REEXAMINING SCHREBER THROUGH THE LENS OF A PRESENT-DAY CASE: FANTASIES OF DEATH, REBIRTH, AND GENDER TRANSFORMATION.

In the history of psychoanalysis, the Schreber case has long been a source of controversy. Speculations about Schreber have abounded essentially because none of the speculators, including Freud (), has been constrained by the reality of interactive dynamics with Schreber on the couch. This author contends, however, that knowing someone analytically must involve the transference experience. He presents the case of Z, a middle-aged patient of his who described a fantasy that was uncannily similar to Schreber's, permitting a present-day reexamination of the original case, as well as ongoing speculations that include the way in which live clinical material can interact with the reading of a historical document.

Association of Systemic Sclerosis With a Unique Colonic Microbial Consortium.

OBJECTIVE: To compare colonic microbial composition in systemic sclerosis (SSc) patients and healthy controls and to determine whether certain microbial genera are associated with gastrointestinal (GI) tract symptoms in patients with SSc. METHODS: Healthy controls were age- and sex-matched (1:1) with adult SSc patients. Cecum and sigmoid mucosal lavage samples were obtained during colonoscopy. The microbiota in these samples were determined by Illumina HiSeq 2000 16S sequencing, and operational taxonomic units were selected. Linear discriminant analysis effect size was used to identify the genera that showed differential expression in SSc patients versus controls. Differential expression analysis for sequence count data was used to identify specific genera associated with GI tract symptoms. RESULTS: Among 17 patients with SSc (88% female; median age 52.1 years), the mean ± SD total GI Tract 2.0 score was 0.7 ± 0.6. Principal coordinate analysis illustrated significant differences in microbial communities in the cecum and sigmoid regions in SSc patients versus healthy controls (both P = 0.001). Similar to the findings in inflammatory disease states, SSc patients had decreased levels of commensal bacteria, such as Faecalibacterium and Clostridium, and increased levels of pathobiont bacteria, such as Fusobacterium and γ-Proteobacteria, compared with healthy controls. Bifidobacterium and Lactobacillus, which are typically reduced under conditions of inflammation, were also increased in abundance in patients with SSc. In SSc patients with moderate/severe GI tract symptoms, the abundance of Bacteroides fragilis was decreased, and that of Fusobacterium was increased, compared with patients who had no or mild symptoms. CONCLUSION: This study demonstrates a distinct colonic microbial signature in SSc patients compared with healthy controls. This unique ecologic change may perpetuate immunologic aberrations and contribute to clinical manifestations of SSc.

A nationwide 2010-2012 analysis of U.S. health care utilization in inflammatory bowel diseases.

BACKGROUND: Implementation of the 2010 Affordable Care Act (ACA) calls for a collaborative effort to transform the U.S. health care system toward patient-centered and value-based care. To identify how specialty care can be improved, we mapped current U.S. health care utilization in patients with inflammatory bowel diseases (IBD) using a national insurance claims database. METHODS: We performed a cross-sectional study analyzing U.S. health care utilization in 964,633 patients with IBD between 2010 and 2012 using insurance claims data, including pharmacy and medical claims. Frequency of IBD-related care utilization (medication, tests, and treatments) and their charges were evaluated. Subsequently, outcomes were put into the framework of current U.S. guidelines to identify areas of improvement. RESULTS: A disproportionate usage of aminosalicylates in Crohn's disease (42%), frequent corticosteroid use (46%, with 9% long-term users), and low rates of corticosteroid-sparing drugs (thiopurines 15%; methotrexate 2.7%) were observed. Markers for inflammatory activity, such as C-reactive protein or fecal calprotectin were not commonly used (8.8% and 0.13%, respectively). Although infrequently used (11%), anti-TNF antibody therapy represents a major part of observed IBD charges. CONCLUSIONS: This analysis shows 2010-2012 utilization and medication patterns of IBD health care in the United States and suggests that improvement can be obtained through enhanced guidelines adherence.

Local thrombolysis: a newer approach to treating inflammatory bowel disease-related thromboembolism.

GOALS: To review the experience with a relatively novel treatment, local thrombolysis, in patients with inflammatory bowel disease (IBD)-related thromboembolism (TE). BACKGROUND: TE is an extraintestinal complication of IBD for which there are no clear treatment guidelines. Systemic treatment with anticoagulants or thrombolytics often raises fear of hemorrhagic complications, particularly hematochezia. STUDY: Cases of IBD-related and non-IBD-related TE treated with local thrombolysis were searched for in PubMed, reviewed, and grouped into anatomic areas. Outcomes in each anatomic area were compared between IBD and non-IBD patients. Due to the small number of IBD-related TE cases, a descriptive, not statistical, analysis was performed. RESULTS: There were 17 cases of IBD-related TE treated with local thrombolysis grouped as follows: 7 of cerebral venous thrombosis, 3 of lower extremity arterial TE, 1 of deep vein thrombosis, 1 of upper extremity deep vein thrombosis, 3 of abdominal vein thrombosis, and 2 of inferior vena cava TE. Mean age was 32 (range, 14 to 50) years, and 13 of 17 patients were female. Twelve had ulcerative colitis, 3 had Crohn's disease, and 1 was indeterminate. Four of the 7 patients with active IBD had pretreatment hematochezia, 2 of whom had worsening of hematochezia secondary to treatment. The rates of radiologic resolution, clinical resolution, and hemorrhagic complications in the IBD patients were favorable in all the anatomic areas and were very similar to non-IBD patients. CONCLUSIONS: Local thrombolysis may be considered a viable therapeutic option for IBD-related TE. As more cases of local thrombolysis for IBD-related TE accumulate, further recommendations can be made as to the indications for its use.

Some problems with treatment: destructive enactments in combined therapy.

Abstract The aim and hope of combined therapy is that the arrangement of group and individual treatment affords greater therapeutic effect because of its psychic interactions. For some patients, the modalities together may lead to promising, if often complex, analysis through an open flow of information between the two modalities. However, the two cases I present illustrate problems that may arise in combined treatment. In these two cases, the interaction between the modalities may have prevented important working through and caused an irreparable breach in the therapeutic alliance. The interdependence among complex enactments, my countertransference, and the respective groups' transferences was emotionally complex. In this paper I describe various forms of these enactments, explore some ideas about why enactments occurred, and discuss their impact on the treatment of these patients.