Infectious Diseases News/Literature Review/2020

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Ηθική της Ψυχανάλυσης – Από το κλασικό μοντέλο στη θεραπευτική συμμαχία – Μελέτη κλινικής περίπτωσης σε Ιατρικό πλαίσιο

Στην εργασία αυτή κατατίθεται η ηθική πτυχή των ψυχοδυναμικών συγκρούσεων. Το κεντρικό ερώτημα που ανακύπτει είναι το αν η εξατομικευμένη ψυχοδυναμική ψυχοθεραπεία μπορεί να θεωρηθεί «ηθικό επίτευγμα». Μπορεί θεραπευτής και θεραπευόμενος, μέσα από μια αμοιβαία, αλλά ασύμμετρη, διαδικασία, να συγκροτήσουν ένα δυναμικό θεραπευτικό ζευγάρι, δοσμένο μέσα από το βλέμμα της ηθικής, μέσα στο ψυχιατρικό τμήμα ενός γενικού νοσοκομείου, κατά τέτοιο τρόπο ώστε να υπηρετηθεί το βασικό φροϋδικό αξίωμα «εκεί που είναι το Αυτό να γίνει Εγώ»; Κατά πόσον ο θεραπευτής, μέσω της δικής του υποκειμενικότητας και ψυχοσυναισθηματικής και νοητικής εμπειρίας, λειτουργώντας ως προβλητικό αντικείμενο του θεραπευόμενου, μπορεί να συμβάλλει τα μέγιστα στην πορεία της θεραπευτικής διαδικασίας; Η ψυχανάλυση βρίσκεται στο σταυροδρόμι επιστήμης και τέχνης και είναι κατεξοχήν ανθρωποκεντρική. Η επιστήμη με τα διάφορα παρακλάδια της, εκπροσωπεί ό,τι μπορεί να μετρηθεί και να αποδειχθεί πειραματικά, είναι μια έγκυρη και αξιόπιστη ανθρώπινη πείρα, που μπορεί να χρησιμοποιηθεί ως εργαλείο. Η τέχνη, μέσα από τις διάφορες εκφάνσεις της, υπηρετεί την αναπαράσταση της πραγματικότητας συνεισφέροντας στον προσανατολισμό του όντος, στο θεμελιακό δίπολο ζωής ηδονή- οδύνη (Three General Theories of Ethics and the Integrative Role of Integrity Theory, Muel Kaptein- Johan Wempe, article in SSRN Electronic Journal – July 2002). Η ψυχαναλυτική διαδικασία είναι ένας συγκερασμός και των δύο. Καλείται να ανιχνεύσει τις ασυνείδητες διαδικασίες, να αναδείξει τα άρρητα τραύματα και να ρίξει φως στο συγκεκριμένο δίπολο ηδονή-οδύνη, που είναι από τους βασικούς μοχλούς της ανθρώπινης ύπαρξης. Αν υπάρχει μια σχετική ισορροπία μεταξύ ηδονής και οδύνης, επέρχεται ευεξία. Σε διαφορετική περίπτωση, παραμονεύει η ψυχική κόπωση, που οδηγεί σε αρρώστια και θάνατο. Στο σημείο αυτό, καίριας σημασίας είναι η σύγκλιση της Ψυχανάλυσης με το οικοδόμημα που λέγεται Ηθική. Η Ηθική στηρίζεται στη συνειδητή πλευρά της ψυχικής ζωής του ανθρώπου και καθορίζει το σύνολο των σχέσεων και των πράξεών του ατόμου με τον εαυτό του και τους άλλους. Η ψυχανάλυση εγείρει ως αξίωση, να αυξήσει αυτή τη συνειδητότητα. Η Ηθική είναι ένα αξιολογικό σύστημα με προστακτικό χαρακτήρα, ορίζεται δε, από τον πρωταγωνιστή, τη δράση και τις συνέπειες. Τίθεται το θέμα, λοιπόν, τι από τα παραπάνω θα οριστεί σαν αφετηρία. Αν ως αφετηρία οριστεί η δράση, προκύπτει η Δεοντοκρατική ηθική. Αν ως αφετηρία είναι οι συνέπειες έχουμε τη Συνεπειοκρατική- χρησιμοθηρική ηθική. Αν ως κύρια συνθήκη οριστεί ο πρωταγωνιστής, έχουμε την ενάρετη – Αριστοτελική ηθική. (Virtue Ethics, Deondology and Consequalism, Brandon Roby – University of Mary Washington 2018). Στην παρούσα εργασία μελετάται κλινική περίπτωση (case study) που αφορά σε μια διυποκειμενική συνάντηση με ψυχοδυναμική κατανόηση ψυχιάτρου και ασθενούς, ψυχοθεραπευτή - ψυχοθεραπευόμενου, που λαμβάνει χώρα μέσα στο πλαίσιο μιας ψυχιατρικής κλινικής Δημοσίου Γενικού Νοσοκομείου, με παραπομπή, κατόπιν εισαγγελικής εντολής. Στη μελέτη αυτή, που έχει τον χαρακτήρα ποιοτικής έρευνας, επιχειρείται, μέσα από το πρίσμα της Ηθικής, να μελετηθούν έννοιες όπως η διυποκειμενική συνάντηση, η θεραπευτική συμμαχία, η σχέση περιέχοντος-περιεχομένου, το τραύμα, η χρήση του φαρμάκου κι ο ρόλος του ως «Τρίτος» και ως μεταβατικό αντικείμενο, η απαρτίωση του σωματοψυχικού Εγώ. Επίσης, γίνεται αναφορά στις έννοιες μεταβίβαση-αντιμεταβίβαση, στις αμυντικές διαδικασίες αμφοτέρων των πλευρών θεραπευτή και θεραπευόμενου, καθώς και στις αντιστάσεις που προκύπτουν εκατέρωθεν των δύο υποκειμενικοτήτων, αλλά κι από τις γενικότερες δυσκολίες του αναλυτικού πλαισίου. Τέλος, κατατίθενται δύο ψυχομετρικές κλίμακες, που αφορούν την έννοια της Ηθικής, δοσμένης μέσα από την Δεοντοκρατική και τη Συνεπειοκρατική πλευρά: Ethical Standards of Judgment Questionnaire (Love, Salinas & Roth 2018), The Consequalist Scale (Robinson 2012). Η εργασία αυτή τεκμηριώνεται μέσα από βιβλιογραφικές αναφορές και στόχο έχει να συμβάλει στην υπό εξέλιξη έρευνα.This paper places the moral aspect of psychosocial conflicts. The central question that arises is whether personalized psychodynamic psychotherapy can be considered a "moral achievement". Can the psychotherapist and the patient, through a mutual, but asymmetrical, process, form a dynamic therapeutic couple, given through the look of morality, within the psychiatric section of a general hospital, in such a way that the basic freudian position "where Id becomes Ego" is served? Whether, through his own subjectivity and psycho-emotional and cognitive experience, acting as a projective object of the patient, the psychotherapist can make a major contribution to the course of the therapeutic process? Psychoanalysis is at the crossroads of science and art and is predominantly anthropocentric. Science with its various branches represents what can be measured and proven experimentally, is a valid and reliable human experience, which can be used as a tool. Art, through its various expressions, serves to represent reality by contributing to the orientation of the being, in the fundamental dipole of pleasure - pain (Three General Theories of Ethics and the Integrative Role of Integrity Theory, Muel Kaptein-Johan Wempe, article in SSRN Electronic Journal - July 2002). The psychoanalytic process is a co-ordination of both. It is called upon to detect unconscious processes, to highlight the unexpressed traumas and to shed light on this dipole pleasure-pain, which is one of the main levers of human existence. If there is a relative balance between pleasure and pain, well-being occurs. Otherwise, mental fatigue, which leads to illness and death, is occurs. In this respect, the convergence of Psychoanalysis with the structure called Ethics is crucial. Morality is based on the conscious side of human mental life and determines the sum of the relationships and actions of the individual with himself and others. Psychoanalysis makes it a claim to increase that consciousness. Morality is an evaluation system of imperative character and defined by the protagonist, action and consequences. The question arises, then, as to which of these will be set as a starting point. If action is defined as a starting point, then Deondocratic ethics arises. If the starting point is the consequences, we have the Consequalist ethics. If the main condition is defined as the protagonist, we have the virtuous — Aristotelian ethics. (Virtue Ethics, Deondology, and Consequalism, Brandon Roby - University of Mary Washington 2018). This paper studies a clinical case study relating to an intersubjective meeting with a psychodynamic understanding of a psychiatrist-psychotherapist and a psychanalysant, taking place within the framework of a psychiatric clinical General Hospital, with reference to a prosecutor's office. This study, which is of the nature of quality research, seeks, through the prism of Ethics, to study concepts such as intersubjective encounter, therapeutic alliance, content-based relationship, trauma, drug use and its role as a "Third" and as a transitional object, the reparation of psychosomatic Ego. Reference is also made to the concepts of transference-countertransference, the defense procedures of both therapist and patient parts, and to the resistance that arises on either side of the two subjectives, but also to the general difficulties of the analytical framework. Finally, two psychometric scales are submitted, which relate to the concept of ethics, given through the Deondocratic and Consequalist aspects: Ethical Standards of judgment Questionnaire (Love, Salinas & Roth 2018), The Scale (Robinson 2012). This work is documented by bibliographical references and is intended to contribute to the ongoing research

Infectious Diseases Corner

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The Role of Levocarnitine in the Management of Valproic Acid Intoxication: A Case-Based Review

The administration of L-carnitine to patients with VPA intoxication and CNS depression with normal ammonia concentrations has a rationale, on the grounds that it is a safe compound with no severe adverse effects reported. Herein, we present a case of valproate poisoning with normal ammonia levels and discuss about the therapeutic as well as the prophylactic potential of L-carnitine administration in such cases

Diseases of the Eye with Systemic Involvement and /or Acute Presentation

Opticneuritis is defined as an inflammation of the optic nerve, which is mostlyidiopathic. However, it can be associated with variable causes: demyelinatinglesions, autoimmune disorders, infectious conditions, compressive, toxic,metabolic and hereditary conditions. It is divided intoarteritic, which is commonly seen in temporal arteritis/polymyalgia rheumaticaand non arteritic, which is associated with advanced age, atherosclerosis,hypertension and hyperlipidemia. Among demyelinating disorders, multiplesclerosis is the most common cause. The term optic neuritis is indicated bysub-acute unilateral painful visual loss mostly in a young healthy female andby excluding glaucoma. The clinical diagnosis of optic neuritis consists of theclassic triad of visual loss, periocular pain and dyschromatopsia whichrequires careful ophthalmic, neurologic and systemic examinations todistinguish between typical and atypical optic neuritis. In neuromyelitis optica,optic neuritis is initially misdiagnosed as optic neuritis in multiplesclerosis or other conditions such as ischemic optic neuritis and Leber’sdisease. Therefore, differential diagnosis is necessary to make a propertreatment plan. According to Optic Neuritis Treatment Trial, the first line oftreatment is intravenous methylprednisolone with faster recovery and lesschance of recurrence of optic neuritis and conversion to multiple sclerosis.Apart from optic neuritis of various causes, loss of vision could be due toglaucoma or uveitis. Glaucoma is optic nerve damage due to an interruption ofthe production and/or abduction of vitreous gel of the eye. Uveitis refers to a group of heterogeneous diseasesthat share the features of intraocular inflammation, but whose etiologies includeidiopathic autoimmune disease, infections and masquerade syndromes. Acute retinal necrosis and detachment may have a debilitatingeffect on vision and must be rapidly diagnosed and confronted, too. Theabove-mentioned clinical entities, their etiologies and current therapies arebriefly discussed in this review.Key-words: optic neuritis; multiple sclerosis; age-relatedmacular degeneration; diabetic retinopathy; glaucoma; uveitisAbbreviations: AMD (age-related macular degeneration); DR (diabeticretinopathy); DME (diabetic macular edema); AGEs (advanced end glycationproducts

Diabetic Nephropathy: from bench to bedside

Diabetes mellitus together with arterial hypertension are the most common causes of chronic kidney disease (CKD). Notably, diabetic kidney disease (DKD) remains a major and independent risk for premature mortality. Therefore, continuous and accurate control of risk factors for the development of diabetic nephropathy is mandatory. Measurement of serum creatinine levels and calculation of estimated glomerular filtration rate (eGFR) according to CKD-EPI equation must be performed annually, Also, measurement of urine albumin and calculation of the urine albumin to creatine ratio rate (uACR) is recommended to be performed annually, too, as  uACR > 30 mg/g creatinine is considered to be a continuous risk factor for cardiovascular disease. Equally important is good glycemic control, as determined by glycated hemoglobin levels of < 7%, as well as control of hypertension, often with more than three anti-hypertensive drugs needed to achieve this goal. Inhibition of the renin-angiotensin-aldosterone system (RAAS) is not only effective in managing hypertension, but seems to reduce albuminuria levels among patients with diabetic nephropathy. However, combination of  angiotensin converting enzyme inhibitors  (ACE’s) with angiotensin receptor antagonists (AT2) or with direct renin inhibitors is not recommended due to the increased risk of hyperkalemia, hypotension and acute kidney injury.  Other antihypertensive drugs which decrease albuminuria levels are the newer dihydropyridines calcium blockers manidipine and the latest b-blockers (carvedilol). Dyslipidemia parameters should be improved, too, especially the serum LDL-cholesterol levels <100 mg/dl. Vitamin D analogues have been shown to decrease albuminuria if eGFR < 60 ml/min/1.73 cm2 on account of a) inhibition of RAAS b) immunomodulatory and anti-inflammatory effects and c) inhibition of interstitial fibrosis in conjunction with FGF-23 (Fibroblast Growth Factor-23). Besides, sodium glucose co-transporter 2 inhibitors, which produce glucosuria seem to possess nephroprotective properties among type 2 diabetic patients. In particular, the EMPAREG study has documented that empagliflozin reduces the relative risk of serum creatinine doubling by 44%, while the relative risk of introducing hemoperfusion has been decreased by 55% within four years. It seems likely that atrasentan, a selective antagonist of the receptor of endothelin A also reduces albuminuria by approximately 35%. Moreover, the significance of substances with anti-inflammatory properties, such as oxidase inhibitors, pentoxyfilline, and N-acetyl-cysteine remains to be elucidated. It is noteworthy that weight loss together with dietary consultation, not only are implicated in better glycemic control and dyslipidemia management, but also  in improving diabetic nephropathy per se

Inverse Relationship between Adherence to the Mediterranean Diet and Serum Cystatin C Levels

OBJECTIVE: The aim of the present study was to examine serum cystatin C levels in association with the Mediterranean diet in a healthy Greek population. METHODS: Cystatin C together with basic clinical chemistry tests was measured in a total of 490 adults (46±16 years, 40% of males), who underwent an annual health check. Demographic, anthropometric and lifestyle characteristics were recorded, while adherence to the Mediterranean diet was evaluated through the MedDietScore (0-55). RESULTS: The mean level of serum cystatin C was 0.84 mg/L, while men had increased serum cystatin C levels compared to women (0.86 mg/L vs. 0.83 mg/L, respectively, 0.017). After adjusting for age, gender, body mass index, smoking status, hypertension, diabetes, hypercholesterolemia, estimated glomerular filtration rate (eGFR), albumin and ferritin levels, each unit increase in MedDietScore led to 0.002 mg/dL drop off in cystatin C serum levels. CONCLUSIONS: We have demonstrated an inverse relationship between the MedDietScore and serum cystatin C levels. Our finding that increases in MedDietScore are associated with decreases in serum cystatin C levels could imply that adherence to the Mediterranean diet may reduce the cardiovascular risk, as assessed by cystatin C, a prognostic marker of the cardiometabolic risk. This notion could have a great impact on public health

Resveratrol and Cancer

Resveratrol is a stilbene substance, belonging to the superfamily of phytoalexins, which are compounds synthesized by plants when stress occurs, usually an infection. It is abundant in red wine, red grapes, blueberries, peanuts and pistachios. Resveratrol induces p53-dependent apoptosis. A novel resveratrol analogue, HS-1793, has recently been demonstrated to inhibit vascular endothelial growth factor (VEGF) in human prostate cancer cells. Pterostilbene, an analog of resveratrol, has been demonstrated to exert both autophagy and apoptosis in human bladder and breast cancer cell lines. It has also been found to cause accumulation of autophagic vacuoles as well as promote cell death via a mechanism involving lysosomal membrane permeabilization in human melanoma, colon, lung and breast cancer cell lines. Identification of a receptor site for resveratrol in cancer cells, supports the potential of this compound as a therapeutic agent. The receptor could also serve as a vehicle for studies of future resveratrol analogues. Resveratrol has also been documented to overcome chemo-resistance by inhibiting NF-κB and STAT3 pathway. Resveratrol has shown much promise in preclinical trials and because of its good safety profile it may be an ideal chemo-preventive and chemotherapeutic agent