followed by an "acute" oral potassium load of 0.5 mEq/kg. Acute potassium loading with DOCA resulted in a lower increment in serum potassium than with spironolactone (P less than 0.01). The volume of distribution of the acute potassium load at three hours was 55% of body weight with DOCA, which was significantly greater (P less than 0.05) than with either spironolactone (35%) or control (34%). However, with the dietary load of potassium, the increments in serum potassium measured at 24 and 48 hours (13 hours post-prandial) were similar in all three periods. The volume of distribution of the dietary potassium was not altered by DOCA or spironolactone but had risen to an average of 172% at 24 hours and 243% at 48 hours in the three periods. Plasma aldosterone levels were low, positively correlated to the serum potassium and similar in all three periods without evidence of feedback inhibition by DOCA or stimulated by spironolactone.(ABSTRACT TRUNCATED AT 250 WORDS)

Parathyroid hormone impairs extrarenal potassium tolerance in the rat.

The effect of parathyroid hormone (PTH) on the extrarenal disposition of an acute potassium load was examined in acutely nephrectomized rats infused with KCl (0.75 meq.kg-1.h-1 for 90 min) alone or in combination with 8-10 U.kg-1.min-1 PTH, with serial monitoring of plasma potassium every 10 min. The rise in plasma potassium concentration (delta PK) in the PTH group was higher than control. PTH was then administered along with KCl to two groups of nephrectomized and acutely thyroparathyroidectomized (TPTX) rats in doses of 1 and 0.25 U.kg-1.min-1 for 90 min. delta PK with PTH in both groups was higher than TPTX control (P less than 0.01). The two higher doses of PTH resulted in a decrease in mean arterial pressure from their respective controls. A similar reduction in arterial pressure in three groups of nephrectomized rats by administration of hydralazine or nitroprusside or by acute blood loss did not change delta PK subsequent to potassium infusion from that in control rats. Furthermore, the lowest dose of PTH did not lower arterial pressure from its respective control. Therefore, hypotension is not a cause for the PTH-induced potassium intolerance. Serum levels of insulin, aldosterone, catecholamines, calcium, plasma HCO3 concentration, and pH were not different in PTH-infused vs. respective control rats. These data suggest that PTH impairs extrarenal potassium disposal in the rat. The effect of PTH may relate to enhanced calcium entry into cells.

Calcium channel blockers enhance extrarenal potassium disposal in the rat.

The effect of calcium channel blockers on the extrarenal disposition of an acute potassium load was examined in acutely nephrectomized rats infused with KCl (0.75 meq X kg-1 X h-1 for 60 min) alone or in combination with either verapamil or nifedipine. The increment in plasma potassium concentration during the potassium infusion (delta PK) with either verapamil or nifedipine was less than control (P less than 0.05 and 0.01, respectively). Studies were repeated in acutely adrenalectomized rats (ADX) to evaluate whether the changes in plasma potassium were consequent to the enhanced activity of epinephrine and other adrenal hormones. delta PK with ADX was higher than control (P less than 0.01). Verapamil or nifedipine with ADX resulted in a lower delta PK than ADX alone (P less than 0.05). Further studies were then conducted with the selective beta 2-adrenergic blocker butoxamine hydrochloride to rule out enhanced peripheral sympathetic activity of the beta 2-adrenergic system in facilitating the potassium disposal. delta PK with butoxamine was greater than control (P less than 0.01) but not significantly different from ADX. Verapamil or nifedipine in conjunction with butoxamine resulted in a lower delta PK than butoxamine alone (P less than 0.01). Changes in arterial pH and plasma bicarbonate were similar in all groups. In conclusion, during potassium infusion the delta PK is lower in the presence of calcium channel blockers. The alteration in potassium transport produced by calcium channel blockers does not appear to be dependent on adrenal function or peripheral sympathetic activity. Impaired calcium entry into cells may alter potassium transport in the intact animal.

Extrarenal potassium transport and the beta 2-adrenergic system.

The distribution of a short-term potassium load was quantitated in three groups of acutely nephrectomized rats infused with KCl at 0.75, 1.50, and 2.25 mEq/kg/hr for 90 minutes. The rate of net potassium transfer from the extracellular fluid compartment to the intracellular fluid compartment was stable from 30 to 90 minutes and proportional to the rate of infusion, with no evidence of saturation of transport mechanisms. In the period 60 to 90 minutes, the calculated increments in intracellular potassium concentration over 10-minute intervals were similar to the respective increments in extracellular potassium concentration. The apparent volume of distribution of the infused potassium over this period was similar to total body water. At the termination of the infusions, the net potassium transfer rates rapidly fell to very low levels. Our studies support the view that the extrarenal modulation of short-term potassium load is dependent on changes in plasma potassium concentration that conform to a first-order linear kinetic model. The infusion of the selective beta 2-adrenergic blocker butoxamine without potassium administration to acutely nephrectomized rats resulted in a net efflux of potassium from the intracellular fluid compartment. The addition of butoxamine to three groups of rats receiving KCl at the previous rates resulted in a fixed decrement in net potassium transfer to the intracellular fluid compartment that was not significantly different from the net efflux of potassium seen with butoxamine alone. Despite beta blockade, the net transfer of potassium remained proportional to the infusion rate. Thus, in our studies, beta 2-adrenergic blockade had a relatively fixed influence on decreasing net potassium transfer, both under basal conditions and during short-term potassium administration.

Psychological assessment of psychopathology in opiate addicts.

A sample of 99 opiate addicts seeking treatment were assessed on three well established clinical assessment procedures; the Loevinger Sentence Completion, the Bellak Ego Functions Interview, and the Rorschach. Their scores were compared using normal and clinical reference groups. On all three procedures, opiate addicts had a significantly greater impairment than normals but significantly less thought disorder and impairments in ego functions than hospitalized borderline and psychotic patients. The results indicate that a primary disturbance in opiate addicts appears to be their relative inability to conceptualize people as well differentiated, articulated, and involved in meaningful, purposeful, and constructive activity. In addition, opiate addicts appear to have greater affective lability. These difficulties in interpersonal relations and affect modulation are consistent with disturbances in the neurotic range and suggest that opiate addicts have selected a particularly untoward, self-destructive, isolated mode of adaptation for achieving the satisfactions and pleasures most people seek in intimate personal relationships.

Features of gentamicin nephrotoxicity and effect of concurrent cephalothin in the rat.

Sprague-Dawley rats given gentamicin from 10 to 70 mg/kg/day for 9 days showed a linear decrease in glomerular filtration rate with increasing dose, paralleled by histologic changes of acute tubular necrosis and cast formation only at the higher doses. Nephrotoxicity was correlated with the peak, rather than trough, serum gentamicin levels in this study, suggesting that it is the mean level of gentamicin over time that determines renal injury. The polyuria caused by gentamicin resulted mainly from a tubular concentrating defect rather than enhanced sodium or osmolal excretion and may be explained by the finding of a predominance of casts in the medullary thin limbs of the loops of Henle. No effect of gentamicin on the activity of cortical or medullary sodium-potassium adenosine triphosphatase was found to account for the modest sodium wasting. Concurrent administration of sodium cephalothin decreased the renal toxicity of gentamicin at high doses, an effect not explained by the added sodium or nonreabsorbable anion.

Ego boundary disturbance in anorexia nervosa: preliminary findings.

Boundary disturbance and the developmental level of the Rorschach human representations of anorectic patients were studied. A group of 12 anorectics was compared with a control group in regard to their degree of boundary disturbance, the developmental level of their human responses, the degree to which they attribute affect to their percepts, and the nature and degree of drive-dominated ideation. The anorectic patients showed significantly more contamination responses, reflective of a breakdown in their self-other boundaries. The affect elaboration, human representations, and drive-dominated ideation measures failed to differentiate the two groups. These findings provide preliminary support for clinical observations from both individual and family perspectives that families of anorectics show greater boundary disturbance which appears to be internalized by these patients. Thus, much of their symptomatology might be understood as an attempt to gain autonomy through an overaccentuation of the boundary between themselves and others. The failure of the drive-dominated ideation measures to differentiate the two groups supports the deemphasis of the role of psychosexual factors.