A flatline Lead I in a neonate with suspected congenital heart disease.

In a neonate with bradycardia and hypoxia, and clinical concern for critical congenital heart disease (CCHD), highly unusual ECG findings were present. These included a flatline Lead 1, and identical Leads 2, 3, and AVF. These abnormalities were due to bilateral arm to leg lead exchanges and not to heart disease. Complete cardiac workup including echocardiogram was normal.

ECG quiz: Murphy's law strikes again!

ECG Quiz: An unusual ECG in a 77year old man with chest pain.

Is LAD encasement a common substrate component in Takotsubo cardiomyopathy?

Evidence from computerized tomographic angiography (CTA) has demonstrated LAD encasement with compromised antegrade systolic flow In Takotsubo cardiomyopathy patients. This mechanism may explain both the contractile and ECG abnormalities observed in this disorder.

Transient post-reperfusion left bundle branch block and accelerated idioventricular rhythm with paradoxical QRS narrowing.

Accelerated idioventricular rhythm (AIVR) commonly follows coronary reperfusion and has been called a "reperfusion arrhythmia". Transient left bundle branch block (LBBB) is only rarely seen after interventional reperfusion and is usually considered a procedural complication. We report herein electrocardiograms (ECGs) in a case of acute lateral myocardial infarction which demonstrate both post-perfusion AIVR and a simultaneous transient LBBB with fusion complexes causing paradoxical QRS narrowing.

Identity disturbance in distant patients.

Chronically distant, emotionally isolated patients often present with identity disturbance. Identity, it is argued, develops as a thematic pattern of narcissism, shaped by the nature of the mother's early libidinal influences on the child's sense of self. Identity provides a form of self-definition that addresses the question, Who am I? In the treatment of these patients, resistances to narcissistic vulnerabilities (narcissistic resistances) provide an illusory sense of security and induce the analyst to avoid attention to a central pathological problem: primitive and frightening needs for, and unconscious fantasies of, dependence on, and functionality for, another. Patients' avoidance of material and therapeutic interactions that deal with their dependencies are aspects of a tacit contract with the analyst to foreclose examination of their considerable problems with inner stability. Among these problems are anxieties regarding intrusion and loss of separateness. As analysis proceeds, elements of such a patient's identity become clarified and are used to understand and organize the material for both analyst and patient. This can allow the patient to articulate a more embodied and vital experience of individuality. A case is presented to illustrate the analysis of a patient using this approach.

Doublethinking our way to "scientific" legitimacy: the desiccation of human experience.

A multifaceted contemporary movement aims to correct alleged weaknesses in the scientific foundation of psychoanalysis. For both pragmatic-political and scientific reasons we are encouraged to do and/or study systematic empirical research on psychoanalytic process and outcome, as well as apparently relevant neuroscience. The thesis advanced here is that the privileged status this movement accords such research as against in-depth case studies is unwarranted epistemologically and is potentially damaging both to the development of our understanding of the analytic process itself and to the quality of our clinical work. In a nonobjectivist hermeneutic paradigm best suited to psychoanalysis, the analyst embraces the existential uncertainty that accompanies the realization that there are multiple good ways to be, in the moment and more generally in life, and that the choices he or she makes are always influenced by culture, by sociopolitical mind-set, by personal values, by countertransference, and by other factors in ways that are never fully known. Nevertheless, a critical, nonconformist psychoanalysis always strives to expose and challenge such foundations for the participants' choices. The "consequential uniqueness" of each interaction and the indeterminacy associated with the free will of the participants make the individual case study especially suited for the advancement of "knowledge"-that is, the progressive enrichment of sensibility-in our field.

Ventricular free wall rupture: ten year survival after surgical repair.

Ventricular free wall rupture is a devastating complication of acute myocardial infarction. It occurs in 15-25% of fatal cases. However, the overall incidence in acute MI cases is about 2%. [1] Clinical markers suggesting free wall rupture include pulseless electrical activity in a first MI, and pericardial tamponade. Subacute rupture takes hours or days to develop, and is suggested clinically by pericardial pain, transient hypotension, nausea, restlessness and agitation. [2, 3] When the diagnosis is established by pericardiocentesis or echocardiography, surgical patch repairs are possible, using standard or even sutureless technique. [4] The long term course of survivors of free wall rupture repair has not been extensively reported. There are scattered reports in the literature of survival up to eight years. [5, 3] We report herein a case of a status freewall rupture from an inferior-posterior wall myocardial infarction with survival of ten years after surgical repair. We believe this to be the longest survival thus far reported in the literature.

A flatline lead I results from bilateral arm-to-leg electrode exchange.

A flatline lead I plus P and T inversions in leads II, III, and aVF in a 31-year-old male patient suggested interchange of the arm and leg electrodes bilaterally. Prompt repetition of the ECG with corrected lead placement resulted in a normal ECG and prevented incorrect diagnosis, workup, and treatment.