A Clinical Case Presentation: Understanding and Interpreting Dreams while Working Through Developmental Trauma.

The purpose of this paper is to demonstrate the unique place of understanding and interpreting dreams in the psychoanalytic process while working through developmental trauma. This psychoanalytic process extended over six years and is presented in four phases: establishing the therapeutic alliance, a crisis, working through, and termination. Dreams from each of these four phases of the analysis are presented, and the collaborative work of understanding and interpreting these dreams is highlighted. Evidence is presented that from this analytic work there ensued an amelioration of the impact of developmental trauma and a furtherance of the development of internal psychic structure.

Humanized cobra venom factor: structure, activity, and therapeutic efficacy in preclinical disease models.

The complement system is an integral component of both innate and adaptive immunity. However, complement is also a pathogenetic factor in many diseases. The development of agents for therapeutic complement inhibition is the topic of intense investigations by many investigators. We have developed a distinctly different therapeutic approach: complement depletion rather than inhibition. This approach is based on cobra venom factor (CVF), a C3 analog known to be able to safely deplete complement. This manuscript will briefly review the structure and activity of CVF, along with its similarities and differences to C3. Exploiting the knowledge of the structure/function relationship of CVF and C3, we created derivatives of human C3 which display the CVF-like activity of depleting complement, referred to as humanized CVF (hCVF). This review describes the structure and activity of hCVF, including the important property of not cleaving C5. The efficacy of hCVF for therapeutic complement depletion in nine preclinical models diseases with complement pathology is reviewed, including reperfusion injury, age-related macular degeneration (AMD), paroxysmal nocturnal hemoglobinuria (PNH), and immunogenicity of Factor VIII in hemophilia A. Complement depletion is characterized by the absence of toxicity, even after intra-arterial injection into the pulmonary artery of primates. No immunogenicity has been observed.

Fairbairn e personalidades múltiplas / Fairbairn and multiple personalities / Fairbairn y las personalidades múltiples

Fairbairn descreveu sua teoria madura como "obviamente adaptada para explicar tais manifestações severas como as encontradas em casos de personalidade múltipla" (1952/2002, p. 159). Nosso objetivo aqui é demonstrar a utilidade da teoria de Fairbairn para a compreensão e tratamento psi-canalítico deste transtorno. Começaremos com um breve resumo introdutório da teoria madura do autor, salientando alguns aspectos de seu pensamento anterior sobre este transtorno que guiaram o subsequente desenvolvimento dessa teoria. A seguir, apresentaremos uma versão estendida do modelo de Fairbairn. Em nossa discussão do material clínico de cinco casos de personalidade múltipla, ilustramos as maneiras pelas quais este modelo nos permite: 1) identificar diferentes personalidades múltiplas com estruturas de ego ou objetos internos específicos; 2) ilustrar agrupamentos (clusters) de múltiplos geralmente encontrados; 3) antecipar aspectos das relações que tipicamente existem entre personalidades múltiplas; e 4) antecipar as dinâmicas transferenciais relacionadas. Em seguida, discutimos nossa perspectiva fairbairniana em relação às importantes contribuições de Davis e Frawley (1992a, 1992b) e de Grotstein (1991, 1992, 1994a, 1994b). Postulamos que pode ocorrer uma dissociação traumática das estruturas endopsíquicas, e que tais estruturas endopsíquicas dissociadas podem ser reprimidas por longos períodos de tempo antes de a repressão ser retirada. Essas estruturas endopsíquicas e suas personalidades relacionadas, novamente conscientes, funcionam de uma maneira indicada pelo conceito de cisão vertical.

Fairbairn described his mature theory as one "obviously adapted to explain such extreme manifestations as are found in cases of multiple personality" (1952/2002, p. 159). Our purpose here is to demonstrate the usefulness of Fairbairn's theory to the psychoanalytic understanding and treatment of this disorder. We begin with a brief introductory summary of Fairbairn's mature theory and highlight some aspects of his early thinking on multiple personality that informed the subsequent development of this theory. We then present an extended version of Fairbairn's model. In our subsequent discussion of clinical material from five cases of multiple personality, we illustrate the ways in which this model allows us: 1) to identify different alter personalities with specific ego-structures or internal objects; 2) to illustrate commonly found clusters of alters; 3) to anticipate aspects of the relationships which are typically found to exist between alter personalities; and 4) to anticipate related transference dynamics. We then discuss our Fairbairnian perspective in relation to the important contributions of both Davis and Frawley (1992a, 1992b) and of Grotstein (1991, 1992, 1994a, 1994b). We posit that a traumatic dissociation of endopsychic structures may occur and that such dissociated endopsychic structures may be repressed for long periods of time prior to the repression being lifted. These endopsychic structures, and their related personalities, conscious once more, then function in a manner indicated by the concept of a vertical splitting.

Fairbairn describió su teoría madura como "obviamente adaptada para explicar tales manifestaciones severas como las encontradas en casos de personalidad múltiple" (1952/2002, p. 159). Nuestro objetivo aquí es demostrar la utilidad de la teoría de Fairbairn para la comprensión y el tratamiento analítico de este trastorno. Comenzaremos con un breve resumen introductorio de la teoría madura del autor, destacando algunos aspectos de su pensamiento anterior sobre el trastorno que guiaron el posterior desarrollo de esa teoría. Luego presentaremos una versión extendida del modelo de Fairbairn. En nuestra discusión del material clínico de cinco casos de personalidad múltiple, ilustramos las formas por las cuales este modelo nos permite: 1) identificar diferentes personalidades múltiples con estructuras de ego u objetos internos específicos; 2) ilustrar agrupamientos (clusters) de múltiplos generalmente encontrados; 3) anticipar aspectos de las relaciones que típicamente existen entre personalidades múltiples; y 4) anticipar las dinámicas transferenciales relacionadas. A continuación, discutimos nuestra perspectiva fairbairniana en relación a las importantes contribuciones de Davis y Frawley (1992a, 1992b) y de Grotstein (1991, 1992, 1994a, 1994b). Planteamos el postulado de que puede ocurrir una disociación traumática de las estructuras endopsíquicas y que tales estructuras endopsíquicas disociadas pueden ser reprimidas durante largos períodos de tiempo antes de la represión ser retirada. Esas estructuras endopsíquicas y sus personalidades relacionadas, nuevamente conscientes, funcionan de una manera indicada por el concepto de división vertical.

Complement 3 is involved with ventilator-induced lung injury.

Humoral molecules can trigger injury on mechanically stressed and damaged tissue. We have studied the role of complement 3 (C3) in a mouse model of ventilator-induced lung injury (VILI). Compared with sham-treated wild type (WT) mice, ventilated WT mice have reduced total bronchoalveolar lavage (BAL) cells; and elevated activities of thrombin and matrix metalloproteinases (MMPs), such as gelatinase/collagenase in the BAL fluid. In contrast, these parameters in ventilated C3 null mice are not significantly different from sham-treated WT and C3 null mice. In mechanically ventilated mice, thrombin activity and MMPs are lower in C3 null mice than in WT mice and are inversely correlated with total single BAL cells. C3 activation is associated with MMP activation in vitro. Pretreatment of WT mice with humanized cobra venom factor, which inactivates C3, reduces C3 deposition in the lung and increases total BAL cells in VILI. We propose that C3 is involved with VILI and inhibition of complement activation may be a potential therapeutic strategy.

Myocardial infarction following coronary artery bypass graft surgery increases healthcare resource utilization.

OBJECTIVE: To assess the health economic impact of perioperative myocardial infarction in a cohort of patients undergoing coronary artery bypass graft surgery. DESIGN: Retrospective cohort analysis using data from hospital bills and uniform billing forms. SETTING: A total of 147 geographically diverse hospitals in the United States. PATIENTS: The study population consisted of 2,102 coronary artery bypass graft surgery patients enrolled in the PRIMO-CABG trial at U.S. sites between January 2002 and February 2003. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Resource utilization and costs during the index hospitalization and during a 6-month follow-up period were compared between patients who had a myocardial infarction by postoperative day 4 and those who did not. Linear regression was used to examine whether myocardial infarction by day 4 was associated with index hospitalization costs, after adjusting for baseline characteristics. Myocardial infarction occurred in 191 (9.1%) patients undergoing coronary artery bypass graft surgery. Myocardial infarction was associated with a doubling of intensive care unit time (3.5 days among patients with no myocardial infarction and 7.1 days among patients with myocardial infarction, p < .01) and a 48% increase in hospital length of stay. Myocardial infarction by day 4 was associated with a 43% increase in hospital costs, a 29% increase in physician service costs, a 41% increase in total costs during the index hospitalization, and a 38% increase in cumulative 6-month costs. After baseline adjustment, myocardial infarction continued to be associated with higher index hospitalization costs. CONCLUSIONS: Myocardial infarction following coronary artery bypass graft surgery was associated with a significant increase in intensive care unit time, hospital length of stay, and overall costs, which contributed to greater hospital and physician service costs. Healthcare resource utilization is increased in patients sustaining a myocardial infarction following coronary artery bypass graft surgery.

Increased creatine kinase MB level predicts postoperative mortality after cardiac surgery independent of new Q waves.

BACKGROUND: Recent consensus statements recommend cardiac enzyme release as the essential criterion for diagnosing myocardial infarction. However, the outcome implications of cardiac enzyme release in patients undergoing coronary artery bypass grafting are controversial. METHODS: Eight hundred patients were followed for 30 days after elective on-pump coronary artery bypass grafting in a multicenter, prospective, randomized trial of the anti-C5 complement antibody pexelizumab. Data from centralized electrocardiography and creatine kinase MB analyses were examined for any association with death or severe left ventricular dysfunction. RESULTS: More than half of the 800 patients had peak creatine kinase MB levels of more than 5 times the upper limit of 5 ng/mL set by the core laboratory. The median peak value was 29 ng/mL. The incidence of the combined outcome (death or severe left ventricular dysfunction) was 1.7% if the peak creatine kinase MB level was less than 25 ng/mL and 18.0% if 100 ng/mL or greater (P < .01). Similarly, the incidence of new Q-wave myocardial infarction was 3.9% if the peak creatine kinase MB level was less than 25 ng/mL and 30.6% if 100 ng/mL or greater (P < .01). In a multivariate analysis that included preoperative and intraoperative factors, as well as peak enzyme release and Q-wave myocardial infarction, the strongest predictor of the combined outcome was a peak creatine kinase MB level of 100 ng/mL or greater. New Q-wave myocardial infarction did not significantly predict the combined outcome. CONCLUSIONS: Increased postoperative peak creatine kinase MB level, especially when 20 times or more of the upper limit of normal, indicates increased risk of severe postoperative left ventricular dysfunction and mortality within 30 days of coronary artery bypass grafting. High peak enzyme level is a stronger predictor of adverse outcomes than is postoperative Q-wave myocardial infarction in this population.