RESUMO
Borderline personality disorder (BPD) is a severe and relatively prevalent psychiatric disorder, responsible for high rates of suicidal behaviors. Disturbed identity appears as at the very core of this disorder, being inter-related with all other BPD features. Notably, from a dimensional perspective on mental disorders, one should realize that it is from our usual self-representation that we live all our daily experiences. Then, if the understanding of self-concept (or identity) is impaired, all the interventions implemented to decrease the self's suffering will subsequently be impaired. The purpose of the present case study was to illustrate the nine identity diffusion categories described by Jørgensen & Bøye (2022) and how the level of identity function can be improved in a third-wave cognitive and behavioral therapy targeting progressive correct self-identification.
Assuntos
Transtorno da Personalidade Borderline , Humanos , Transtorno da Personalidade Borderline/terapia , Transtorno da Personalidade Borderline/psicologia , Terapia Comportamental , Ideação Suicida , AutoimagemRESUMO
OBJECTIVE: This study presents data from a randomized outcome study comparing mentalization-based and supportive psychotherapy for patients with borderline personality disorder (BPD). METHOD: Eighty-five SCID-II diagnosed borderline patients were randomized to either i) 2 years of intensive (twice weekly) combined (individual and group), mentalization-based psychotherapy (MBT) or ii) 2 years of less-intensive (biweekly) supportive group therapy. Treatment outcome was assessed using a battery of self-report questionnaires, SCID-II interviews and therapist-rated global assessment of functioning (GAF). RESULTS: Fifty-eight patients completed 2 years of treatment. Significant changes in both treatment groups were identified for several outcome measures, including self-reported measures of general functioning, depression, social functioning and number of diagnostic criteria met for BPD, as outlined by the SCID-II interview. General linear modelling was used to compare treatment outcome in the two groups. Only GAF showed a significantly higher outcome in the MBT group. A trend was found for a higher rate of recovery from BPD in the MBT group. Pre-post effect sizes were high (0.5-2.1) and for the most part highly significant in both groups. CONCLUSION: The study indicates that both MBT and supportive treatment are highly effective in treating BPD when conducted by a well-trained and experienced psychodynamic staff in a well-organized clinic.
Assuntos
Transtorno da Personalidade Borderline/terapia , Psicoterapia/métodos , Teoria da Mente , Adulto , Terapia Combinada , Depressão , Feminino , Humanos , Estudos Longitudinais , Masculino , Psicoterapia de Grupo/métodos , Recuperação de Função Fisiológica , Ajustamento Social , Resultado do Tratamento , Adulto JovemRESUMO
In this report, we describe a patient who had purulent Nocardia asteroides pericarditis. In addition, we identified 13 previously suspected and reported cases of Nocardia pericarditis, but only 5 of these studies reported isolation of Nocardia from cultures of pericardial fluid or pericardium. Analysis of the clinical course of these five patients and our patient revealed the importance of long-term sulfonamide antibiotic therapy in combination with surgical pericardial drainage procedures. In our review, only patients who received antibiotics and underwent pericardiectomy survived. Our case substantiates the excellent penetration of sulfisoxazole into the pericardial fluid, even with oral administration of the drug, and provides evidence in support of aggressive management of Nocardia pericarditis.
Assuntos
Nocardiose/terapia , Pericardite/terapia , Adulto , Terapia Combinada , Feminino , Humanos , Nocardia asteroides/isolamento & purificação , Pericardiectomia , Sulfisoxazol/uso terapêuticoRESUMO
In an effort to characterize the effectiveness of cardiology consultation, the outcomes of consultants' recommendations for diagnostic actions and cardiac drugs were quantitatively examined in 394 cases. Drug recommendations were made more frequently (49 percent) than diagnostic recommendations (38 percent) and were associated with a higher rate of concordance (82 percent to 64 percent). Recommendations to start therapy with a drug, especially an antihypertensive or an antianginal, were associated with a lower concordance rate than recommendations to continue or discontinue drug therapy. Consultees' responses to recommendations for diagnostic action did not vary significantly according to the type of action suggested. Nonconcordance with diagnostic suggestions was particularly high when a service made a large number of consult requests. Concordance was increased if the consultant left a follow-up note. Consultees' responses to drug and diagnostic recommendations were independent of one another. The study represents the first systematic assessment of cardiology consultation activities and provides a methodology for subsequent studies.
Assuntos
Fármacos Cardiovasculares/uso terapêutico , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/tratamento farmacológico , Encaminhamento e Consulta , Adulto , Cardiologia , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Cooperação do Paciente , Estudos RetrospectivosRESUMO
This report comprises 16 consecutive patients with ascending aortic aneurysms caused by cystic medical necrosis. We replaced the ascending aorta and aortic valve with a tightly woven Dacron graft containing a Lillehei-Kaster valve prosthesis and implanted the coronary ostia in the sides of the graft. All but two patients had massive aortic insufficiency. Postoperative catheterization was performed in 13 patients, and all surviving patients have been seen within the past 6 months. There was one perioperative death (6 percent) and two late deaths. Eleven survivors are in Class I and two are in Class II (N.Y.H.A.). Angiographically demonstrated late complications have included psuedoaneurysms of the coronary ostium (two), paravalvular leak (one), and pseudoaneurysm of the distal suture line (one). Two of these four patients were asymptomatic. Two of the four patients have had successful repair of these defects and a third is awaiting operation. Compositive replacement carries a low operative risk and minimizes problems of intraoperative bleeding. In view of the incidence of late suture line problems, routine angiography 6 to 12 months postoperatively is recommended. If new symptoms occur or if there is a change in the cardiac silhousette on chest roentgenogram, the patient should be recatheterized.
Assuntos
Aneurisma Aórtico/cirurgia , Insuficiência da Valva Aórtica/cirurgia , Prótese Vascular/métodos , Próteses Valvulares Cardíacas/métodos , Adolescente , Adulto , Aneurisma Aórtico/complicações , Aneurisma Aórtico/mortalidade , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/mortalidade , Prótese Vascular/mortalidade , Cateterismo Cardíaco , Seguimentos , Próteses Valvulares Cardíacas/mortalidade , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidadeRESUMO
Two hundred thirty-two consecutive patients (October 3, 1977, through December, 31, 1980) underwent aortic (AVR), mitral (MVR), or double (DVR) valve replacement with the St. Jude Medical (SJM) prosthesis. Operative mortality for the entire group was 7.3%. There was 100% follow-up. Warfarin (Coumadin) anticoagulation was recommended for all patients. There were no cases of mechanical failure. The incidence of thromboembolism was 0.6/1,000 patient-months for those with AVR, 3/1,000 patient-months for those with MVR, and 0% for those with DVR. Thrombosis of a prosthesis occurred in two patients with DVR. Clinically significant hemolysis occurred in three patients with paravalvar leaks following MVR. Late postoperative prosthetic infection has not occurred. Postoperative catheterization studies in 33 patients revealed no transvalvular gradient at rest in 21 patients. The remainder of the patients catheterizd had low transvalvular gradients. There was a minimal increase in transvalvular gradient with exercise. The SJM cardiac valve is a viable alternative in the surgical therapy of valvular heart disease.
Assuntos
Próteses Valvulares Cardíacas/normas , Tromboembolia/complicações , Varfarina/uso terapêutico , Adolescente , Adulto , Idoso , Valva Aórtica/cirurgia , Criança , Pré-Escolar , Feminino , Próteses Valvulares Cardíacas/mortalidade , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia/prevenção & controle , Valva Tricúspide/cirurgiaRESUMO
Hyperlipidemia and obesity are common problems after heart transplantation, which may increase the risk of chronic graft atherosclerosis. The intent of this study was to (1) determine the impact of a history of hyperlipidemia on the occurrence of lipid abnormalities after transplantation, (2) compare lipid profiles of those patients being treated with triple-drug immunosuppression versus those patients weaned from prednisone therapy, and (3) identify any factors that would predict which patients are at highest risk for the development of hyperlipidemia after transplantation. Of 89 patients who lived for more than 12 months, 35 patients had a history of hyperlipidemia before heart transplantation (cholesterol level of more than 240 mg/dl; low-density lipoprotein cholesterol level of more than 160 mg/dl). The most dramatic rise in cholesterol level was observed in patients with no history of hyperlipidemia who were treated with triple-drug immunosuppression, in whom a 64% increase occurred versus a 24% increase in patients receiving steroid-free immunosuppression (p < 0.001). In patients with a history of hyperlipidemia, cholesterol level increased by 20% with triple-drug immunosuppression versus 14% with steroid-free immunosuppression (p = 0.613); however, 83% of the patients in the triple-drug group and 92% in the steroid-free group had elevated cholesterol levels. Multiple regression analysis revealed that significant independent and additive (p < 0.00001) contributions with respect to percent change in cholesterol level were evident for (1) a negative history of hyperlipidemia (p = 0.005), (2) triple-drug immunosuppression (p = 0.0021), and (3) female sex (p = 0.0113). A negative history of hyperlipidemia was predictive of the percent change in low-density lipoprotein cholesterol level (p = 0.0049), and triple-drug immunosuppression administration predicted the percent change in high-density lipoprotein cholesterol (p = 0.0119). Patients with a positive history of hyperlipidemia had higher lipid values at 12 and 24 months after transplantation; however, patients with no previous history of hyperlipidemia experienced the greatest percent change in both cholesterol and low-density lipoprotein levels. Patients receiving prednisone therapy gained more weight (9.0 +/- 7.0 kg) as compared with those patients tapered from prednisone therapy (5.9 +/- 8.6 kg); however, neither the increase in actual weight (p = 0.120) nor the increase in percent ideal body weight (14% +/- 11% versus 9% +/- 13%, respectively) were significant (p = 0.133). This study identified that postoperative weight gain is best predicted by premorbid habitus, rather than the type of immunosuppression used.(ABSTRACT TRUNCATED AT 400 WORDS)
Assuntos
Transplante de Coração/efeitos adversos , Hiperlipidemias/induzido quimicamente , Terapia de Imunossupressão , Obesidade/induzido quimicamente , Prednisona/efeitos adversos , Síndrome de Abstinência a Substâncias/epidemiologia , Colesterol/sangue , Feminino , Humanos , Hiperlipidemias/epidemiologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Prednisona/uso terapêutico , Análise de Regressão , Estudos Retrospectivos , Fatores de RiscoRESUMO
A group of high-risk heart transplant patients (n = 35) were treated from May 1987 through June 1990, with murine-derived monoclonal CD3 antibody (OKT3) induction therapy and steroid-free maintenance immunosuppression. This group was compared with a group of transplant patients (n = 47) who were not considered high risk and who were treated simultaneously with triple-drug immunosuppression (cyclosporine, azathioprine, and prednisone). The 1- and 3-year actuarial survival rates were similar: 97% and 91% for the OKT3 and 92% and 85% for the triple-drug immunosuppression groups, respectively. The overall incidence of rejection was equal for both groups (56%). No rejection occurred during the OKT3 course and rejection episodes occurred significantly later in patients treated with OKT3, with a mean first rejection episode of 111 +/- 104 days versus 27 +/- 21 days for the triple-drug immunosuppression group (p less than or equal to 0.05). Bacterial infections were seen more frequently (29% vs 6% of the patients treated) in the early period (less than 3 months) in the OKT3 group (p = 0.01) and were associated with the use of mechanical assistance in this group. The incidence of late infections or cytomegalovirus disease was similar for both groups. Patients treated with OKT3 and subsequent steroid-free maintenance immunosuppression had no significant posttransplantation increases of serum cholesterol levels, and hypertension was less common. Initial hospitalization was longer (p less than or equal to 0.05) in the OKT3 group (23 +/- 19 vs 13 +/- 5 days) but after the initial discharge the number of hospital days for the first year was similar for both groups (8 +/- 14 vs 9 +/- 13 days). Ventricular function at 1 year after transplantation was similar for both groups with average ejection fraction of 57% and 59% for the OKT3 and triple-drug immunosuppression groups, respectively. In conclusion, high-risk patients treated with OKT3 and steroid-free maintenance immunosuppression were managed on smaller doses of immunosuppressive drugs in the early postoperative period, and had excellent long-term survival rates. In this group of patients, rejection was delayed and the incidence of hypercholesterolemia, hypertension, and steroid-induced complications was decreased. Such a regimen offers a relatively drug-free period in the early posttransplant stages and freedom from the long-term complications of steroids.
Assuntos
Rejeição de Enxerto , Transplante de Coração , Terapia de Imunossupressão/métodos , Imunossupressores/uso terapêutico , Muromonab-CD3/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Análise Atuarial , Infecções Bacterianas/epidemiologia , Infecções por Citomegalovirus/epidemiologia , Feminino , Transplante de Coração/mortalidade , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prednisona/efeitos adversos , Prednisona/uso terapêutico , Fatores de RiscoRESUMO
Recent advances in immunotherapy have resulted in improved survival after heart transplantation. The use of OKT3 as an induction agent has allowed the identification of a subset of patients who can be successfully withdrawn from prednisone and maintained on only cyclosporine and azathioprine. The latter regimen offers several theoretic advantages in terms of freedom from complications of long-term steroid therapy. To compare both the long-term efficacy and toxicity of steroid-free maintenance immunosuppression with triple-drug therapy, the medical records of 68 patients undergoing transplantation at the Minneapolis Heart Institute during a 3-year period (1988 through 1990) were reviewed. Thirty-six patients were treated with OKT3 induction immunotherapy, 29 were successfully tapered off prednisone by 114 +/- 44 days after transplantation, whereas 32 patients were maintained on triple-drug therapy. The incidence of treated rejection was equivalent in both groups; however, the time to first rejection was longer in patients treated with OKT3/steroid-free maintenance (205 +/- 214 vs 27 +/- 17 days) (p = 0.02). Bacterial infections during the early posttransplant period were more common in the OKT3/steroid-free maintenance group (p = 0.008); however, fungal and viral infections were equally distributed between both groups. The incidence of hypertension was slightly higher in patients maintained on prednisone (67% vs 51%; p = 0.242).(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Transplante de Coração , Terapia de Imunossupressão , Imunossupressores/uso terapêutico , Prednisona/efeitos adversos , Síndrome de Abstinência a Substâncias , Feminino , Rejeição de Enxerto , Humanos , Hiperlipidemias/induzido quimicamente , Hipertensão/induzido quimicamente , Masculino , Pessoa de Meia-Idade , Muromonab-CD3/uso terapêutico , Complicações Pós-Operatórias/epidemiologia , Estudos Prospectivos , Fatores de Tempo , Aumento de PesoRESUMO
The central-flow low profile disc-valve prosthesis has been offered as an alternative to ball- and tissue-valve prostheses. Extensive laboratory investigation with both pulse duplicator and experimental animals has been reported for the Lillehei-Kaster prosthesis. A series of patients receiving this prosthesis underwent postoperative cardiac catheterization to better define the hemodynamic function of this prosthesis in vivo. Because of the variations in reports of hemodynamic data from various institutions, the results of post-operative studies in an earlier group of patients with Starr-Edwards prostheses were used as a standard for comparison. Good hemodynamic function was found with the pivoting-disc prosthesis in all but the smallest valve sizes. Lillehei-Kaster and early model Starr-Edwards prostheses with equivalent tissue annulus dimensions were found to have nearly equal valve areas in vivo in the aortic position. The Lillehei-Kaster mitral valves provided larger areas than Starr-Edwards prostheses in large tissue annulus sizes.
Assuntos
Próteses Valvulares Cardíacas/normas , Hemodinâmica , Estudos de Avaliação como Assunto , Seguimentos , Próteses Valvulares Cardíacas/efeitos adversos , Humanos , Desenho de PróteseRESUMO
From October 1985 through December 1989, 92 heart transplant procedures were performed in 89 patients. Nine patients (aged 19 to 66 years; 7 male, 2 female) required mechanical circulatory support after transplantation because of primary idiopathic organ failure (n = 2), implant difficulty (2), poor organ quality (2), or acute right heart failure (3). Devices used included the intraaortic balloon pump (6), centrifugal right ventricular assist device (2), left ventricular assist (1), biventricular assists (2), and total artificial heart (1). Two patients required multiple devices. One patient underwent retransplantation. Implant time ranged from 1 to 18 days. One early death occurred owing to right heart failure 6 days after transplantation, 7 hours after removal of a right ventricular assist device, for an overall mortality of 11%. The remaining 8 patients are alive 4 months to 28 months after transplantation. The actuarial 1-year survival of 89% +/- 10% compares well with the survival of 87% +/- 4% for the entire transplant group. All surviving patients are in functional class I. Echocardiographic examination in all patients revealed left ventricular ejection fraction to be normal in 7 and depressed in 1. Extending the criteria for organ donors or difficulty with the implant procedure can lead to early organ failure, which may be reversible with circulatory assistance allowing excellent survival.
Assuntos
Circulação Assistida/métodos , Transplante de Coração/métodos , Adulto , Idoso , Ecocardiografia , Feminino , Transplante de Coração/mortalidade , Transplante de Coração/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Reoperação , Volume Sistólico/fisiologia , Taxa de SobrevidaRESUMO
The comprehensive approach to the patient with angina pectoris begins with a thorough history, physical examination, and noninvasive studies such as the exercise electrocardiogram. Classification of individual patients with coronary artery disease into clinical subsets is critical in allowing the physician to make rational choices of therapy. The medical, surgical, and angioplasty approaches to the disease are effective therapeutic modalities.