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Biomedical subjects

D Silver

Publications and source records attributed to D Silver.

At least 109 records · Page 6Linked to original sources
PubMed1983

The characterologically difficult patient: a hospital treatment model.

A treatment model for the hospitalized borderline patient has evolved from the long-term, intensive treatment of these patients in a psychodynamically oriented setting. Four stages are identified and described. Each has a therapeutic goal and strategy, and repeatedly observable patient responses and staff counter-responses. Although patients vary in the lengths of time in each stage and there is much back and forth between stages, the regularity with which this pattern occurs greatly increases the capacity of the treating personnel to understand and guide the treatment process. The model clarifies perplexing, discouraging, or stale-mating affects and behaviours in the patients, and misleading counter-therapeutic affects and behaviours in the staff. Further, it can predict certain features and, to some extent, probable outcome in any particular course of treatment.

Acting Out↗
PubMed1983

Psychotherapy of the characterologically difficult patient.

The increasing number of characterologically difficult patients in psychiatric practices has produced a plethora of theoretical formulations, treatment strategies and techniques. The major shifts in theoretical emphasis from drive theory to object relations theories and self-psychology has encouraged many psychiatrists to treat these patients in psychotherapy. The heterogeneity and variability of clinical profiles represented in this group of patients, however, still prevents prescription of "the" treatment of choice for this patient population. A major focus on treatment considerations in this paper is the assessment process with emphasis on determining the capacities for inter-personal relationships, psychological mindedness, empathy and psychological soothing of self and others. The advisability of establishing a "contract" as a prerequisite to treatment is suggested as an important factor in determining outcome. Other particular treatment issues are addressed such as frequency of sessions, "secrets", premature provocation of intense affect, medications, consultations, hospitalization, self-mutilation, substance abuse and indications for termination. The complex vissicitudes of the transference and countertransference processes with this group of patients is pointed out especially those feelings of helplessness and range sometimes experienced in the counter-transference. Long term intensive psychotherapy with many of these patients probably still belongs to the area of therapeutic heroics. Hard evidence for good and poor outcome is scarce and therapeutic zeal is too often based on anecdotal testimonial from adherents of one approach or another.

Adaptation, Psychological↗
PubMed1983

The creation of a surgical endoscopy training program--is there sufficient clinical material?

The American Board of Surgery now requires surgical training programs to provide instruction in gastrointestinal endoscopy. In order to demonstrate that an independent Surgical Endoscopy Service could generate sufficient patient volume for an endoscopy training program, we reviewed our experience before and after the organization of such a service. In the year before formation of the Surgical Endoscopy Service (1981), surgical endoscopists performed 134 upper gastrointestinal (UGI) endoscopies and 25 colonoscopies for a total of 159 procedures. This represented 17% of the total institutional endoscopies performed. Further analysis indicated that 30.5% of UGI endoscopies and 24% of colonoscopies were performed on patients referred from surgical services. During the first year of the Surgical Endoscopy Service (1982), we performed 322 UGI endoscopies and 102 colonoscopies for a total of 424 procedures. This represented an increase to 36.5% of the total institutional endoscopies. During this time 41% of the UGI endoscopies and 33% of the colonoscopies were performed on patients referred from surgical services. Thus, with the formation of a Surgical Endoscopy Service we were able to dramatically increase our procedure volume and to provide effective gastrointestinal endoscopic training for our residency program. This confirmed our premise that in a typical university training program there is sufficient clinical material to provide training in surgical endoscopy.

Academic Medical Centers↗
PubMed1982

Isolated atherosclerotic aneurysms of the internal iliac arteries: report of two cases and review of literature.

Isolated arteriosclerotic aneurysms of the internal iliac artery are uncommon, with an incidence approaching 0.4%. Although the symptoms invariably involve the genitourinary or gastrointestinal systems, the aneurysms may be found during abdominal, rectal, or vaginal examinations. The 75% mortality associated with the rupture of an internal iliac aneurysm mandates for early surgery for these aneurysms. Operation may consist of ligation of the internal iliac artery, excision of the aneurysm, or an obliterative endoaneurysmorrhaphy. While the operative mortality has average 33.3%, there were no operative deaths in this series.

Aged↗
PubMed1982

Successful surgical treatment of anuria caused by renal artery occlusion.

Anuria resulting from obstruction of the renal arteries to both Kidneys or to a solitary kidney is unusual. The tolerance of the kidney to this ischemia is largely dependent upon the presence of collaterals, stimulated by pre-existing arterial disease. Our experience with six patients with anuria caused by renal artery occlusion supports the role of revascularization in the recovery of significant renal function. Four of these patients had hypertension, impaired renal function, and the existence of collateral circulation to an ischemic kidney, prior to occlusion, while two patients had normal renal function (serum creatinine = 0.5 and 0.9 mg/dl) before occlusion. The intervals of anuria for the two previously normal kidneys were six hours and five days, and 2 to 14 days in the four patients with vascular disease. Isotope scanning suggested renal artery occlusion in two patients, but arteriograms confirmed the diagnosis in all six. A thrombectomy restored blood flow through the two previously normal renal arteries. Grafts from the aorta or celiax axis were used for three patients and the splenic artery was used for the sixth patient. Urine flow began during or soon after operation in all patients. Dialysis was necessary for 30 and 45 days in the two patients with normal kidneys, but in only one of the four patients with previous disease (for ten days). Serum creatinine decreased to <2.0 mg/dl after operation, except in the man with a solitary kidney, who five years later has a creatinine of 3 mg/dl. All four patients with previous arterial disease died from cardiac failure within 1 to 30 months after operation. Therefore, anuria of acute onset should be evaluated by renal scan and arteriogram to detect those patients with proximal renal artery occlusion in preparation for revascularization.

Adolescent↗
PubMed1982

Transcutaneous quantitation of arterial flow with ultrasound.

Arterial blood flow was measured in dogs simultaneously with electromagnetic flow probes and with ultrasonic "flow probes." The ultrasonic probes were used to determine transcutaneously the mean velocity of arterial flow and the cross-sectional area of the blood vessel. A 10 MHz probe was used for blood vessels 1 cm deep or less, while a 5 MHz probe was used for vessels between 1.0 and 2.5 cm deep. The correlation coefficient between the flow calculated with the ultrasound method and the flow measured with the electromagnetic flow probes was 0.966, p less than 0.01. Blood flow was also measured intraoperatively in five patients. There was a correlation coefficient of 0.999, p less than 0.01, between the flow obtained with the ultrasound method and that determined simultaneously by the electromagnetic flow probes. The coefficient of determination for the regression of electromagnetic-determined flow on ultrasound-determined flow was 0.99. Thus, accurate transcutaneous determination of blood flow is possible with slightly modified ultrasound equipment.

Animals↗
PubMed1982

Vascular trauma in a rural population.

Most reports on vascular trauma from metropolitan centers indicate that prompt repair of injuries contributes to significant limb salvage. A review of 89 cases of vascular trauma seen during the past 10 years revealed higher amputation and complication rates than are usually experienced at urban centers. The University of Missouri Health Sciences Center serves a predominately rural area of 10,000 square miles. The average delay between injury and arrival at the center was 3.4 hours. Farm and industrial accidents accounted for 16% of the cases, motor vehicle accidents 33%, and penetrating wounds from guns, knives, and glass the remainder. Eighty-two percent of the injuries involved extremities, and 12 of 116 injured vessels were veins. Arteriography was performed in 34% of the patients. Surgery consisted of primary repair or autogenous vein graft in 60% of the vessels and ligation in approximately 35%. Thirteen primary amputations were performed for extensive tissue damage. There were six additional delayed amputations, yielding an overall amputation rate of 16.4%. The mortality rate was 5.6%, with deaths occurring only in patients with multiple severe injuries. The complication rate associated with vascular repair was 12.4%. Most complications and all deaths and amputations occurred in patients suffering trauma from farm, industrial, and motor vehicle accidents. These patients also had longer times in transit. The increased amputation and complication rates appear to be related to the severity of injuries and the time lapse before initiation of definitive therapy.

Accidents, Occupational↗
PubMed1981

Heparin-induced thrombocytopenia with thrombosis and hemorrhage.

Thrombocytopenia (platelet count, 5,000 to 96,000/cu mm; average platelet count, 48,000/cu mm) developed in 31 patients while they were receiving prophylactic or therapeutic heparin sodium therapy. Twenty-one of these patients had associated thromboembolic complications that contributed to the deaths of eight patients. Twelve arterial thromboembolectomies were required for limb preservation in eight patients, with seven arterial thrombolectomies, early in the series, failing because heparin therapy was continued in the postoperative period. Coagulation tests failed to identify a consumptive coagulopathy as the cause of the thrombocytopenia. Cessation of heparin administration was associated with avoidance or remission of the thromboembolic complication and immediate improvement of the thrombocytopenia. Platelet count monitoring during heparin therapy remains the most effective means for the identification of this disorder before the development of the thromboembolic complications.

Adult↗
PubMed1981

The resident and the borderline in-patient: a supervisor's perspective.

The problems of residents working intensively with borderline inpatients in a general hospital psychiatric unit area described. The resident feels pressure because of inexperience with intensive psychotherapy, and the high visibility of working in a closely supervised team setting. The border line patient baffles the resident with his defensive activity characterized by splitting, erotization, idealization, and negative therapeutic response. These difficulties complicate supervision, necessitating the supervisor's alertness to being caught in team splits or collusion with the resident's unrealistic hopefulness or nihilism. Supervision must actively address the resident's countertransference and the supervisor's counterresponses. Clinical vignettes illustrate the various problems.

Borderline Personality Disorder↗
PubMed1981

The teaching and learning of psychotherapy in a general hospital.

A general teaching hospital provides an excellent setting for the teaching of psychiatric residents. The Canadian model for a teaching network, including general and specialty hospitals, allows for special interests to develop within given hospitals. A department of psychiatry which chooses the teaching of psychotherapy as a special interest is examined. The teaching occurs in all areas of the department (ambulatory, inpatient, consultation-liaison) and is backed up by appropriate seminars. Individual supervision provides the backbone of the teaching program. The special interest exists within a department which must answer all of the psychiatric needs of a general hospital population. From the university point of view, the network is strengthened by the existence of various areas of concentrated interest within various component units of the network.

Ambulatory Care↗
PubMed1981

Populations with the Leriche syndrome.

Complete infrarenal aortic occlusion was found in 20 of 325 patients who underwent bypass for atherosclerosis of the distal aorta. Eleven had normal distal arteries as demonstrated by arteriography; the remaining patients had multilevel areas of stenosis and occlusion below the inguinal ligament. The two groups were significantly different in age, blood pressure levels, and duration of symptoms. The bypass relieved symptoms and restored flow in all the patients with normal distal vessels. There were four acute graft failures, two of which resulted in death, in the group with distally diseased vessels, and only two of these nine patients were symptomatically improved by the bypass. These data indicate that there are at least two distinct patient populations with the Leriche syndrome. Anatomic changes at the aortic bifurcation may be responsible for the clinical differences.

Aged↗
PubMed1980

Evaluation of lymphovenous anastomoses in obstructive lymphedema.

Direct lymphovenous anastomoses were constructed in dogs with chronic obstructit on the course of the lymphedema. Early patency rates of the lymphovenous anastomoses of 100 percent related to a 32 percent decrease in the lymphedema. However, by 3 weeks, all lymphovenous anastomoses became occluded and the edema level returned to the original state or was somewhat worse. Patent lymphovenous anastomoses seem clearly capable of improving the lymphedema state. However, long-time patency was not maintained in this series. We postulate that effective decompression of the lymphedematous leg by the patent lymphovenous anastomoses results in decreased flow through the anastomoses with subsequent occlusion.

Animals↗
PubMed1980

Noninvasive determination of LeVeen shunt patency.

The LeVeen peritoneovenous shunt is being used with increasing frequency for management of intractable ascites. The question of postoperative shunt patency frequently arises. This report describes a unique, noninvasive method of assessing shunt patency using Doppler ultrasound. Four of five patients with shunts judged to be occluded by this new method had the findings substantiated by peritoneal instillation of radioisotope; the fifth patient was not studied by any other method. The evaluation with ultrasound is easily performed at operation and after operation and is reliable for assessing shunt patency.

Ascites↗
PubMed1979

Vasospastic disorders.

Acute digital ischemia not due to thromboembolism may be the result of either a primary vasospastic disorder (Raynaud's disease, acrocyanosis, livedo reticularis) or vasospasm associated with a systemic, regional, or traumatic disorder (Raynaud's syndrome, cold injury). Raynaud's disease versus syndrome is distinguishable up to 95% of the time from clinical criteria.

Arteries↗
PubMed1979

Bone formation by revascularized periosteal and bone grafts, compared with traditional bone grafts.

Three groups of dogs were studied to compare the bone formation obtained with traditional bone grafting techniques, and that obtained with revascularized periosteum or revascularized bone grafts--all in unstressed bone. Revascularized periosteum did not produce a significant amount of bone in this unstressed model. At 4 months the revascularized rib grafts had a slightly greater tolerance to stress at the callus site than traditional bone grafts, but the incidence of non-union was the same. We conclude that the use of revascularized bone grafts should be reserved for situations in which traditional bone grafting techniques are unlikely to be successful.

Animals↗