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Wolbrecht E, Ketkar V, Perry JC. Impedance Control of a 2-DOF Spherical 5-Bar Exoskeleton for Physical Human-Robot Interaction During Rehabilitation and Assessment. IEEE Int Conf Rehabil Robot 2023; 2023:1-6. [PMID: 37941197 DOI: 10.1109/icorr58425.2023.10304762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
This paper presents a novel impedance controller for THINGER (THumb INdividuating Grasp Exercise Robot), a 2-degree-of-freedom (DOF) spherical 5-bar exoskeleton designed to augment FINGER (Finger INdividuating Grasp Exercise Robot). Many rehabilitation and assessment tasks, for which THINGER is designed, are improved by rendering near-zero impedance during physical human-robot interaction (pHRI). To achieve this goal, the presented impedance controller includes several novel features. First, a reference trajectory is omitted, allowing free movements. Second, force-feedback gains are reduced near actuator limits and a saturation function limits the maximum commanded force; both allow more responsive (higher) force-feedback gains within the workspace and mitigate transient oscillations caused by external disturbances. Finally, manipulability-based directional force-feedback gains help improve rendered impedance isotropy. Validation experiments included free exploration of the workspace, following a prescribed circular thumb motion, and intentional exposure to external disturbances. The experimental results show that the presented impedance controller significantly reduces impedance to subject-initiated motion and accurately renders the desired isotropic low-impedance environment.
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Di Giuseppe M, Perry JC, Prout TA, Conversano C. Editorial: Recent Empirical Research and Methodologies in Defense Mechanisms: Defenses as Fundamental Contributors to Adaptation. Front Psychol 2021; 12:802602. [PMID: 34925197 PMCID: PMC8678405 DOI: 10.3389/fpsyg.2021.802602] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/28/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - John Christopher Perry
- McGill University and the Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, QC, Canada
| | - Tracy A Prout
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
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Di Giuseppe M, Perry JC, Lucchesi M, Michelini M, Vitiello S, Piantanida A, Fabiani M, Maffei S, Conversano C. Preliminary Reliability and Validity of the DMRS-SR-30, a Novel Self-Report Measure Based on the Defense Mechanisms Rating Scales. Front Psychiatry 2020; 11:870. [PMID: 33005160 PMCID: PMC7479239 DOI: 10.3389/fpsyt.2020.00870] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/10/2020] [Indexed: 12/26/2022] Open
Abstract
Defense mechanisms are psychological factors that influence emotional distress and quality of life. There are a number of measures assessing the construct of defense mechanisms, but only few available instruments reflect the gold-standard theoretical hierarchical organization of defenses. We report on the development of a novel 30 item self-report questionnaire, the DMRS-SR-30, based on the parent instrument, the Defense Mechanism Rating Scales (DMRS). This study tested preliminary reliability and validity of the Italian version of the DMRS-SR-30. We first extracted 30 items from the DMRS Q-sort version (DMRS-Q) and adapted them for a self-reported format. We then applied the DMRS quantitative scoring algorithms to provide proportional scores for the 28 individual defenses and summary scores for seven defense levels and overall defensive functioning (ODF) scores. A dynamic interview was used for assessing participant's defense mechanisms with the observer-rated DMRS and DMRS-Q. We examined internal consistency of the scales along with criterion, concurrent, convergent and discriminant validity among participants (N = 94) who completed the DMRS-SR-30, SCL-90, BDI, and IES-R. Results showed very good internal consistency for ODF (Cronbach's alpha = .890) and the high adaptive defense level, whereas some subscales with few items had lower values. Correlation analyses between DMRS-SR-30 and the two DMRS-based observer-rated measures showed very good criterion and concurrent validity for ODF and moderate to high for defense levels subscales. Correlations between the DMRS-SR-30 ODF and SCL-90 GSI, BDI and IES=R (r = -.456, r= -.540, r = -.402, respectively, all p <.001), indicated good convergent validity. Despite the well-known limitations of self-report methods of psychodynamic phenomena, self-report measures are highly practicable for assessing large samples. The DMRS-SR-30 is the first self-assessed measure describing the whole hierarchy of 28 defense mechanisms and providing scores for ODF, defensive categories, defense levels, and individual defenses. Preliminary examination of the Italian version of the DMRS-SR-30 showed promising results of internal consistency, criterion and concurrent validity, and convergent validity and of the measure. Further validation is needed to confirm these findings and explore other aspects of validity and reliability.
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Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - John Christopher Perry
- Department of Psychiatry, Institute of Community and Family Psychiatry, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Matilde Lucchesi
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Monica Michelini
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Sara Vitiello
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Aurora Piantanida
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Matilde Fabiani
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Sara Maffei
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
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Di Giuseppe M, Zilcha-Mano S, Prout TA, Perry JC, Orrù G, Conversano C. Psychological Impact of Coronavirus Disease 2019 Among Italians During the First Week of Lockdown. Front Psychiatry 2020; 11:576597. [PMID: 33192713 PMCID: PMC7554332 DOI: 10.3389/fpsyt.2020.576597] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/04/2020] [Indexed: 12/21/2022] Open
Abstract
Pandemics and government-mandated quarantining measures have a substantial impact on mental health. This study investigated the psychological impact of the coronavirus disease 2019 (COVID-19) crisis on Italian residents during the first week of government-imposed lockdown and the role of defense mechanisms as protective factors against distress. In this cross-sectional study, 5,683 Italians responded to an online survey assessing socio-demographics, overall psychological distress, post-traumatic symptoms, and defense mechanisms using validated measures as the Symptom Checklist-90 (SCL-90), the Impact of Event Scale-Revised (IES-R), and the Defense Mechanisms Rating Scale-Self-Report-30 (DMRS-SR-30). Data were collected from March 13 to March 18, within the first week of lockdown in Italy. Results showed that younger age and female gender were associated with increased psychological distress. Having positive cases nearby, more days on lockdown, and having to relocate were also associated with greater distress. Higher overall defensive functioning (ODF) was associated with lower levels of depression (r = -.44, 95% CI -0.48, -0.40), anxiety (r = -.38, 95% CI -0.42, -0.35), and post-traumatic stress symptoms (PTSS) (r = -.34, 95% CI -0.38, -0.30). Conversely, less adaptive defensive functioning was related to greater affective distress across all domains. Each increased unit of ODF decreased the chances of developing post-traumatic stress symptoms (PTSS) by 71% (odds ratio = 0.29, p < 0.001, 95% CI.026,.032). The psychological impact of COVID-19 among Italians during the early weeks of government lockdown has been significant. The pandemic continues to have extraordinary mental health impact as it moves across the globe. Given the salience of defensive functioning in psychological distress, consideration of interventions that foster the use of more adaptive defenses may be an important component of building resilience amidst a pandemic.
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Affiliation(s)
- Mariagrazia Di Giuseppe
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | | | - Tracy A Prout
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States
| | - John Christopher Perry
- Institute of Community and Family Psychiatry, JGH, McGill University, Montreal, QC, Canada
| | - Graziella Orrù
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
| | - Ciro Conversano
- Department of Surgical, Medical and Molecular Pathology, Critical and Care Medicine, University of Pisa, Pisa, Italy
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Babl A, Grosse Holtforth M, Perry JC, Schneider N, Dommann E, Heer S, Stähli A, Aeschbacher N, Eggel M, Eggenberg J, Sonntag M, Berger T, Caspar F. Comparison and change of defense mechanisms over the course of psychotherapy in patients with depression or anxiety disorder: Evidence from a randomized controlled trial. J Affect Disord 2019; 252:212-220. [PMID: 30986736 DOI: 10.1016/j.jad.2019.04.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/26/2019] [Accepted: 04/07/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Defense mechanisms play an important role in the development and maintenance of both health and psychopathology. Research is still in the early stages of investigating the specific relationships among diagnostic groups and defense mechanisms along with their response to different treatment types. METHODS For the present study a total of 47 outpatients diagnosed with depression or anxiety disorders were randomized to receive 25±3 sessions of cognitive-behavioral therapy with integrated elements of either emotion-focused therapy (CBT + EFT) or treatment components based on self-regulation theory (CBT + SR). An observer-rated method, the Defense Mechanism Rating Scale (DMRS) was used to code transcripts of the 1st, 8th, 16th and 24th session to assess change in defensive functioning. RESULTS Over the course of therapy, overall defensive functioning (ODF) as well as adaptive defenses increased significantly, whereas maladaptive and neurotic defenses did not change. At the beginning of treatment, the proportion of adaptive defenses and ODF was significantly higher in patients diagnosed with anxiety disorders than in patients with depressive disorders. However, depressed patients exhibited greater improvement in their defensive functioning over the course of therapy. CONCLUSIONS Results support the view of defense mechanisms as a useful transdiagnostic and transtheoretical concept and supports the notion that change of defense mechanisms may be a relevant mechanism of change in psychotherapy.
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Affiliation(s)
- Anna Babl
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland.
| | - Martin Grosse Holtforth
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland; University Hospital Insel, Bern, Switzerland
| | | | - Noemi Schneider
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Eliane Dommann
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Sara Heer
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Annabarbara Stähli
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Nadine Aeschbacher
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Michaela Eggel
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Jelena Eggenberg
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Meret Sonntag
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
| | - Franz Caspar
- Department of Clinical Psychology and Psychotherapy, University of Bern, Fabrikstrasse 8, 3012 Bern, Switzerland
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Dahl HSJ, Ulberg R, Friis S, Perry JC, Høglend PA. Therapists' Inadequate Feelings and Long-Term Effect of Transference Work. Psychother Psychosom 2017; 85:309-10. [PMID: 27513346 DOI: 10.1159/000444647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 02/09/2016] [Indexed: 11/19/2022]
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Dahl HSJ, Høglend P, Ulberg R, Amlo S, Gabbard GO, Perry JC, Christoph PC. Does Therapists' Disengaged Feelings Influence the Effect of Transference Work? A Study on Countertransference. Clin Psychol Psychother 2016; 24:462-474. [DOI: 10.1002/cpp.2015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 03/04/2016] [Accepted: 03/09/2016] [Indexed: 01/10/2023]
Affiliation(s)
| | - Per Høglend
- Division of Mental Health and Addiction; University of Oslo; Oslo Norway
| | - Randi Ulberg
- Division of Mental Health and Addiction; Vestfold Hospital Trust; Tønsberg Norway
- Division of Mental Health and Addiction; University of Oslo; Oslo Norway
| | - Svein Amlo
- Division of Mental Health and Addiction; Vestre Viken Hospital Trust; Drammen Norway
| | - Glen O Gabbard
- Psychiatry and Behavior Sciences; Baylor College of Medicine; Houston Texas USA
| | | | - Paul Crits Christoph
- Department of Psychiatry; University of Pennsylvania; Philadelphia Pennsylvania USA
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Almeida FR, Perry JC, Futuro-Neto HA, Almeida VR, Sebastião RM, Andersen ML, Tufik S, Campos RR, Bergamaschi CT. Cardiovascular function alterations induced by acute paradoxical sleep deprivation in rats. Clin Exp Hypertens 2014; 36:567-71. [PMID: 24678694 DOI: 10.3109/10641963.2014.881843] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Sleep loss has been implicated in triggering the hypertension. The goal of the present study was investigated the possible mechanisms underlying cardiovascular alterations after acute paradoxical sleep deprivation (PSD). Male Wistar rats were assigned in two experimental groups: (1) control and (2) PSD for 24 h using the modified single platform method. Paradoxical sleep deprived rats exhibited higher blood pressure, heart rate (HR) and impaired baroreceptor sensitivity. After pharmacological autonomic double blockade (propranolol and methylatropine administration), intrinsic heart rate was decreased after PSD. The PSD rats showed a reduction in the vagal tone without affecting sympathetic tone. Isoproterenol administration (0.001, 0.01 and 1 µg/kg) induced an increase in ΔHR responses in PSD group. Electrocardiographic analysis in response to β-adrenergic stimulation indicated that PSD contributed to ventricular cardiac arrhythmias. Our findings suggest that acute paradoxical sleep loss induce cardiovascular alterations, autonomic imbalance accompanied by impaired baroreflex sensitivity and increased arrhythmia susceptibility.
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Affiliation(s)
- F R Almeida
- Cardiovascular Division, Department of Physiology, Universidade Federal de São Paulo , SP , Brazil
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Banon E, Perry JC, Semeniuk T, Bond M, de Roten Y, Hersoug AG, Despland JN. Therapist interventions using the Psychodynamic Interventions Rating Scale (PIRS) in dynamic therapy, psychoanalysis and CBT. Psychother Res 2013; 23:121-36. [DOI: 10.1080/10503307.2012.745955] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Nakhost A, Perry JC, Frank D. Assessing the outcome of compulsory treatment orders on management of psychiatric patients at 2 McGill University-associated hospitals. Can J Psychiatry 2012; 57:359-65. [PMID: 22682573 DOI: 10.1177/070674371205700605] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Some literature suggests that compulsory community treatment orders (CTOs) are effective in reducing hospitalizations in a subgroup of psychiatric patients with histories of repeated hospitalization, allowing them to be treated in the community under less restrictive measures. However, studies have yielded contradictory findings, in part because of methodological differences. Our study examines the effectiveness of CTOs in reducing hospitalizations and increasing community tenure of such patients. METHOD The sample included all psychiatric patients who had been given a CTO during a 9-year period at 2 of McGill University's hospitals. This is a naturalistic, observational, retrospective, before-and-after study where patients acted as their own control subjects. We examined variables, including the number, duration, and time to psychiatric admissions, comparing 4 time periods: early, pre-index, index (when the first CTO was in force), and post-index periods. The total study duration per subject encompasses the longest period of observation within existing studies in Canada. RESULTS Psychiatric patients with histories of frequent readmissions demonstrated a significant reduction in their number of hospitalizations as well as an increase in the median time to re-hospitalization, during the period when they were treated under a CTO. This effect of CTO was sustained even after the CTO had expired. CONCLUSIONS Our study suggests that CTOs are effective in assisting psychiatric patients with histories of repeated hospitalizations to live and be treated in the community, diminishing the occurrence of frequent hospitalization.
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Affiliation(s)
- Arash Nakhost
- McGill University, Institute of Community and Family Psychiatry, Jewish General Hospital, Montreal, Quebec, Canada
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Abstract
Nutritional benefits from nuptial gifts have been difficult to detect in some species, raising the question: what maintains nuptial feeding when gifts do not benefit females? The sensory trap hypothesis proposes that nuptial feeding may be explained by pre-existing sensory responses that predispose females to ingest gifts. Recent studies have shown that male seminal proteins can induce a nonspecific increase in female feeding after mating, which may represent a sensory trap for nuptial feeding if it results in increased intake of post-mating gifts. I tested these ideas using female beetles that ingest a spermatophore after mating. I show that males stimulate strongly increased female feeding post-mating. However, there was little evidence for dose dependence in the feeding response that could allow males to stimulate feeding beyond the female optimum. Moreover, the post-mating feeding response could not explain nuptial feeding: despite feeding more in general, newly mated females were less likely than nonmated females to ingest spermatophore gifts.
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Affiliation(s)
- J C Perry
- Department of Ecology and Evolutionary Biology, University of Toronto, Toronto, ON, Canada.
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Andersen ML, Perry JC, Battisti MC, Calzavara MB, Costa JL, Neto ON, Frussa-Filho R, Tufik S. Association of paradoxical sleep deprivation and ecstasy (MDMA) enhances genital reflexes in male rats. Behav Brain Res 2006; 170:287-92. [PMID: 16621058 DOI: 10.1016/j.bbr.2006.03.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Revised: 02/24/2006] [Accepted: 03/07/2006] [Indexed: 11/25/2022]
Abstract
Ecstasy ((+/-)3,4-methylenedioxymethamphetamine, MDMA) is a psychostimulant and a synthetic derivative of amphetamine that, according to its consumers, promotes the enhancement of sexual pleasure. This study sought to investigate the effects of ecstasy in the genital reflexes of paradoxical sleep deprived (PSD) male rats. Distinct groups of PSD rats were administered with saline or different doses of ecstasy. The incidence of genital reflexes was verified for 100 min. The four doses that were used induced genital reflexes in PSD animals and these significantly differed from their respective treated control groups. Under the influence of two intermediary doses (2.5 and 5mg/kg), all animals displayed erection and ejaculation. The frequency of genital reflexes was also significantly greater than in relation to the PSD-saline group. The comparison between cocaine and ecstasy in PSD rats revealed that ecstasy induced more erections and ejaculations than cocaine. Thus, the present results showed a great enhancement of the genital reflexes of PSD rats that might have occurred due to serotoninergic alterations induced by this illicit substance when associated to sleep deprivation.
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Affiliation(s)
- M L Andersen
- Department of Psychobiology - Universidade Federal de São Paulo, Rua Napoleão de Barros, 925, Vila Clementino - SP - 04024-002, São Paulo, Brazil.
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Abstract
Sibling cannibalism occurs in many species, yet understanding of sibling cannibalism as an adaptation currently lags behind understanding of other antagonistic interactions among siblings. Observed sibling cannibalism phenotypes likely reflect the interaction between competitive games among siblings and parent-offspring conflict. Using a game-theoretic approach, we derive optimal offspring cannibalism behaviour and parental modifiers that limit or facilitate cannibalism. The results are compared to contemporary frequency-independent analysis. With the addition of game interactions among siblings or parent-offspring co-evolution, our model predicts increased cannibalism (compared to the frequency-independent prediction), as offspring compete to eat siblings. When infertile eggs are present--strengthening competition--offspring risk eating viable siblings in order to gain access to infertile eggs, intensifying parent-offspring conflict. We use the results to make new predictions about the occurrence of sibling cannibalism. Additionally, we demonstrate the utility of trophic egg laying as a maternal mechanism to promote egg eating.
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Affiliation(s)
- J C Perry
- Behavioural Ecology Research Group, Department of Biological Sciences, Simon Fraser University, Burnaby, Canada.
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14
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Perry JC, Vital MABF, Frussa-Filho R, Tufik S, Palermo-Neto J. Monosialoganglioside (GM1) attenuates the behavioural effects of long-term haloperidol administration in supersensitive rats. Eur Neuropsychopharmacol 2004; 14:127-33. [PMID: 15013028 DOI: 10.1016/s0924-977x(03)00074-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2001] [Revised: 04/22/2003] [Accepted: 05/27/2003] [Indexed: 11/17/2022]
Abstract
In the present study we investigated the effects of co-administration of GM(1) (15.0 mg/kg, twice daily, for 30 days) and haloperidol (1.0 mg/kg, twice daily, for 30 days), as well as the effects of a 5-day treatment with this dose of GM(1) after withdrawal from haloperidol in rats. The animals were evaluated in the open-field test and apomorphine-induced stereotyped behaviour. The results show that GM(1) was able to attenuate dopaminergic supersensitivity evaluated by the locomotion frequency at 24 and 48 h after the withdrawal from haloperidol. On the other hand, rearing frequency was changed neither by haloperidol nor by GM(1.) In haloperidol-treated rats immobility time differs from 30 min observation session in comparison with the following sessions after the withdrawal from neuroleptic. Apomorphine-induced stereotyped behaviour produced a significant increase in scores of haloperidol-withdrawn rats. GM(1) did not modify the haloperidol effects and did not change the dopamine receptor affinity to apomorphine 100 h from abrupt neuroleptic withdrawal.
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Affiliation(s)
- J C Perry
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil
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Abstract
This study examined defensive functioning in adults entering open-ended dynamic psychotherapy and determined whether defenses predict retention at 1 year. Beginning at about the fifth session, 14 adults with personality and or depressive disorders entering open-ended dynamic psychotherapy had five therapy sessions audiotaped. The sessions were rated according to the Defense Mechanism Rating Scales, quantitative method. Interrater reliability of overall defensive functioning (ODF) and the number of defenses used per session were intraclass R = .85 and .83, respectively, whereas that of seven defense levels yielded a median of .625 (range .52 to .80). Stability of ODF across the five sessions was intraclass R = .48. The 11 subjects with personality disorders (PDs) used predominantly lower immature (49.3%) and neurotic (40.8%) level defenses. Subjects with borderline PD had significantly lower ODF than those with other PD types. Higher ODF was associated with remaining in treatment at 1 year, although this was confounded with a higher frequency of weekly sessions. Quantitative assessment of defenses demonstrated fair to excellent reliability and indicated that in the short term approximately half of defensive functioning reflects a stable repertoire, whereas the remaining variation may be due to occasion and error. PDs and especially BPD are characterized by a predominance of lower defenses. Higher defensive functioning was associated with twice-weekly sessions and retention in therapy at 1 year. In therapy, adjusting technique to the patient's defenses may improve retention and outcome.
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Affiliation(s)
- J C Perry
- McGill University Department of Psychiatry at the Institute of Community & Family Psychiatry, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
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Cecchin F, Jorgenson DB, Berul CI, Perry JC, Zimmerman AA, Duncan BW, Lupinetti FM, Snyder D, Lyster TD, Rosenthal GL, Cross B, Atkins DL. Is Arrhythmia Detection by Automatic External Defibrillator Accurate for Children? Circulation 2001; 103:2483-8. [PMID: 11369689 DOI: 10.1161/01.cir.103.20.2483] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
—Use of automatic external defibrillators (AEDs) in children aged <8 years is not recommended. The purpose of this study was to develop an ECG database of shockable and nonshockable rhythms from a broad age range of pediatric patients and to test the accuracy of the Agilent Heartstream FR2 Patient Analysis System for sensitivity and specificity.
Methods and Results
—Children aged ≤12 years who either developed arrhythmias or were at risk for developing arrhythmias were studied. Two sources were used for the database: children whose rhythms were recorded prospectively via a modified AED and children who had arrhythmias captured on paper and digitized for subsequent analysis. The rhythms were divided into 5-second strips, classified by 3 reviewers, and then assessed by the AED analysis algorithm. A total of 696 five-second rhythm strips from 191 children (81 female and 110 male) aged 1 day to 12 years (median 3.0 years) were analyzed. There was 100% specificity for nonshockable rhythms. Sensitivity for ventricular fibrillation was 96%.
Conclusions
—There was excellent AED rhythm analysis sensitivity and specificity in all age groups for ventricular fibrillation and nonshockable rhythms. The high specificity and sensitivity indicate that there is a very low risk of an inappropriate shock and that the AED correctly identifies shockable rhythms, making the algorithm both safe and effective for children.
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Affiliation(s)
- F Cecchin
- University of Washington, Seattle, USA.
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Despland JN, de Roten Y, Despars J, Stigler M, Perry JC. Contribution of patient defense mechanisms and therapist interventions to the development of early therapeutic alliance in a brief psychodynamic investigation. J Psychother Pract Res 2001; 10:155-64. [PMID: 11402078 PMCID: PMC3330648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
This preliminary study examined how patients' defense mechanisms and psychotherapists' techniques influence early alliance formation. The authors assessed the relationships among defense mechanisms, therapist interventions, and the development of alliance in a sample of 12 patients undergoing Brief Psychodynamic Investigation (4 sessions). Alliance development occurred rapidly and was clearly established by the third session. Neither defensive functioning nor supportive or exploratory interventions alone differentiated early alliance development. However, the degree of adjustment of therapists' interventions to patients' level of defensive functioning discriminated a low alliance from both improving and high alliances. The adjustment of therapeutic interventions to patients' level of defensive functioning is a promising predictor of alliance development and should be examined further, alongside other predictors of outcome.
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Affiliation(s)
- J N Despland
- Département Universitaire de Psychiatrie de l'Adulte, Faculté de Médecine de Lausanne, Switzerland
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18
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Abstract
Limited information is available that describes the practical conversion of a pediatric echocardiography laboratory from videotape to a primarily digital format. To help pediatric echocardiographers begin to make the analog-to-digital transition, we report our pediatric digital acquisition protocol and the acquisition and storage parameters of 1000 unselected, consecutive digitally acquired studies of pediatric patients with known or suspected congenital or acquired heart disease. With the use of our acquisition protocol, a complete normal study requires 46 moving clips and 12 still-frame images. Five hundred consecutive patient studies acquired with "high" JPEG (Joint Photographers Experts Group) compression (group 1) were compared with the next 500 examinations acquired using "medium" JPEG compression (group 2) for number of moving clips, still images, and megabytes of storage space. No intergroup difference was found in the number of moving clips or still images. When JPEG compression was decreased from high to medium, the average clip storage requirement per patient increased, and the number of patients stored per 230-MB magneto optical disk decreased significantly. Non-ECG-triggered timed single-plane clips and still images required significantly more storage space than ECG-triggered single-beat clips and still images. The frequency of multiplane sweeps was.03% and was independent of diagnosis. With the use of high JPEG compression, the digital storage cost per patient was $1.90, which was 6.0 times greater than that for simultaneously recorded 120-minute VHS videotape. Many features of the digital paradigm, including decreased MOD storage space, enhanced serial study comparisons, random image access, and improved image quality, mitigate this cost differential.
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Affiliation(s)
- J W Mathewson
- Children's Heart Institute, Children's Hospital-San Diego, CA 92123-4282, USA.
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19
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Abstract
Pacing in neonates and infants continues to be challenging due to size constraints, growth potential, and the need for life long pacing. Indications for permanent pacing in pediatric patients have been difficult to determine due to the lack of data from controlled studies and multicenter trials. Temporary pacing has been useful to restore cardiac output in pediatric patients quickly and efficiently. Methods of temporary pacing include transcutaneous, transesophageal, transvenous, and epicardial. Permanent pacemaker implantation can be accomplished by transvenous or epicardial approaches, but the use of transvenous pacing in neonates and infants offers no advantages over epicardial pacing. Transvenous pacing in infants is often prohibitive due to size and growth constraints as well as the subsequent risk of skin erosion and venous thrombosis. Smaller pulse generators, multiprogrammable features, and steroid-eluting epicardial leads are a few of the technological advances that have made pacing in neonates and infants easier and safer. Data supporting the use of pacing systems in very young patients are sparse. Pacing 'indications' should be viewed as guidelines until such data can be accumulated.
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Affiliation(s)
- KR Maginot
- Children's Hospital San Diego, Division of Cardiology, San Diego, CA, USA
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20
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Abstract
OBJECTIVE The authors examined the evidence for the effectiveness of psychotherapy for personality disorders in psychotherapy outcome studies. METHOD Fifteen studies were located that reported data on pretreatment-to-posttreatment effects and/or recovery at follow-up, including three randomized, controlled treatment trials, three randomized comparisons of active treatments, and nine uncontrolled observational studies. They included psychodynamic/interpersonal, cognitive behavior, mixed, and supportive therapies. RESULTS All studies reported improvement in personality disorders with psychotherapy. The mean pre-post effect sizes within treatments were large: 1.11 for self-report measures and 1.29 for observational measures. Among the three randomized, controlled treatment trials, active psychotherapy was more effective than no treatment according to self-report measures. In four studies, a mean of 52% of patients remaining in therapy recovered--defined as no longer meeting the full criteria for personality disorder--after a mean of 1.3 years of treatment. A heuristic model based on these findings estimated that 25.8% of personality disorder patients recovered per year of therapy, a rate sevenfold larger than that in a published model of the natural history of borderline personality disorder (3.7% recovered per year, with recovery of 50% of patients requiring 10.5 years of naturalistic follow-up). CONCLUSIONS Psychotherapy is an effective treatment for personality disorders and may be associated with up to a sevenfold faster rate of recovery in comparison with the natural history of disorders. Future studies should examine specific therapies for specific personality disorders, using more uniform assessment of core pathology and outcome.
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Affiliation(s)
- J C Perry
- Institute of Community and Family Psychiatry, McGill University, Canada
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21
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Abstract
Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the Emergency Department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This, the second of a two-part series, covers the causes, diagnosis, and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference.
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Affiliation(s)
- T Y Cardall
- Department of Emergency Medicine, University of California, San Diego, School of Medicine, La Jolla, USA
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22
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Cameron PM, Leszcz M, Bebchuk W, Swinson RP, Antony MM, Azim HF, Doidge N, Korenblum MS, Nigam T, Perry JC, Seeman MV. The practice and roles of the psychotherapies: a discussion paper. Working Group 1 of the Canadian Psychiatric Association Psychotherapies Steering Committee. Can J Psychiatry 1999; 44 Suppl 1:18S-31S. [PMID: 10390652 DOI: 10.1177/07067437990440s103] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- P M Cameron
- Department of Psychiatry, University of Ottawa, Ontario
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23
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Abstract
Many people benefit from the implantation of cardiac pacemakers for management of certain cardiac dysrhythmias. These patients are seen regularly in the emergency department with a variety of pacemaker complications and malfunctions. The presence of a pacemaker may also affect management of unrelated medical problems. This two-part series reviews the medical issues related to patients with permanent pacemakers. Part I covers pacing modes and terminology, complications of the implant procedure, and the approach to a patient with a permanent pacemaker. Part II covers the causes, diagnosis and management of pacemaker malfunction; the pacemaker syndrome; the pacemaker Twiddler's syndrome; and other considerations in the paced patient including diagnosis of acute myocardial infarction, ACLS protocols, trauma, and sources of interference. Indications for permanent pacemaker implantation and temporary external pacing will not be covered.
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Affiliation(s)
- T Y Cardall
- Department of Emergency Medicine, University of California, San Diego, School of Medicine, La Jolla, USA
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Affiliation(s)
- J J Sigal
- Department of Psychiatry (ICFP), Jewish General Hospital, Montreal, Quebec, Canada
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Milbrath C, Bond M, Cooper S, Znoj HJ, Horowitz MJ, Perry JC. Sequential consequences of therapists' interventions. J Psychother Pract Res 1999; 8:40-54. [PMID: 9888106 PMCID: PMC3330527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Using sequential analysis, the authors examined how therapists' actions related to the verbal disclosure and defensive patterns that followed therapists' interventions within a single therapy hour for 20 patients. At the same time, a new measure, the Psychodynamic Intervention Rating Scale (PIRS), was tested for reliability and construct validity. Results indicated that therapists fit their styles of intervention to patients' levels of distress and functioning. Within the session, patient's emotional elaboration was followed by therapist's defense interpretation, followed by more patient emotional elaboration. Patient elaboration of significance was followed by more transference interpretation, followed by more patient elaboration of significance. Noninterpretive interventions were followed by patient's disclosure of facts, not emotion. Both interpretive intervention process sequences and therapist's use of support predicted posttreatment symptom reduction. The PIRS was shown to have satisfactory reliability and construct validity.
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Affiliation(s)
- C Milbrath
- Department of Psychiatry, University of California, San Francisco, USA
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Abstract
We examined the validity of the construct of overall defensive functioning and its discrimination from standard diagnostic assessments. Within a multisite field trial, patients received intake diagnostic interviews by clinicians who made standard axis I through V diagnoses, then rated defense mechanisms using the Defense Mechanism Rating Scales (DMRS). Patients filled out self-report measures of distress and defenses, the SCL-90-R, and Defense Style Questionnaire (DSQ). Overall defensive functioning (ODF) scales were derived from both the DMRS and the DSQ. Overlap between clinical and self-report ratings of defenses was modest. By two different methods of factor analysis, followed by confirmatory factor analysis, clinical ratings of ODF were clearly discriminable from axis I, axis II personality disorders, current and usual global functioning, and subjective distress. ODF measured by the DSQ was not clearly discriminated from subjective distress ratings, consistent with the hypothesis that subjective distress may distort conscious derivatives of actual defensive processes. The DSQ alone probably should not be considered as a substitute for observer-rated assessment of defensive functioning, although further study of the issue is warranted.
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Affiliation(s)
- J C Perry
- Department of Psychiatry, McGill University at the Institute of Community and Family Psychiatry, Sir Mortimer B. Davis-Jewish General Hospital, Montréal, Québec, Canada
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27
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Abstract
Chronic fatigue syndrome (CFS), a controversial illness without clear etiology, causes profound debilitation in its sufferers. This study explored subjects' perceptions of the variables that mediated the course of their illness and identified coping strategies in 15 women with CFS referred from the practice of a primary care physician. Exploratory semistructured interviews were adapted from Kleinman's Illness Narratives. Four instruments were used: the Beck Depression Inventory, the Sickness Impact Profile, a modified Karnofsky scale, and the Defense Mechanism Rating Scale. Of the 15 women, 60% reported improvement and/or recovery at the time of the interview. Improvement was associated with social support and lower levels of depressive symptoms. Health status was influenced by how subjects perceived their illness, their future, and the doctor's prognosis; and by the physician's early diagnosis, validation of the CFS, and intensive medical follow-up. Obsessional and healthy neurotic defense levels predominated, which differs from historical comparison groups with dysthymia and panic disorder. Psychological adaptation to CFS is similar to adaptive coping in other chronic illnesses: subjective perceptions of health status can predict functional status. Physician validation is particularly important given the controversial status of CFS. Maintaining relationships with others--doctor, work, family, and group/spiritual activities reflected healthy coping strategies that promoted hope and attitudinal shifts. The finding of a mixture of neurotic and healthy defenses and a low proportion of defenses associated with personality disorders has not been previously reported in the CFS literature and warrants further investigation.
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28
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Abstract
Following critiques that the DSM multiaxial system lacks psychodynamic information useful for treatment, an axis for defense mechanisms was developed for DSM-IV, including up to 7 individual defenses from a glossary of 27, and 3 predominant defense levels from a list of 7. We tested the feasibility, reliability, and discriminability of the proposed axis. Clinician and psychiatric resident volunteers were trained at two U.S. and one Norwegian sites. After conducting initial interviews on 107 patients, they rated the DSM-III-R and defense axes, as did a second blind rater. Median kappa reliabilities were .42 (individual defenses), and .47 (defense levels). A summary measure, Overall Defensive Functioning (ODF), had similar reliability to current GAF (IR .68 vs. .62), similar 1-month stability (.75 vs. .78), but greater 6-month stability (.51 vs. .17). Independent of Axis III, ODF had small to moderate associations with other Axes and symptoms. Our findings indicate that the defense axis is a feasible, acceptably reliable, and nonredundant addition to DSM-IV, which may prove useful for planning and conducting treatment.
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29
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Li H, Chen Q, Moss AJ, Robinson J, Goytia V, Perry JC, Vincent GM, Priori SG, Lehmann MH, Denfield SW, Duff D, Kaine S, Shimizu W, Schwartz PJ, Wang Q, Towbin JA. New mutations in the KVLQT1 potassium channel that cause long-QT syndrome. Circulation 1998; 97:1264-9. [PMID: 9570196 DOI: 10.1161/01.cir.97.13.1264] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Long-QT syndrome (LQTS) is an inherited cardiac arrhythmia that causes sudden death in young, otherwise healthy people. Four genes for LQTS have been mapped to chromosome 11p15.5 (LQT1), 7q35-36 (LQT2), 3p21-24 (LQT3), and 4q25-27 (LQT4). Genes responsible for LQT1, LQT2, and LQT3 have been identified as cardiac potassium channel genes (KVLQT1, HERG) and the cardiac sodium channel gene (SCN5A). METHODS AND RESULTS After studying 115 families with LQTS, we used single-strand conformation polymorphism (SSCP) and DNA sequence analysis to identify mutations in the cardiac potassium channel gene, KVLQT1. Affected members of seven LQTS families were found to have new, previously unidentified mutations, including two identical missense mutations, four identical splicing mutations, and one 3-bp deletion. An identical splicing mutation was identified in affected members of four unrelated families (one Italian, one Irish, and two American), leading to an alternatively spliced form of KVLQT1. The 3-bp deletion arose de novo and occurs at an exon-intron boundary. This results in a single base deletion in the KVLQT1 cDNA sequence and alters splicing, leading to the truncation of KVLQT1 protein. CONCLUSIONS We have identified LQTS-causing mutations of KVLQT1 in seven families. Five KVLQT1 mutations cause the truncation of KVLQT1 protein. These data further confirm that KVLQT1 mutations cause LQTS. The location and character of these mutations expand the types of mutation, confirm a mutational hot spot, and suggest that they act through a loss-of-function mechanism or a dominant-negative mechanism.
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Affiliation(s)
- H Li
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex 77030, USA
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30
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Abstract
We investigated the predictive effect of psychological defenses on the course of major depression in a subsample of psychiatric patients from a larger study. We tested the hypothesis that a group of eight defenses, associated with depression in previous research, would predict, outcome of major depression. After an intake interview, 37 patients were rated on all DSM-III-R Axes, the SCL-90-R, and 28 defenses, using the Defense Mechanism Rating Scales. At 6-month follow-up interview, SCL-90-R and Global Assessment and Functioning (GAF) were redetermined on 34 (92%), 16 of whom had major depression at intake. Overall Defensive Functioning (ODF) significantly predicted GAF at 6-month follow-up over and above initial level of global functioning and presence of a personality disorder. The group of eight defenses were identified more often (p = .068) in depressed patients who improved less than predicted by their initial functional status. The high adaptive level defense, self-observation, was identified more often in those who improved more than predicted by their initial status. Our findings support the theory of a hierarchy of defenses, and the mediating effects of specific low and high adaptive level defenses on the course of a major depressive episode. Further research should examine passive aggression, acting out, help-rejecting complaining, splitting of self-images, splitting of others' images, projective identification, projection, and devaluation in relationship to the onset, course, and treatment response of depressive disorders.
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Affiliation(s)
- P Høglend
- Department of Psychiatry, University of Oslo, Norway
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31
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Abstract
Infant VT can be a devastating arrhythmia, with high mortality for those presenting with myocarditis, long QT syndrome, or cardiovascular collapse with rapid VT due to tumors. While management of these patients can be challenging and discouraging, other infants with wide QRS rhythms tend to follow a more benign course. These latter patients have accelerated idiopathic ventricular rhythm or aberrant forms of infant supraventricular tachycardia. Distinguishing these forms of wide QRS tachycardia from the more lethal forms is paramount to institution of appropriate therapies.
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Affiliation(s)
- J C Perry
- Children's Heart Institute, Children's Hospital San Diego, California, USA
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32
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Steketee G, Perry JC, Goisman RM, Warshaw MG, Massion AO, Peterson LG, Langford L, Weinshenker N, Farreras IG, Keller MB. The psychosocial treatments interview for anxiety disorders. A method for assessing psychotherapeutic procedures in anxiety disorders. J Psychother Pract Res 1997; 6:194-210. [PMID: 9185065 PMCID: PMC3330464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The authors report on development, reliability, and findings of the Psychosocial Treatments Interview (PTI) to assess treatments reported by patients in a naturalistic study of the longitudinal course of anxiety disorders. The PTI ascertains frequency of different types of psychosocial treatments, based on patients' reports. The PTI showed good internal consistency and very good interrater reliability. At first 6-month follow-up, the most common modalities were supportive, medication discussion, and dynamic intervention. Combinations were common. Delivery of treatments differed by site. Overall, the PTI fills a methodological need for the assessment of the treatments reported by patients in naturalistic follow-up studies.
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Affiliation(s)
- G Steketee
- Boston University School of Social Work, Massachusetts 02215, USA
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33
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Perry JC, Fenrich AL, Hulse JE, Triedman JK, Friedman RA, Lamberti JJ. Pediatric use of intravenous amiodarone: Efficacy and safety in critically ill patients from a multicenter protocol. Resuscitation 1996. [DOI: 10.1016/0300-9572(96)89051-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Perry JC, Fenrich AL, Hulse JE, Triedman JK, Friedman RA, Lamberti JJ. Pediatric use of intravenous amiodarone: Efficacy and safety in critically ill patients from a multicenter protocol. Resuscitation 1996. [DOI: 10.1016/s0300-9572(96)90073-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Van Hare GF, Lesh MD, Ross BA, Perry JC, Dorostkar PC. Mapping and radiofrequency ablation of intraatrial reentrant tachycardia after the Senning or Mustard procedure for transposition ofthe great arteries. Am J Cardiol 1996; 77:985-91. [PMID: 8644650 DOI: 10.1016/s0002-9149(96)00034-3] [Citation(s) in RCA: 88] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Senning and Mustard procedures are often associated with the development of atrial tachyarrhythmias, which may be a cause of sudden death. We hypothesized that atrial surgery creates barriers to impulse propagation, establishing potential routes for atrial reentry, and that mapping combined with knowledge of the surgical anatomy could identify zones that are critical to the tachycardia to be targeted for radiofrequency catheter ablation. Patients underwent mapping to identify early sites of atrial activation that were related to anatomic or surgically created obstacles, with confirmation by pacing to demonstrate concealed entrainment. Radiofrequency lesions were placed to connect these obstacles, while observing for tachycardia termination. Thirteen tachycardias were attempted in 10 patients, 10 successfully. Three patients had 2 distinct tachycardias. Successful sites were in right atrial tissue, although in many, a retrograde approach to the pulmonary venous atrium was necessary. Ablation of the clinically documented tachycardia was successful in 9 of 10 patients. The most common successful site was the region of the coronary sinus mouth, approached antegrade or retrograde. Ablation of intraatrial reentrant tachycardias after the Senning or Mustard procedure is feasible using concealed entrainment mapping techniques, but requires a detailed knowledge of the individual surgical anatomy and the ability to approach the pulmonary venous atrium. Radiofrequency ablation offers significant advantages over other management modalities in this patient group.
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Affiliation(s)
- G F Van Hare
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve School of Medicine, Cleveland, Ohio 44106, USA
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Perry JC, Fenrich AL, Hulse JE, Triedman JK, Friedman RA, Lamberti JJ. Pediatric use of intravenous amiodarone: efficacy and safety in critically ill patients from a multicenter protocol. J Am Coll Cardiol 1996; 27:1246-50. [PMID: 8609351 DOI: 10.1016/0735-1097(95)00591-9] [Citation(s) in RCA: 152] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze the efficacy and safety of intravenous amiodarone in young patients with critical, drug-resistant arrhythmias. BACKGROUND Intravenous amiodarone has been investigated in adults since the early 1980s. Experience with the drug in young patients is limited. A larger pediatric study group was necessary to provide responsible guidelines for the drug's use before its market release. METHODS Eight centers obtained institutional approval of a standardized protocol. Other centers were approved on a compassionate use basis after contacting the primary investigator (J.C.P). RESULTS Forty patients were enrolled. Standard management in all failed. Many patients had early postoperative tachyarrhythmias (25 of 40), with early successful treatment in 21 (84%) of 25. Twelve patients had ventricular tachyarrhythmias: seven had successful therapy, and six died, none related to the drug. Eleven patients had atrial tachyarrhythmias: 10 of 11 had immediate success, but 3 later died. Fourteen patients had junctional ectopic tachycardia, which was treated with success (sinus rhythm or slowing, allowing pacing) in 13 of 14, with no deaths. Three other patients had supraventricular tachycardias, with success in two and no deaths. The average loading dose was 6.3 mg/kg body weight, and 50% of patients required a continuous infusion. Four patients had mild hypotension during the amiodarone bolus. One postoperative patient experienced bradycardia requiring temporary pacing. There were no proarrhythmic effects. Deaths (9 [23%] of 40) were not attributed to amiodarone. CONCLUSIONS Intravenous amiodarone is safe and effective in most young patients with critical tachyarrhythmia. Intravenous amiodarone can be lifesaving, particularly for postoperative junctional ectopic tachycardia, when standard therapy is ineffective.
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Affiliation(s)
- J C Perry
- Children's Hospital San Diego, California, USA
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Abstract
UNTIL recent years, the personality disorders have been relatively unexplored compared to other psychiatric diagnoses. Over 15 years ago, there was little agreement on the diagnosis of borderline personality disorder (Perry and Klerman 1978), but efforts to specify the constructs and respective criteria for the borderline diagnosis spurred a plethora of systematic research. The result is that, next to antisocial personality disorder, borderline has become one of the best-documented and validated personality disorders (Perry and Vaillant 1989). One important shift has been that good descriptive studies have gradually led to studies of etiological factors, such as childhood physical and sexual abuse, and severe neglect (Herman et al. 1989; Perry and Herman 1992), which in turn have led to empirically based treatment approaches (Herman 1992; Perry et al. 1990). Despite inclusion in The Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-III-R), narcissistic personality is still at the beginning of this process of description, empirical testing, and validation (Gunderson et al. 1991). This study empirically examines three descriptions of narcissistic personality in order to look for common underlying dimensions that may have etiological and treatment significance.
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Moore JW, Spicer RL, Perry JC, Mathewson JW, Kirkpatrick SE, George L, Uzark K, Mainwaring RL, Lamberti JJ. Percutaneous use of stents to correct pulmonary artery stenosis in young children after cavopulmonary anastomosis. Am Heart J 1995; 130:1245-9. [PMID: 7484776 DOI: 10.1016/0002-8703(95)90149-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Pulmonary artery distortion is a risk factor among candidates for the Fontan procedure. In 57 patients evaluated by catheterization after successful cavopulmonary anastomosis, 8 had proximal left pulmonary artery (LPA) stenosis, either discrete (4 patients) or long segment (4 patients). Median age was 27 months (range 19 to 60 months). Median weight was 11.4 kg (range 9.1 to 20.0). Mean diameter at LPA stenosis was 4.4 +/- 0.4. Proximal right pulmonary artery mean diameter was 10.4 +/- 1.0 mm. After angiographic and hemodynamic assessment, short 11F sheaths were placed in the right internal jugular (6 patients) or subclavian veins (2 patients). Pulmonary artery angioplasty and stent placement were performed. LPA stenoses were enlarged using 10 Palmaz stents dilated to 10 mm (7 patients) or to 12 mm (3 patients). Poststent angiograms showed that narrowest LPA dimensions were significantly enlarged to 9.9 mm +/- 1.0 mm, p < 001). There were no complications. Follow-up studies (catheterizations in 4 patients, echocardiograms in 8 patients) were performed 4 to 9 months after stent implantation. No restenosis was observed. Five patients had completion of their Fontan procedures; three patients are pending Fontan completion. This study demonstrates the efficacy and safety of the percutaneous use of Palmaz stents to correct pulmonary artery stenosis in young children after cavopulmonary anastomosis.
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Affiliation(s)
- J W Moore
- Children's Heart Institute, Children's Hospital, USA
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39
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Abstract
The purpose of this study was to determine the effects of newer Fontan modifications (lateral tunnel with or without fenestration) and patient's age at surgery on the incidence and impact of symptomatic postoperative early and intermediate arrhythmias. Modifications to the Fontan procedure are used to decrease postoperative complications, and the Fontan procedure is now being performed on younger patients to reduce age-related changes in ventricular function. A retrospective review was done of the medical records of 151 consecutive patients, ranging in age from 1 to 49 years, who underwent a Fontan procedure at Texas Children's Hospital between 1987 and 1993. Risk factors were identified for early and intermediate arrhythmias. Age at time of the procedure was an independent predictor of early atrial arrhythmias (p = 0.03), ventricular arrhythmias (p = 0.003), and junctional ectopic tachycardia (JET) (p = 0.05). We found that the older the patient at surgery, the higher the incidence of atrial and ventricular arrhythmias, whereas the younger the patient, the higher the incidence of JET. Using Cox's proportional-hazards model, the risk of intermediate atrial arrhythmias after lateral tunnel modification was 1/3 that after atriopulmonary connection. Younger patients who underwent the Fontan procedure had a lower risk for early atrial and ventricular arrhythmia but an increased risk for JET. The lateral tunnel modification can be performed in order to reduce the risk of intermediate atrial arrhythmias.
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Affiliation(s)
- F Cecchin
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, Texas, USA
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40
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Abstract
Because limited information is available on significant arrhythmias after myocardial infarction in pediatric patients, this study was performed to determine the incidence and impact of ventricular tachycardia or fibrillation on the postinfarction course in patients aged 1 day to 16 years. Review of 96 such children showed a wide range of underlying heart disease (56 patients with congenital heart disease, 12 with cardiomyopathy, and 28 with acquired heart disease). Postinfarction ventricular tachycardia/fibrillation occurred commonly (28% of patients with acute myocardial infarction) and early (84% by 2 days after diagnosis). Postinfarction mortality was high in patients with acute myocardial infarction (61%) and appeared to be independent of type of associated heart disease. Ventricular tachycardia/fibrillation was associated with higher mortality rates (approximately 80%) in patients with acute or remote myocardial infarction. The 61 postinfarction survivors were monitored for an average of 4.9 years, and none had significant recurrent ventricular arrhythmias or late sudden death.
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Affiliation(s)
- C L Johnsrude
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, TX 77030, USA
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41
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Affiliation(s)
- A B Martin
- Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
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42
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Abstract
OBJECTIVES This study assessed the safety and efficacy of combined flecainide and amiodarone therapy in controlling refractory tachyarrhythmias in infants. BACKGROUND Single-drug as well as standard combination medical therapy for tachyarrhythmias in infants sometimes fails. In those cases, one may consider interventional therapy. However, this option may carry a high risk of morbidity and mortality in infants. The natural history of tachyarrhythmias in infants often favors eventual resolution and reinforces the importance of selecting an effective medical regimen. METHODS We performed a retrospective analysis of nine infants (median age 2 months) who received combined flecainide and amiodarone therapy for attempted control of refractory tachyarrhythmias. Trough serum drug levels of flecainide were monitored, and 24-h ambulatory electrocardiographic monitoring was used to determine efficacy of therapy. RESULTS Single-drug treatment with flecainide or amiodarone failed in all of the infants studied. An average of four drugs failed (range one to six) before administration of combined flecainide and amiodarone therapy. During combined therapy, the flecainide dose was 70 to 110 mg/m2 per day, and that for amiodarone was 7.5 to 13.5 mg/kg per day for a mean (+/- SD) of 9 +/- 2 days to load and 5 to 12 mg/kg per day as maintenance. Successful control of tachyarrhythmias was demonstrated in seven (78%) of nine infants (95% confidence interval 46% to 99%) (three of three with congenital junctional ectopic tachycardia, three of three with supraventricular tachycardia and one of three with ventricular tachycardia). During combined therapy, flecainide trough levels ranged from 350 to 731 ng/ml. Corrected QT intervals varied from 0.440 to 0.488 ms. No proarrhythmia occurred. None of the infants required a pacemaker, and all had normal left ventricular dimensions and fractional shortening by echocardiography. Eight of nine infants had a structurally normal heart. One infant had surgical correction of an atrioventricular septal defect. CONCLUSIONS Combination therapy with flecainide and amiodarone appears to be safe and effective in controlling refractory tachyarrhythmias in infants. The combination of flecainide and amiodarone may obviate the need for early interventional therapy or may allow delay until the child is older.
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Affiliation(s)
- A L Fenrich
- Section of Pediatric Cardiology, Texas Children's Hospital, Houston 77030
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Johnsrude CL, Perry JC, Cecchin F, Smith EO, Fraley K, Friedman RA, Towbin JA. Differentiating anomalous left main coronary artery originating from the pulmonary artery in infants from myocarditis and dilated cardiomyopathy by electrocardiogram. Am J Cardiol 1995; 75:71-4. [PMID: 7801869 DOI: 10.1016/s0002-9149(99)80531-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Anomalous left main coronary artery (ALMCA) originating from the pulmonary artery is an important cause of morbidity from heart failure and mortality in infants. Discriminating ALMCA from myocarditis or other forms of dilated cardiomyopathy (DC) in infants is critical for proper early management of this treatable disease. This study was performed to characterize electrocardiographic (ECG) patterns in infants with ALMCA, and to identify features that would allow differentiation of these infants from those with myocarditis/DC. Presenting electrocardiograms from 28 patients with ALMCA < 2 years of age were analyzed for 103 variables, and compared with electrocardiograms from 28 aged-matched infants with myocarditis/DC using the t test, Fisher's exact test, and discriminant analysis using stepwise logistic regression techniques. ECG findings characteristic of infants with ALMCA were confirmed, including deep (> or = 3 mm) and wide (> or = 30 ms) Q waves and a QR pattern in at least 1 of the following leads: I, aVL, V5 to V7. Also, the complete absence of Q waves from leads II, III, and aVF in all infants with ALMCA was noted. These and other ECG patterns were more common in infants with ALMCA than in those with myocarditis/DC (p < 0.05), but were also noted in some patients with myocarditis/DC. Stepwise logistic regression analysis identified 3 ECG variables that best discriminated ALMCA from myocarditis/DC, including Q wave width (w) in lead I, and Q-wave depth (d) and ST-segment amplitude (s) in lead aVL.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- C L Johnsrude
- Division of Pediatric Cardiology, Baylor College of Medicine, Houston, Texas
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Perry JC. Fetal arrhythmias, pediatric arrhythmias, and pediatric electrophysiology. Curr Opin Cardiol 1995; 10:52-7. [PMID: 7787265 DOI: 10.1097/00001573-199501000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The practice of pediatric electrophysiology has been altered drastically and irrevocably over the past 5 years. With the advent of widespread application of transcatheter radiofrequency ablative techniques in young patients, decision-making in the management of childhood arrhythmias has focused less on palliative medical therapies and more on the potential for curative, nonsurgical interventions. This review examines the published contributions in the area of pediatric catheter ablation, antiarrhythmic drug therapy, postoperative arrhythmias, fetal arrhythmias, and electrocardiographic phenomena after cardiac transplantation.
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Affiliation(s)
- J C Perry
- Children's Heart Institute, Children's Hospital, San Diego, California, USA
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45
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Abstract
OBJECTIVES We sought to examine whether resolution of occult myocarditis in children with associated ventricular arrhythmia correlated with the presence of arrhythmia at late follow-up. BACKGROUND Complex ventricular arrhythmias have been documented in children with myocarditis. Therapy is aimed at controlling the arrhythmia and any associated ventricular dysfunction. However, no reported studies have documented whether resolution of myocarditis in children is associated with resolution of the associated arrhythmias. METHODS We performed a retrospective analysis of 12 patients (mean age 12 years) with myocarditis. Ambulatory electrocardiographic (Holter) monitors were reviewed for ventricular arrhythmias at presentation and follow-up. Patients were assigned to Group I if they received corticosteroids in addition to any antiarrhythmic agents and to Group II if they did not receive steroids. Follow-up endomyocardial biopsy was performed in some patients, and results were analyzed in relation to the presence of arrhythmias at follow-up. RESULTS Eleven patients had ventricular tachycardia, and one had multiform couplets. Corticosteroids were given to seven patients (Group I). Follow-up biopsy was performed in seven patients (six received steroids), with resolution of inflammation in all; four of the seven still had ventricular arrhythmias but with improved control. Of the five patients without follow-up biopsy, three had persistent arrhythmia. Absence of inflammation at follow-up biopsy did not correlate with loss of ventricular arrhythmias, and there was no difference between Group I and II patients with respect to resolution of arrhythmia (Fisher exact test, p = 0.70, power 11%). CONCLUSIONS Complex ventricular arrhythmias persist after apparent resolution of occult myocarditis in children. Although these arrhythmias are easier to control after such resolution, the patients may require long-term antiarrhythmic therapy.
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Affiliation(s)
- R A Friedman
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston 77030
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46
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Abstract
This study empirically supported Antonovsky's predictions that a person's Sense of Coherence is implicated in coping with life stresses and psychological distress. Sense of Coherence scales accounted for as much variance in criterion measures of Life Events stressors, Depression, and Anxiety as did traditional locus of control and social support predictor measures. Sense of Coherence scales emerged as useful additions for studies of personality characteristics implicated in personal reactions to distressing life events.
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Reich J, Perry JC, Shera D, Dyck I, Vasile R, Goisman RM, Rodriguez-Villa F, Massion AO, Keller M. Comparison of personality disorders in different anxiety disorder diagnoses: panic, agoraphobia, generalized anxiety, and social phobia. Ann Clin Psychiatry 1994; 6:125-34. [PMID: 7804388 DOI: 10.3109/10401239409148991] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Recently there has been increasing interest in the relationship of the personality and the anxiety disorders. This paper presents comorbidity findings between DSM-III-R personality pathology and several DSM-III-R anxiety disorders and makes direct comparisons between anxiety groups. This is the most extensive comparison of this kind reported thus far. This report is on the first 475 anxiety patients who were recruited from multiple sites to take part in a naturalistic study of anxiety. All had a DSM-III-R diagnosis of panic, agoraphobia, social phobia, or generalized anxiety disorder (GAD). Previous studies which found a high comorbidity between the anxiety and the personality pathology were confirmed, with a significantly higher prevalence of personality pathology occurring with social phobia and GAD. Among our patients, all of whom had anxiety disorders, the presence of comorbid major depression is associated with an increase in the levels of comorbid personality pathology--as previously described in the literature. The relationship between low social functioning and the presence of personality pathology was confirmed, however, the relationship appears to be specific to certain areas of functioning, a new finding. There is a clinically important relationship between Personality Diagnostic Questionnaire--Revised personality pathology and the anxiety disorders characterized by different prevalences of personality disorders in different anxiety disorders and specific areas of social dysfunction.
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48
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Kugler JD, Danford DA, Deal BJ, Gillette PC, Perry JC, Silka MJ, Van Hare GF, Walsh EP. Radiofrequency catheter ablation for tachyarrhythmias in children and adolescents. The Pediatric Electrophysiology Society. N Engl J Med 1994; 330:1481-7. [PMID: 8164700 DOI: 10.1056/nejm199405263302103] [Citation(s) in RCA: 295] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Although radiofrequency catheter ablation has been used extensively to treat refractory supraventricular tachycardia in adults, few data are available on its safety and efficacy in children and adolescents. We reviewed registry data obtained from 24 centers to evaluate the indications, early results, complications, and short-term follow-up data in young patients who underwent this procedure. METHODS Standardized data were submitted for 652 patients who underwent 725 procedures between January 1, 1991, and September 1, 1992. The mean length of follow-up was 13.5 months. RESULTS The median age of the patients was 13.5 years, and 84 percent of them had structurally normal hearts. The initial success rates for ablation of atrioventricular accessory pathways (508 of 615 procedures) and atrioventricular-node reentry (63 of 76 procedures) were both 83 percent. Greater institutional experience in performing ablation in children and location of the accessory pathway in the left free wall correlated with greater likelihood of sustained success. Conversely, a right free-wall pathway, the presence of other heart disease, and higher body weight were all associated with a lesser chance of sustained success. Recurrences of arrhythmia accounted for 45 percent of the failures overall in the series. Atrial ectopic-focus tachycardia had the highest recurrence rate. The total complication rate was 4.8 percent (35 of 725 procedures), and the only variables that independently correlated with a higher complication rate were very low weight and less institutional experience. CONCLUSIONS These early results suggest that radio-frequency catheter ablation has a good success rate and a low complication rate in pediatric patients, especially when it is carried out in experienced pediatric cardiology centers.
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Affiliation(s)
- J D Kugler
- Section of Pediatric Cardiology, University of Nebraska Medical Center, Omaha, NE 68198-2166
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Friedman RA, O'Laughlin MP, Moak JP, Perry JC, Mullins CE, Garson A, Feltes TF. Successful closure of a previously unsuspected atrial septal defect by an implantable Clamshell device and subsequent transvenous pacemaker implantation. Tex Heart Inst J 1994; 21:161-5. [PMID: 8061541 PMCID: PMC325152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Implantation of transvenous leads for a permanent cardiac pacing system usually requires the absence of intracardiac shunts. We report the case of an asymptomatic atrial septal defect in an 11-year-old boy who required permanent pacing. We implanted an atrial septal defect closure (Clamshell) device prior to implantation of transvenous leads. This new device makes transvenous implantation possible and may reduce the risk of stroke in patients with these anomalies.
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Affiliation(s)
- R A Friedman
- Lillie Frank Abercrombie Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Texas 77030
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Abstract
When the QT interval is prolonged in a patient with structural heart disease, there is a question of whether the QT interval prolongation is the result of coexistent long QT interval syndrome or ventricular hypertrophy. The purpose of this study was to assess whether QT interval prolongation can be attributed to ventricular hypertrophy/dilation alone. Electrocardiograms (ECGs) of 25 children in each of six echocardiographically proven groups (right ventricular hypertrophy, left ventricular hypertrophy, biventricular hypertrophy, hypertrophic cardiomyopathy, dilated cardiomyopathy, and normals) were analyzed. All patients had QRS interval durations < 100 msec, and patients with ventriculotomies were excluded. No patients in the normal group had a QTc interval > or = 0.45 sec. Eight (32%) of 25 patients with dilated cardiomyopathy had a QTc interval > or = 0.45 sec (p = 0.007 vs normal), 6 (24%) of 25 patients with hypertrophic cardiomyopathy had a QTc interval > or = 0.45 sec (p = 0.03 vs normal), and 2 of 25 patients each with right ventricular hypertrophy, left ventricular hypertrophy, and biventricular hypertrophy had a QTc interval > or = 0.45 sec (p = NS vs normal). There was no relation of the QTc interval to age, QRS duration, T-wave axis, or heart rate in any group. In the dilated cardiomyopathy group, there was no relationship of QTc interval to age, shortening fraction, or left ventricular end diastolic dimension. In conclusion, (1) a significant number of patients (24% to 32%) with dilated or hypertrophic cardiomyopathy may have a long QTc interval on the surface ECG, and (2) ventricular hypertrophy/dilation may be additional rare causes of acquired prolongation of the QT interval.
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Affiliation(s)
- A B Martin
- Lillie Frank Abercrombie Section of Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston
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