Biomedical subjects
A Goldberg
Publications and source records attributed to A Goldberg.
Self psychology and the narcissistic personality disorders.
This article is about the self psychological approach to narcissistic personality disorders. Starting from the vantage point of considering the growth and development of the self as crucial to understanding any and all disorders of narcissism, it describes the various forms of self development. These forms are felt to emerge and grow according to patterns seen in the transference of these patients in treatment. The transferences are called selfobject transferences and are based on the use of another person as part of the self, that is, as a part of the structure needed for growth. The three kinds of transferences that have been described are the mirror transference, the idealizing transference, and the twinship transference. These are considered to be expressions of childhood development that has gone awry and thus to be the focus for psychological intervention. Short-term treatment aims for repair of an injured or traumatized self. Long-term treatment or analysis aims for a reorganized self that pursues its own further development. Some factors involving etiology and the role of empathy in treatment are noted in the discussion.
Magnetic resonance imaging in acute spinal cord trauma.
Magnetic resonance imaging (MRI) has proven to be an invaluable tool for evaluating neoplastic, congenital, and degenerative conditions of the spine and spinal cord. Because of various technical limitations, however, the use of MRI in acutely spinal cord-injured patients has not been fully explored. Sixty-two spinal cord-injured patients underwent MRI within the first 36 hours of injury. A variety of pathological findings were detected on the MRI scans: anatomical cord transection (7 cases), spinal cord deformity secondary to extrinsic compression (28), focal cord enlargement/swelling (21), hyperintense intramedullary lesions (17), and disc herniations (2). MRI may be a useful adjunct in the evaluation of acute spinal cord injury.
Prolonged interval maintenance venom immunotherapy.
Current guidelines recommend indefinite administration of venom immunotherapy at 4-week intervals. To simplify this therapy, we examined the clinical and immunologic response after extending the interval between maintenance venom injections to 6, 8, and 12 weeks. Twenty-six patients who had had sting anaphylaxis and positive skin tests received maintenance bee or yellow jacket venom immunotherapy at greater or equal to 6-week intervals. This extended interval was started after a prior average 4-week maintenance interval of 2.3 years. Injections were given at 6-week intervals to all 26 patients and extended to 8-week intervals in 10, and 12-week intervals in 3 patients. Following venom injections, there were 14 mild local reactions and no systemic reactions. No adjustment in dosing was necessary. While on prolonged interval maintenance venom immunotherapy, there were 17 re-stings in 12 patients with no systemic reactions. During prolonged interval maintenance venom immunotherapy, either the serum venom-specific IgG increased or the already elevated titers remained the same in 18 patients and decreased in 2. In the others, preexisting titers were low and unchanged. Serum venom-specific IgE tended to slowly decrease. These clinical and immunologic data suggest that a 4-week maintenance interval may be safely extended.
Tuberculosis and breast cancer: case report and review.
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Effect of haem arginate therapy on porphyrin metabolism and mixed function oxygenase activity in acute hepatic porphyria.
The effect of haem arginate on porphyrin metabolism and haemoprotein function was studied during seven attacks of acute hepatic porphyria in 5 patients. In each attack it greatly reduced the overproduction of porphyrin precursors and repressed the overactivity of the rate-controlling enzyme of haem synthesis delta-aminolaevulinic acid (ALA) synthase measured in leucocytes. Antipyrine clearance, an index of the oxidative function of cytochromes P-450, the major group of hepatic haemoproteins, was increased during haem therapy. Thus, haem arginate not only suppresses the overproduction of haem precursors but also improves hepatic oxidative metabolism in acute porphyria.
Monte Carlo algorithm for calculating moments of atomic transition arrays.
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The effects of a beta-2 selective adrenergic agonist and a beta-nonselective antagonist on theophylline clearance.
Beta-adrenergic agonists and antagonists have been shown to alter theophylline pharmacokinetics. It was the purpose of this study to characterize further the effects that terbutaline and propranolol have on theophylline disposition. In nine healthy male volunteers, mean parameters for theophylline disposition did not change after four days of terbutaline (5 mg q8h). Theophylline clearance, however, did change within the subjects. Clearance increased in five subjects, decreased in three, and remained unchanged in one volunteer. Pretreatment with four days of terbutaline (5 mg q8h) and propranolol (60 mg q8h) significantly decreased mean theophylline clearance (60.1 +/- 12.9 vs 40.6 +/- 9.9 mL/min/1.73m2; P less than .01) increased half-life (8.37 +/- 1.77 vs 12.32 +/- 2.70 hours; P less than .05), and increased postinfusion theophylline concentration (13.5 +/- 2.7 vs 18.95 +/- 2.5 micrograms/mL; P less than .001). In five subjects theophylline clearance increased after terbutaline pretreatment (64.6 +/- 13.0 vs 75.0 +/- 13.9 mL/min/1.73m2). The percentage increase ranged from 3.9 to 28.5%. These subjects were restudied after receiving propranolol alone (60 mg q8h). Comparison between the propranolol and terbutaline study and the propranolol alone study indicated no mean change in clearance in these five subjects (41.8 +/- 12.7 vs 36.1 +/- 5.1 mL/min/1.73m2). Thus it appears that the changes observed in these five subjects after terbutaline pretreatment may have been random in occurrence as has been shown to occur with theophylline disposition and are not related to terbutaline pretreatment. It is concluded that beta-2 adrenergic stimulation does not alter theophylline pharmacokinetics, whereas nonselective beta-adrenergic antagonism profoundly affected theophylline disposition. This is an additional reason not to use propranolol in patients who receive theophylline.
An assessment of preoperative coagulation screening for tonsillectomy and adenoidectomy.
Preoperative coagulation studies are commonly employed in order to try to identify the 2-4% of all patients undergoing tonsillectomy/adenoidectomy surgery who experience hemorrhagic complications. In an atmosphere of increasing cost consciousness, evaluation of the efficacy of screening tests is warranted. The records of 994 out of 1050 patients consecutively scheduled for tonsillectomy, adenoidectomy or T&A over a 2.5-year period were retrospectively reviewed in order to determine the usefulness of partial thromboplastin (PTT) and prothrombin time (PT) screening in predicting surgical and postsurgical bleeding. For patients with no history or clinical signs indicating possible bleeding disorder, preoperative PT and PTT failed to predict bleeding as an outcome. Also no patients were identified in this series to have previously undiagnosed coagulopathies on the basis of screening PT/PTT. The purpose of any screening test is to identify disease early enough for therapeutic intervention to be effective. Although preoperative PT/PTT will occasionally identify an unsuspected von Willebrand's or other coagulopathy, the prevalence of bleeding disorders in patients with negative history and examination is low enough that PT/PTT has essentially a zero predictive value for surgical bleeding. Screening PT/PTT should therefore be reserved for patients with known or suspected coagulopathies.
Intraindividual variability in theophylline pharmacokinetics in subjects with mild/moderate asthma.
Intrasubject variability in theophylline pharmacokinetics was assessed in six subjects with mild/moderate asthma. On four occasions, each separated by a minimum of 3 weeks, a 6 mg/kg intravenous aminophylline dose was infused during 30 minutes, and multiple blood samples were obtained thereafter. The pharmacokinetic parameters of clearance (Cl), volume of distribution, and half-life were determined by noncompartmental analysis. There was evidence for within-subject variability in these parameters. In comparison to the first study day, Cl changed by greater than 15% in all but one subject and by greater than 25% in two of six subjects. Changes in half-life exceeding 25% of the value observed on the first study day occurred in three of six subjects. Within-subject coefficient of variation for Cl was 14.9% (range 3.9% to 33.3%) and 14.4% (range 5.8% to 24.3%) for half-life. Volume of distribution, however, was a more stable parameter with a within-subject coefficient of variation of 7.2% (range 2.3% to 11.1%). Thus, within-subject changes in the pharmacokinetics of theophylline do exist over time. These data suggest that close monitoring of patients receiving theophylline is warranted, particularly when theophylline concentrations are maintained at either extreme of the therapeutic range.
Antipyrine metabolism in acute hepatic porphyria in relapse and remission.
Antipyrine kinetics following a single oral dose were obtained in porphyric patients in attack and in remission and in controls. The clearance of antipyrine was significantly lower during an acute porphyric attack (median: 0.34 ml min-1 kg-1; range: 0.1-0.71, P less than 0.05) than in patients in remission (median: 0.53 ml min-1 kg-1; range: 0.28-0.87) or controls (median: 0.52 ml min-1 kg-1; range: 0.32-0.93). There was a significant negative correlation between weight-adjusted antipyrine clearance and the urinary excretion of the porphyrin precursors, delta-aminolaevulinic acid (r = 0.86, P less than 0.001) and porphobilinogen (r = 0.82, P less than 0.002). These data suggest that the more severe the porphyric attack, the greater the impairment of hepatic monooxygenase activity.
Lead effects on the heme biosynthetic pathway. Relationship to toxicity.
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Porphyrin metabolism and haem biosynthesis in Gilbert's syndrome.
Studies in 14 patients with unconjugated hyperbilirubinaemia caused by Gilbert's syndrome have revealed abnormalities of the enzymes of haem biosynthesis measured in peripheral blood cells. The activity of the penultimate enzyme of haem biosynthesis protoporphyrinogen (PROTO) oxidase was reduced at 3.1 +/- 2.6 nmol PROTO/g protein/h (mean +/- ISD) compared with 8.2 +/- 5.1 in controls (p less than 0.005). This was associated with a compensatory increase in the activity of the initial and rate controlling enzyme of the pathway delta-aminolaevulinic acid (ALA) synthase at 866 +/- 636 nmol ALA/g/protein/h compared with 156 +/- 63 in controls (p less than 0.001). Unlike variegate porphyria in which there is a genetic deficiency of PROTO oxidase there was no increased excretion of porphyrins or their precursors in Gilbert's syndrome. Accentuation and subsequent correction of the unconjugated hyperbilirubinaemia with rifampicin produced reciprocal changes in PROTO oxidase activity indicating that bilirubin may be inhibiting the activity of this enzyme.
Drug safety and the CSM.
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A case of watery diarrhoea syndrome due to an adrenal phaeochromocytoma secreting vasoactive intestinal polypeptide with coincidental autoimmune thyroid disease.
A 40 year old woman presented with a 10 year history of watery diarrhoea and an acute quadriparesis. On clinical examination there was severe muscle weakness and a nodule was palpable in the thyroid gland. Biochemical testing revealed a hypokalaemia at 1.6 mmol/l. Plasma levels of VIP were raised at 202 pmol/l. CT scanning demonstrated a mass in the area of the left adrenal gland, and isotope scanning of the thyroid gland showed a 'cold' nodule. The plasma catecholamines and calcitonin were elevated. The patient also presented with psychiatric symptoms, and the relevance of these to her condition has been discussed. At operation a left adrenal tumour was removed. Post-operatively the patient's symptoms disappeared and the plasma hormone levels returned to normal values. Histological examination of the tumour revealed a well differentiated phaeochromocytoma which contained VIP and calcitonin. The thyroid nodule was excised and showed histological features of autoimmune thyroid disease. It is suggested that in all cases of the WDHA syndrome where the tumour is in an extra-pancreatic site patients should be screened for phaeochromocytoma.
Pathogenesis of acute porphyria.
The pathogenesis of the clinical manifestations of acute porphyria has been considered in the light of their pathological changes and their aberrations of the haem biosynthetic pathway. These manifestations may be explained almost entirely upon a neurogenic basis. A number of hypotheses have been considered to explain the clinical, pathological and biochemical features. Of these hypotheses two seem more impressive: (i) the neurological manifestations may be explained by a deficiency of haem in neural tissues; (ii) the porphyrin precursor 5-aminolaevulinic acid (ALA) may have in addition specific pharmacological activity.
Psychoanalysis and negotiation.
Somewhere between the image of psychoanalysis as suggestion and psychoanalysis as unearthing is that of analysis as negotiation. This is a picture of a mutual construction of reality by analyst and patient. Such an interaction allows for reciprocal input of the participants and a possible change in both. This paper sketches the role of negotiation throughout the entire process of treatment--from the initial rules, to the theory of the analyst, to the emergence of the transference, to the goal of the cure. The technique of psychoanalysis is said to lie in the process of negotiation.
Effect of serotonergic, corticostriatal and kainic acid lesions on the dopaminergic neurotoxicity of 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP) in mice.
In mice, prior destruction of striatal 5-hydroxytryptamine (5-HT) neurons by intrastriatal or intraventricular injections of 5,7-dihydroxytryptamine did not abolish or attenuate DA depletions produced in striatum by 1-methyl-4-phenyl-1,2,5,6-tetrahydropyridine (MPTP). This suggests that although they contain monoamine oxidase type B, the oxidative conversion of MPTP to 1-methyl-4-phenyl-pyridinium ion (MPP+) does not take place in 5-HT neurons. Likewise, decortication and kainic acid lesions did not prevent or enhance striatal MPTP-induced DA decrements suggesting that corticostriatal projections and striatal neurons are not involved in the mechanisms of MPTP neurotoxicity.