Some reflections on Termination: Transference and Countertransference

INTRODUCTION Nearing the completion of my psychiatric residency, I ingenuously told my supervisor that I needed to know the steps of termination in therapy with patients. On the surface, this request reflected an awareness of the issues at hand and their importance. Beneath lay ambivalence and countertransference anxiety . For the graduating resident, time ordinarily invested in thought and study fills with practical considerations of job hunting and starting a practice. The resident\u27 s own unresolved and unsettling separation issues can further push aside therapeutic considerations for his patients. Termination, the art of the veteran therapist, becomes an unwelcome task at this time of professional passage when anything codifying professional identity is sought. In the unfortunate sequence of most residencies, this can be the first experience with forced termination of therapy. Forced termination is also a neglected topic within termination literature: a stepchild absent from standard psychotherapy texts from Colby to Tarachow. Weigert (1) and many others expound a necessary mutuality between patient and the rapist before termination can be set. Any prematurity on the therapist\u27s part, by definition, sets up a forced situation with its concommitant transference reactions and may be initiated by unintentional countertransference reactions. In reference to character analysis, Freud (2) doubted if even deep analysis could prevent a return of neurotic symptoms under the pressures of everyday life. The issue here becomes not whether treatment is terminable; but rather, one of understanding transference and countertransference. Supervision and the resident\u27s own therapy can make difficult terrain into a crucial learning experience. I share my experience with just one patient and my imperfect understanding of a complex interaction, in light of termination literature

Gap junction reduction in cardiomyocytes following transforming growth factor- beta treatment and Trypanosoma cruzi infection

Gap junction connexin-43 (Cx43) molecules are responsible for electrical impulse conduction in the heart and are affected by transforming growth factor-beta (TGF-beta). This cytokine increases during Trypanosoma cruzi infection, modulating fibrosis and the parasite cell cycle. We studied Cx43 expression in cardiomyocytes exposed or not to TGF-beta T. cruzi, or SB-431542, an inhibitor of TGF-beta receptor type I (ALK-5). Cx43 expression was also examined in hearts with dilated cardiopathy from chronic Chagas disease patients, in which TGF-beta signalling had been shown previously to be highly activated. We demonstrated that TGF-beta treatment induced disorganised gap junctions in non-infected cardiomyocytes, leading to a punctate, diffuse and non-uniform Cx43 staining. A similar pattern was detected in T. cruzi-infected cardiomyocytes concomitant with high TGF-beta secretion. Both results were reversed if the cells were incubated with SB-431542. Similar tests were performed using human chronic chagasic patients and we confirmed a down-regulation of Cx43 expression, an altered distribution of plaques in the heart and a significant reduction in the number and length of Cx43 plaques, which correlated negatively with cardiomegaly. We conclude that elevated TGF-beta levels during T. cruzi infection promote heart fibrosis and disorganise gap junctions, possibly contributing to abnormal impulse conduction and arrhythmia that characterise severe cardiopathy in Chagas disease

Climate Change and Resulting Floods: Using Social Capital to Strengthen Community Resilience in Eastwick, Philadelphia a known floodplain

• Climate change will produce intense weather events like increased precipitation and flooding • Based on climate projections, Philadelphia will be hotter and wetter, and will experience more frequent and intense weather events (OOS, 2016) •Floods are the second most common hazards in our city (OEM, 2017) • Vulnerable population such as children, people of color, elderly population and people with disability are severely impacted by climate change Poster presented at AHPA conference in Atlanta Georgia, United States.https://jdc.jefferson.edu/jcphposters/1013/thumbnail.jp

Effect of Rotavirus Immunization on Childhood Diarrhea in Nicaragua, Research Plan for International Research Scientist Development Award (K01) Fogarty International Center

The impact of universal rotavirus immunization on childhood diarrhea in Nicaragua is unknown. A clear understanding of the magnitude of the effect of UIRI is important information for Nicaragua and other developing world countries who are considering adding rotavirus vaccines to their current vaccine armamentarium. Although preliminary research is measuring the impact of rotavirus immunization in the hospital setting, virtually nothing is known about the effect of UIRI at the primary care or community level. Also, it is not known if genotype shift of the virus is occurring, which could limit the future effectiveness of rotavirus immunization and would inform needed improvements in the vaccine. Finally, we do not know if UIRI is inducing herd immunity. The purpose of this study is to determine the effect of UIRI on diarrheal disease in Nicaragua at the primary care and community levels. Our specific aims are to: 1. Determine the effectiveness of the rotavirus vaccine in primary care clinical practice, using a case-control study. Hypothesis: We expect that UIRI with Rotateq® will have a vaccine effectiveness of about 75% in reducing rotavirus infections that present to primary care centers. 2. Determine the effect of UIRI on diarrhea incidence at the community level, using an existing population-based surveillance system. We will compare incidences prior to UIRI to incidences following UIRI separately for children who did and did not receive the immunization. Hypothesis: Prior hospital-based studies would lead us to expect a one-third reduction in diarrhea incidence among immunized children at the community level. We expect this reduction to be most pronounced during the dry season, when the incidence of rotavirus infection is higher. We expect to find a modest, but measurable reduction in incidence among unimmunized children. 3. Explore if circulating genotypes of the virus have changed following UIRI. We will compare the distribution of rotavirus genotypes prior to UIRI with the distribution following UIRI. Hypothesis: We expect to find a higher percentage of genotypes not covered by the Rotateq® vaccine among immunized children who subsequently develop rotavirus infection. Our analysis of the overall distribution of genotypes following UIRI is exploratory in nature.Master of Public Healt

Multiple Indicator Cluster Survey 2003 in Afghanistan: Outdated Sampling Frame and the Effect of Sampling Weights on Estimates of Maternal and Child Health Coverage

Due to an urgent need for information on the coverage of health service for women and children after the fall of Taliban regime in Afghanistan, a multiple indicator cluster survey (MICS) was conducted in 2003 using the outdated 1979 census as the sampling frame. When 2004 pre-census data became available, population-sampling weights were generated based on the survey-sampling scheme. Using these weights, the population estimates for seven maternal and child healthcare-coverage indicators were generated and compared with the unweighted MICS 2003 estimates. The use of sample weights provided unbiased estimates of population parameters. Results of the comparison of weighted and unweighted estimates showed some wide differences for individual provincial estimates and confidence intervals. However, the mean, median and absolute mean of the differences between weighted and unweighted estimates and their confidence intervals were close to zero for all indicators at the national level. Ranking of the five highest and the five lowest provinces on weighted and unweighted estimates also yielded similar results. The general consistency of results suggests that outdated sampling frames can be appropriate for use in similar situations to obtain initial estimates from household surveys to guide policy and programming directions. However, the power to detect change from these estimates is lower than originally planned, requiring a greater tolerance for error when the data are used as a baseline for evaluation. The generalizability of using outdated sampling frames in similar settings is qualified by the specific characteristics of the MICS 2003—low replacement rate of clusters and zero probability of inclusion of clusters created after the 1979 census

Benefits of Implementing a Daily Safety Brief at the Baystate Children’s Hospital

Nursing Scholarship Symposium Event Posters.https://scholarlycommons.libraryinfo.bhs.org/nurs_presentations/1001/thumbnail.jp

Brillouin scattering studies in Fe3_3O4_4 across the Verwey transition

Brillouin scattering studies have been carried out on high quality single crystals of Fe$_3$O$_4$ with [100] and [110] faces in the temperature range of 300 to 30 K. The room temperature spectrum shows a surface Rayleigh wave (SRW) mode at 8 GHz and a longitudinal acoustic (LA) mode at 60 GHz. The SRW mode frequency shows a minimum at the Verwey transition temperature $T_V$ of 123 K. The softening of the SRW mode frequency from about 250 K to $T_V$ can be quantitatively understood as a result of a decrease in the shear elastic constant C$_{44}$, arising from the coupling of shear strain to charge fluctuations. On the other hand, the LA mode frequency does not show any significant change around $T_V$, but shows a large change in its intensity. The latter shows a maximum at around 120 K in the cooling run and at 165 K in the heating run, exhibiting a large hysteresis of 45 K. This significant change in intensity may be related to the presence of stress-induced ordering of Fe$^{3+}$ and Fe$^{2+}$ at the octahedral sites, as well as to stress-induced domain wall motion.Comment: 14 pages, 3 figures, accepted in Physical Review B 200

Ultrasound in Emergency Medicine EMERGENCY BILIARY SONOGRAPHY: UTILITY OF COMMON BILE DUCT MEASUREMENT IN THE DIAGNOSIS OF CHOLECYSTITIS AND CHOLEDOCHOLITHIASIS

, Abstract-Background: Measurement of the common bile duct (CBD) has traditionally been considered an integral part of gallbladder sonography, but accurate identification of the CBD can be difficult for novice sonographers. Objective: To determine the prevalence of isolated sonographic CBD dilation in emergency department (ED) patients with cholecystitis or choledocholithiasis without laboratory abnormalities or other pathologic findings on biliary ultrasound. Methods: We conducted a retrospective chart review on two separate ED patient cohorts between June 2000 and June 2010. The first cohort comprised all ED patients undergoing a biliary ultrasound and subsequent cholecystectomy for presumed cholecystitis. The second cohort consisted of all ED patients receiving a biliary ultrasound who were ultimately diagnosed with choledocholithiasis. Ultrasound data and contemporaneous laboratory values were collected. Postoperative gallbladder pathology reports and endoscopic retrograde cholangiopancreatography (ERCP) reports were used as the criterion standard for final diagnosis. Results: Of 666 cases of cholecystitis, there were 251 (37.7%) with a dilated CBD > 6 mm and only 2 cases (0.3%; 95% confidence interval [CI] 0.0-0.7%) of isolated CBD dilation with an otherwise negative ultrasound and normal laboratory values. Of 111 cases of choledocholithiasis, there were 80 (72.0%) with a dilated CBD and only 1 case (0.9%; 95% CI 0.0-2.7%) with an otherwise negative ultrasound and normal laboratory values. Conclusion: The prevalence of isolated sonographic CBD dilation in cholecystitis and choledocholithiasis is <1%. Omission of CBD measurement is unlikely to result in missed cholecystitis or choledocholithiasis in the setting of a routine ED evaluation with an otherwise normal ultrasound and normal laboratory values. Ó 2013 Elsevier Inc