On the stability of Hamiltonian systems with weakly time dependent potentials

We show here that a recently developed criterion for the stability of conservative Hamiltonian systems can be extended to Hamiltonians with weak time dependence. In this method, the geodesic equations contain the Hamilton equations of the original potential model through an inverse map in the tangent space in terms of a geometric embedding. The second covariant derivative of the geodesic deviation generates a dynamical curvature, resulting in a (energy dependent) local criterion for unstable behavior different from the usual Lyapunov criterion. We show by direct simulation that our geometrical criterion predicts correctly the stability/instability of motions, sometimes contrary to indications of the local Lyapunov method.

Narcissistic leadership in psychotherapy groups

Narcissistic leaders in groups are capable of impeding progress of their patients and, at worst, can produce iatrogenic effects. Significant interferences may occur when the therapist is unable to tolerate the expression of negative transferences and when they need to be idealized by their patients. The rare therapist who is a malignant narcissist is capable of inflicting severe damage by sadistically exploiting the group to satisfy his or her own pathological needs. Less severe interferences consist of inhibition in making transference interpretations, reluctance to seek out training or supervision, and a difficulty in protecting patients against being scapegoated as a result of the displacement of negative feelings toward the therapist onto a member. The universality of these issues among therapists is discussed and possible remediation is proposed.

C6 produced by macrophages contributes to cardiac allograft rejection

The terminal components of complement C5b-C9 can cause significant injury to cardiac allografts. Using C6-deficient rats, we have found that the rejection of major histocompatibility (MHC) class I-incompatible PVG.R8 (RT1.A(a)B(u)) cardiac allografts by PVG.1U (RT1.A(u)B(u)) recipients is particularly dependent on C6. This model was selected to determine whether tissue injury results from C6 produced by macrophages, which are a conspicuous component of infiltrates in rejecting transplants. We demonstrated that high levels of C6 mRNA are expressed in isolated populations of macrophages. The relevance of macrophage-produced C6 to cardiac allograft injury was investigated by transplanting hearts from PVG. R8 (C6-) donors to PVG.1U (C6-) rats which had been reconstituted with bone marrow from PVG.1U (C6+) rats as the sole source of C6. Hearts grafted to hosts after C6 reconstitution by bone marrow transplantation underwent rejection characterized by deposition of IgG and complement on the vascular endothelium together with extensive intravascular aggregates of P-selectin-positive platelets. At the time of acute rejection, the cardiac allografts contained extensive perivascular and interstitial macrophage infiltrates. RT-PCR and in situ hybridization demonstrated high levels of C6 mRNA in the macrophage-laden transplants. C6 protein levels were also increased in the circulation during rejection. To determine the relative contribution to cardiac allograft rejection of the low levels of circulating C6 produced systemically by macrophages, C6 containing serum was passively transferred to PVG.1U (C6-) recipients of PVG.R8 (C6-) hearts. This reconstituted the C6 levels to about 3 to 6% of normal values, but failed to induce allograft rejection. In control PVG.1U (C6-) recipients that were reconstituted with bone marrow from PVG.1U (C6-) donors, C6 levels remained undetectable and PVG.R8 cardiac allografts were not rejected. These results indicate that C6 produced by macrophages can cause significant tissue damage.

The utility of quantitative body surface isoarea mapping for predicting ventricular tachyarrhythmias

Noninvasive techniques, such as the signal averaged ECG, have been used to assess risk of ventricular tachyarrhythmias (VT). However, these methods produce false positive and negative results. The purpose of this study was to develop body surface map algorithms which would enhance prediction of susceptibility to VT. Fifty-three patients referred for programmed electrical stimulation were enrolled in this study. All patients underwent signal averaged ECG, body surface map, programmed electrical stimulation. Group I patients had no sustained inducible VT and group II patients had either inducible sustained VT at electrophysiology study or previously documented spontaneous, sustained VT. For body surface map analysis, the difference between extrema on isoarea maps was calculated and defined as the gradient range. An abnormal body surface map was defined as a QRST gradient range < or = 109 mv.ms. The mean QRST gradient range in group II was significantly < that in group I (P < 0.05). By logistic regression analysis, the presence of coronary artery disease, a QRST gradient range < or = 109 mv.ms, an EF < 40% and a signal averaged ECG QRS duration > 114 ms predicted VT. The sensitivity, specificity, positive and negative predictive values for predicting VT susceptibility of an algorithm which combines the signal averaged ECG QRS duration and the QRST gradients were 0.93, 0.76, 0.79, and 0.91, respectively, while those for the signal averaged ECG alone were 0.52, 0.69, 0.63, and 0.59 for VT susceptibility. A combined body surface map-signal averaged ECG algorithm was more sensitive in detecting susceptibility to VT than the signal averaged ECG alone.

A noble profession

Organized psychoanalysis has now achieved an era of openness to new ideas and change, and the result has been an exciting ferment in both theory and technique. Most recently, the field has focused on "intersubjectivity," the study of how the therapist's personality acts and reacts with that of the patient. Despite the subjectivities inherent in the process of treatment, there is good justification for viewing the field as an empirical discipline, indeed a science, because the multiple inputs by practitioners contributing to the literature, debating on panels, and critically assessing new contributions result in a gradual approach to truth and validity. This hermeneutic approach is not sufficient in itself and in no way contradicts the need for other, more controlled, research approaches.

Promiscuous recognition of major histocompatibility complex class II determinants in cyclosporine-induced syngeneic graft-versus-host disease: specificity of cytolytic effector T cells

BACKGROUND

Administration of the immunosuppressive drug cyclosporine after syngeneic/autologous bone marrow transplantation paradoxically elicits a systemic autoimmune syndrome resembling graft-versus-host disease (GVHD). This syndrome, termed autologous or syngeneic GVHD, is associated with the development of a highly restricted repertoire of cytolytic T lymphocytes that promiscuously recognizes major histocompatibility complex class II determinants, including self.

METHODS

Vbeta8.5+CD8+ effector lymphocytes and T-cell clones were isolated from Lewis rats with cylosporine-induced syngeneic GVHD. The specificity of the effector T cells and T-cell clones was examined in vitro. The pathogenicity of the T-cell clones was confirmed in vivo using a local graft-versus-host reaction assay.

RESULTS

Clonal analysis reveals that the pathogenic effector T cells recognize a peptide from the invariant chain termed CLIP in association with major histocompatibility complex class II determinants. Moreover, there appears to be an additional interaction between the N-terminal flanking region of CLIP and the Vbeta segment of the T cell receptor.

CONCLUSION

The results suggest that recognition of this highly conserved peptide along with the additional interaction between the flanking region and the T cell receptor may account for the promiscuous activity of the autologous/syngeneic GVHD autoreactive T cells.

Prevention of coronary vascular abnormalities early in reperfusion with TGF-beta may not prevent late coronary vascular injury

Endothelial injury, manifest by increased protein leak and decreased endothelium-dependent relaxation, occurs during reperfusion after ischemia. Transforming growth factor-beta (TGF-beta) has been shown to improve endothelium-dependent relaxation and reduce infarct size after short periods (from 20 min to 4.5 h) of reperfusion even when administered 24 h before the ischemic period. However, whether this represents a transient delay in the process leading to endothelial injury or prevention of injury has not been clear. To examine this issue, we measured protein leak, an index of coronary microvascular permeability, and endothelium-dependent relaxation, a measure of coronary endothelial function, after brief (1-h) and lengthy (48-h) reperfusion periods in dogs treated 30 min before ischemia with TGF-beta (30 microg/kg, i.v.) and control dogs. The left anterior descending coronary artery (LAD) was ligated for 1 h followed by 1 h of reperfusion (n = 10) or 48 h of reperfusion (n = 12). Protein leak was assessed by a dual-isotope technique by using radiolabeled transferrin and erythrocytes, and endothelium-dependent relaxation was assessed in epicardial coronary rings by using adenosine diphosphate (ADP), an endothelium-dependent vasodilator, and sodium nitroprusside (SNP), an endothelium-independent dilator. In control animals, there was a marked increase in the protein leak index (PLI) in the infarct zone (8.3 +/- 1.4 in 1-h dogs, and 8.7 +/- 0.9 in 48-h dogs) compared with the nonischemic myocardium (3.1 +/- 0.8 at 1 h, and 3.8 +/- 0.9 at 48 h). In TGF-beta treated dogs, there was a marked improvement in PLI in the infarct zone in 1-h dogs (PLI, 4.1 +/- 1.1; p < 0.05; or a 50% reduction compared with untreated dogs). However, the 48-h dogs treated with TGF-beta failed to demonstrate an improvement in PLI (PLI, 8.5 +/- 0.9; p = NS). Endothelium-dependent relaxation was impaired in the LAD in control dogs, and treatment with TGF-beta failed to improve relaxation after 1 or 48 h of reperfusion. Microvascular permeability was increased and endothelium-dependent relaxation was decreased after ischemia at both 1 and 48 h of reperfusion. Pretreatment with TGF-beta reduced the increase in permeability at 1 h of reperfusion but not at 48 h.

Development of an interactive computer-guided method for radiofrequency catheter ablation of ventricular tachycardia

The purpose of this study was to develop a simple computer-guided approach to localizing ventricular tachycardias during ventricular mapping. Six patients with sustained monomorphic ventricular tachycardia were connected to a 32-lead computer body surface mapping system. Isoarea maps of induced ventricular tachycardia were recorded. Then a pacing probe was placed in either the right or left ventricle, and maps were generated from a variety of sites. Differences between ventricular tachycardia and pace map maxima X, Y coordinates were utilized to guide catheter manipulation and localization. In 6 of 6 patients (100%) this method appeared to provide a systematic approach to ventricular tachycardia localization. Computer-generated correlations as well as the X, Y coordinates of the QRS isoarea maxima were used to determine proximity to the ventricular tachycardia foci and direct catheter manipulation. In the next three patients this method was applied prospectively to help guide catheter manipulation during ventricular tachycardia (two right ventricular outflow tract tachycardias, and one left ventricular tachycardia). After a mean of 4.0 +/- 1.7 radiofrequency applications, ventricular tachycardia was no longer inducible, and at 7 +/- 0 months follow-up there have been no arrhythmia recurrences. We conclude that online computerized body surface mapping can assist in localizing ventricular tachycardia. Differences in maxima during pace maps and in-situ ventricular tachycardias can help with catheter manipulation as well as with more precise identification of focal tachycardias. This technique appears to hold the promise of a simple computer-guided method that may facilitate radiofrequency catheter ablation.

Tailoring the psychotherapy to the borderline patient

Views still differ as to the optimal psychodynamic treatment of borderline patients. Recommendations range from psychoanalysis and exploratory psychotherapy to an explicitly supportive treatment aimed at strengthening adaptive defenses. The authors contend that no single approach is appropriate for all patients in this wide-ranging diagnostic category, which spans a continuum from close-to-neurotic to close-to-psychotic levels of functioning. Careful differentiations based on developmental considerations, ego structures, and relationship patterns provide the basis for the optimal treatment approach.

Utility of QT dispersion combined with the signal-averaged electrocardiogram in detecting patients susceptible to ventricular tachyarrhythmia

A simple algorithm that combines QT dispersion with the signal-averaged electrocardiogram QRS duration provides an extremely sensitive method for predicting spontaneous or inducible ventricular tachyarrhythmias. This new algorithm may prove useful in determining which patients are at risk for ventricular tachyarrhythmia.

The role of cyclosporine-induced autoreactive T lymphocytes in solid organ allograft survival and chronic rejection

Cyclosporine (CsA) has profound but paradoxical effects on the immune system. CsA can facilitate the induction of transplantation tolerance in some animal systems but it inhibits the clonal deletion of MHC class II autoreactive T cells. The present studies evaluated whether the autoreactive T cells participate in the induction of facilitated graft acceptance after CsA treatment by recognizing and eliminating activated allograft responsive T cells that express MHC class II determinants. Transfer of autoreactive T cells into naive Lewis rats pretreated with cyclophosphamide significantly prolonged the survival of heterotopic cardiac allografts from MHC-disparate BN strain donors. Following transfer of the autoreactive T cells, there was a marked reduction in the frequency of alloreactive T lymphocytes responsive to donor alloantigens. The role of MHC class II autoreactive CD8+ V beta 8.5+ T cells in facilitated graft acceptance was also supported by the findings that (1) treatment with anti-MHC class II antibody abrogated prolonged allograft survival after CsA therapy and (2) V beta 8.5+ lymphocytes infiltrate the allograft during CsA therapy but are absent in the graft in non-CsA-treated control animals. Although these data are consistent with the hypothesis that autoreactive T cells prolong cardiac allograft survival after CsA treatment, the autoaggressive cells failed to inhibit the development of chronic rejection of both heart and skin allografts. These data suggest either that the autoreactive T cells do not inhibit immune mechanisms responsible for chronic graft rejection or that the autoaggressive lymphocytes may participate in and exacerbate chronic rejection of allografts. Taken together, the induction of MHC class II autoreactive T cells may provide a common fundamental mechanism explaining the paradoxical effects of CsA.

Transference interpretation in the psychotherapy of borderline patients: a high-risk, high-gain phenomenon

The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact--both positive and negative--than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclitic rather than introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapist's difficulty in shifting to a more supportive approach when indicated.

Depth of transference in groups

An ongoing controversy in the field of group psychotherapy is whether transference regression is greater in groups than in individual treatment. There appears to be a general consensus that group behavior may be understood as operating on at least three levels--the conscious--rational, the oedipally determined transference, and the preoedipal maternal transference level. The more rational levels are associated with transference dilution, whereas the more primitive levels accompany transference intensification. Dilution occurs as a result of reality demands and inputs of the group situation and because of multiple targets of displacement. Transference intensification is a product of mutual stimulation, contagion effect, frustrating inputs, and support of the group theme. Certain patients benefit most from the dilution features of a group, and others profit most from intensification. The therapist's technique and the patient's pathology are the main determinants of which aspect gets emphasized and utilized.

Characterization of peripheral autoregulatory mechanisms that prevent development of cyclosporin-induced syngeneic graft-versus-host disease

Administration of cyclosporin after syngeneic bone marrow transplantation paradoxically elicits a T lymphocyte-dependent autoaggression syndrome termed syngeneic graft-vs-host disease (SGVHD). The induction of SGVHD requires two essential components, the emergence of autoreactive lymphocytes from the thymus and the elimination of a T cell-dependent peripheral autoregulatory mechanism. These studies used the SGVHD model to further characterize this regulatory system that modifies the autoimmune potential of autoreactive effector cells. Our studies reveal that although cyclosporin did not interfere with the effector function of the autoregulatory T cells, it prevented the reconstitution of the regulatory system after syngeneic bone marrow transplantation. Furthermore, the autoregulation of SGVHD is a dynamic process specifically recognizing and responding to the autoreactive SGVHD effector cells. Challenge or priming of normal Lewis rats by intravenous infusion of irradiated SGVHD effector cells activates and amplifies this autoregulatory system resulting in: 1) a threefold enhancement of autoregulatory T cell function, 2) the appearance of a dominant autoregulatory T cell population belonging to the CD4+ T helper lymphocyte subset, and 3) the capacity of irradiated primed autoregulatory T cells to inactivate SGVHD effector lymphocytes in vitro. Additional studies reveal that effective autoregulation required a specific interaction of the TCR-alpha/beta on the autoregulatory cells with the MHC class II determinants on the autoreactive lymphocytes.

Characterization of peripheral autoregulatory mechanisms that prevent development of cyclosporin-induced syngeneic graft-versus-host disease

Administration of cyclosporin after syngeneic bone marrow transplantation paradoxically elicits a T lymphocyte-dependent autoaggression syndrome termed syngeneic graft-vs-host disease (SGVHD). The induction of SGVHD requires two essential components, the emergence of autoreactive lymphocytes from the thymus and the elimination of a T cell-dependent peripheral autoregulatory mechanism. These studies used the SGVHD model to further characterize this regulatory system that modifies the autoimmune potential of autoreactive effector cells. Our studies reveal that although cyclosporin did not interfere with the effector function of the autoregulatory T cells, it prevented the reconstitution of the regulatory system after syngeneic bone marrow transplantation. Furthermore, the autoregulation of SGVHD is a dynamic process specifically recognizing and responding to the autoreactive SGVHD effector cells. Challenge or priming of normal Lewis rats by intravenous infusion of irradiated SGVHD effector cells activates and amplifies this autoregulatory system resulting in: 1) a threefold enhancement of autoregulatory T cell function, 2) the appearance of a dominant autoregulatory T cell population belonging to the CD4+ T helper lymphocyte subset, and 3) the capacity of irradiated primed autoregulatory T cells to inactivate SGVHD effector lymphocytes in vitro. Additional studies reveal that effective autoregulation required a specific interaction of the TCR-alpha/beta on the autoregulatory cells with the MHC class II determinants on the autoreactive lymphocytes.

Interferon-γ Potentiates the Antitumor Effect of Cyclosporine-Induced Autoimmunity

Graft-versus-host-disease (GVHD), which results after allogeneic bone marrow transplantation (BMT), is associated with reduced leukemic relapse. This may be mediated by an immunologic attack with subsequent destruction of residual tumor cells. On the other hand, GVHD does not normally occur after autologous BMT (ABMT), which has an inherently high relapse rate. However, an autoimmune syndrome (AIS) similar to GVHD can be induced after autologous/syngeneic BMT by administration of cyclosporine-A (CsA), resulting in the production of major histocompatibility complex (MHC) class II or Ia autoreactive cytolytic effector cells. Since many hematopoietic malignancies express variable levels of class II molecules, we hypothesized that the adjuvant use of interferon-gamma (IFN-gamma) with CsA-induced autoimmunity after autologous/syngeneic BMT may upregulate class II antigens on residual tumor cells and make them more susceptible to attack by the Ia-reactive cells of CsA-induced AIS. The present studies demonstrated that the CsA-induced autoimmune syndrome mediated an anti-tumor effect, although this effect was dependent on challenge with a minimal number of tumor cells. Further studies clearly demonstrated that the antitumor effect could be markedly enhanced by administration of IFN-gamma which increased the susceptibility of the tumor to recognition and lysis by the CsA induced autoimmune effector cells. The induction of MHC class II-restricted AIS similar to GVHD by administration of CsA together with the ability to manipulate the surface phenotype of residual tumor cells may lead to decreased relapse rates in the ABMT setting.

Effect of cyclosporine on T lymphocyte development. Relationship to syngeneic graft-versus-host disease

This report investigates the effects of cyclosporine on the reconstitution of T lymphocytes after syngeneic bone marrow transplantation and its role in the development of a novel T cell-mediated autoimmune disease, syngeneic graft versus host disease. We analyzed the effect of CsA treatment on T lymphocyte differentiation during reconstitution after bone marrow transplantation and correlated the maturation of CD4+ and CD8+ T cell subsets with the onset of syngeneic GVHD. Administration of CsA following syngeneic bone marrow transplantation leads to a developmental arrest of mature CD4+ and CD8+ T lymphocytes in the thymus and a marked reduction in cells expressing the alpha beta T cell receptor. The reduction of CD4+ and CD8+ T cell subsets is also reflected in the peripheral lymphoid compartment with an altered CD4/CD8 ratio. Functional assessment of the cells revealed that CD8+ cells respond normally to mitogenic signalling whereas CD4+ cells exhibit marginal proliferative responses. Both subsets of T lymphocytes respond to syngeneic B lymphoblasts, comparable to the response of T lymphocytes from non-CsA-treated syngeneic BMT recipients, suggesting that autoreactive cells are produced despite CsA treatment. Following discontinuation of CsA, T cell differentiation in the thymus is rapidly restored to normal. However, concurrent with the onset of syngeneic GVHD, a compensatory insurgence of CD4+ T helper cells is observed.

Host resistance to cyclosporine induced syngeneic graft-versus-host disease. Requirement for two distinct lymphocyte subsets

Cyclosporine is crucial for the prevention of organ allograft rejection and allogeneic graft-vs-host disease (GVHD). Despite its potent immunosuppressive activity, cyclosporine elicits a T cell-mediated autoimmune syndrome after autologous or syngeneic bone marrow transplantation, which has been termed syngeneic GVHD (SGVHD). Recent studies have shown that for disease manifestation, a cytoxan and radiation-sensitive T cell dependent host resistance mechanism must be eliminated, allowing the clonal expansion of autoreactive cells. This report characterizes the autoregulatory lymphocyte population, present in normal animals, capable of inhibiting the adoptive transfer of SGVHD. First, twice the number of unfractionated splenocytes from normal animals to those from autoimmune donors ensured complete inhibition of the adoptive transfer of immune reactivity. Second, the phenotype of this host resistance mechanism in normal splenocytes involves dual regulatory T cell subsets. A helper/inducer subset (W3/25+) must be cotransferred with a cytotoxic/suppressor subset (OX8+) in a ratio that approximates the normal ratio in normal unfractionated splenocytes in order to affect inhibition of the transfer of SGVHD. Moreover the specific inducer regulatory activity resides in the OX22-, W3/25+ subset of Th cells.

Host resistance to cyclosporine induced syngeneic graft-versus-host disease. Requirement for two distinct lymphocyte subsets

Cyclosporine is crucial for the prevention of organ allograft rejection and allogeneic graft-vs-host disease (GVHD). Despite its potent immunosuppressive activity, cyclosporine elicits a T cell-mediated autoimmune syndrome after autologous or syngeneic bone marrow transplantation, which has been termed syngeneic GVHD (SGVHD). Recent studies have shown that for disease manifestation, a cytoxan and radiation-sensitive T cell dependent host resistance mechanism must be eliminated, allowing the clonal expansion of autoreactive cells. This report characterizes the autoregulatory lymphocyte population, present in normal animals, capable of inhibiting the adoptive transfer of SGVHD. First, twice the number of unfractionated splenocytes from normal animals to those from autoimmune donors ensured complete inhibition of the adoptive transfer of immune reactivity. Second, the phenotype of this host resistance mechanism in normal splenocytes involves dual regulatory T cell subsets. A helper/inducer subset (W3/25+) must be cotransferred with a cytotoxic/suppressor subset (OX8+) in a ratio that approximates the normal ratio in normal unfractionated splenocytes in order to affect inhibition of the transfer of SGVHD. Moreover the specific inducer regulatory activity resides in the OX22-, W3/25+ subset of Th cells.

A comparison of marrow transplantation with chemotherapy for adults with acute leukemia of poor prognosis in first complete remission

From July 1980 to November 1985, 109 patients with acute myelogenous and lymphoblastic leukemia who had reached a complete remission (CR) following induction treatment were assigned to a study comparing marrow transplantation with chemotherapy as a postremission treatment. Sixty-nine patients did not have a human leukocyte antigen (HLA)-identical donor, and therefore served as chemotherapy controls; 40 patients had HLA-identical donors, and therefore were assigned to the transplant arm. Of these, 23 were transplanted in first remission and 17 were not. Ten of these 17 were subsequently transplanted in relapse. Initially, only patients with poor prognosis determined by a predictive model were entered into the study. Subsequently, patients with moderately poor prognosis were admitted. Comparing the chemotherapy group with the patients transplanted in first CR, significant control of leukemia relapse in transplanted patients was seen in the subgroup with acute myelogenous leukemia (AML) (P less than .1), and acute lymphoblastic leukemia (ALL) (P less than .01), in the poor (P = .01) and intermediate subgroup (P = .01), and in the good-prognostic groups (P = .05). The survival was affected significantly in only the poor and intermediate subgroups. The use of predictive models might help to select patients for whom bone marrow transplantation is appropriate in first remission and those for whom bone marrow transplantation can be left as the initial treatment of relapse. Predictive models could further be helpful in comparing studies performed at different transplant centers.

The effect of therapist interventions on the therapeutic alliance with borderline patients

The authors draw attention to the problems of establishing and maintaining a therapeutic alliance in the psychotherapy of the borderline patient. They elaborate an extensive methodology designed to study the manner in which shifts in collaboration occur in response to therapist interventions. This report demonstrates how one particular borderline patient increased his ability to collaborate with the therapist in response to a transference focus in the psychotherapy. Methodological problems are noted as are directions for future research. Only a series of patients studied with this or with similar methodology will allow for a sophisticated and empirical rationale for choosing a particular form of psychotherapy for a particular kind of borderline patient.

Enhanced antiarrhythmic efficacy of propafenone when used in combination with procainamide or quinidine

This study evaluated the efficacy and safety of combining propafenone with procainamide or quinidine for treating ventricular arrhythmias in patients in whom procainamide or quinidine therapy alone failed to suppress arrhythmias. In 30 patients, the addition of propafenone resulted in a significant reduction of premature ventricular contraction (PVC) frequency compared to drug-free baseline (406 PVC/hr vs 33, p less than 0.001) and to procainamide or quinidine monotherapy (211 PVC/hr vs 27, p less than 0.01). Propafenone alone was also more effective than either procainamide or quinidine and resulted in significant suppression of PVC compared to the drug-free state (406 PVC/hr vs 38, p less than 0.001). However, higher propafenone doses were necessary during monotherapy as compared to propafenone therapy combined with procainamide or quinidine (730 mg/day vs 480 mg/day, p less than 0.001). Of the 30 patients, 22 required an increase in propafenone dose during monotherapy as compared to combination therapy. Thus, propafenone is an effective antiarrhythmic agent when used in combination with type IA antiarrhythmic drugs. With these combinations, lower doses of propafenone can be utilized effectively than with propafenone alone.

High-dose chemoradiotherapy and autologous bone marrow transplantation for resistant multiple myeloma

Seven patients with advanced multiple myeloma, refractory to therapy with alkylating agent-VAD (vincristine-adriamycin-dexamethasone), received a regimen combining high-dose melphalan with total body irradiation supported by autologous bone marrow transplantation. Very rapid, usually greater than 90% tumor mass reduction was achieved in six patients, regardless of prior chemotherapy responsiveness and marrow plasmacytosis up to 30%. Despite signs of early relapse in three patients (median remission duration of all patients, 15 months), five remain alive and well without further cytotoxic therapy from 2 to 21 months (median, 9+ months). Two patients died, one from surgical complications after transplantation and a second due to persistent neutropenia with fatal pneumonia. This treatment provides meaningful disease control for selected patients with resistant myeloma and a poor prognosis.

High dose cyclophosphamide, BCNU, and VP-16 (CBV) as a conditioning regimen for allogeneic bone marrow transplantation for patients with acute leukemia

A high dose combination chemotherapy regimen (CBV) consisting of cyclophosphamide (1.5 gm/m2 day 1 to day 4); BCNU (300 mg/m2 day 1) and etoposide (100 mg/m2 every 12 hours for 6 doses), followed by bone marrow transplant from human leukocyte antigen (HLA) identical sibling donors, was evaluated in 29 patients in whom acute leukemia was in relapse or remission. Engraftment of donor cell type occurred in all but one of 21 patients, in whom marker differences between donor and recipient were established. Two of 11 patients transplanted during relapse of the disease, lived beyond 1 year after bone marrow transplantation. One patient died free of leukemia, 41 months after transplantation of meningitis. Two of seven patients transplanted during the second remission of the disease, are alive and free of leukemia at 42+, and 8+ months. All patients transplanted during the third or fourth remission of the disease have died from either a further relapse, or transplant related causes. The low incidence of organ toxicity with CBV allows for further dose escalation of its drug components.

High-dose melphalan and total body irradiation with bone marrow transplantation for refractory malignancies

We investigated if high dose melphalan and total body irradiation could be administered to adult patients with acceptable toxicity. Nineteen adult patients with relapsed disease, 15 of them having hematologic malignancies, were treated with high-dose melphalan (100 mg/m2-140 mg/m2) divided over 2 consecutive days followed by a rest period of 4 days before receiving total body irradiation, 850 rad administered in five fractionated doses over 3 days. Subsequently 11 patients received autologous, seven allogeneic and one syngeneic, bone marrow transplantation. All patients had severe myelosuppression and the major extramedullary toxicity was mucositis. There were three early deaths, two related to septicemia and one to graft-versus-host disease with associated cytomegalovirus pneumonitis. All patients were heavily pretreated, and 16 were demonstrating progressive disease on alternative salvage therapies at the time of bone marrow transplantation. Two of the 16 evaluable patients (12.5%) achieved complete remissions, and 10 (63%) achieved partial remissions for a total response rate of 75%. One patient is a long-term disease-free survivor (over 1 yr). An occasional patient may be cured by this approach. The combination of melphalan, an alternative alkylating agent to cyclophosphamide and total body irradiation are associated with moderate gastrointestinal toxicity in heavily pretreated adult patients. The combination warrants further investigation in a less heavily pretreated population to determine more accurately the complete response rate.

Development of graft-vs.-host disease-like syndrome in cyclosporine-treated rats after syngeneic bone marrow transplantation. I. Development of cytotoxic T lymphocytes with apparent polyclonal anti-Ia specificity, including autoreactivity

Lethally irradiated rats reconstituted with syngeneic bone marrow and treated with cyclosporine (CsA) for 40 d develop a graft-vs.-host disease-like syndrome (GVHD) after CsA therapy. We attempted to assess the development of autoreactivity in these animals. Results revealed that a majority of the animals with syngeneic GVHD develop autocytotoxic T lymphocytes of the OX8 phenotype. In addition to reactivity with self, these cells were capable of lysing appropriate target cells from a variety of different rat strains. The target antigens appeared to be class II major histocompatibility antigens, because lysis could be effectively blocked by an anti-Ia monoclonal antibody. Cold target inhibition studies indicated that one effector cell was capable of lysing various target cells, and provided evidence against a polyclonal activation of multiple anti-Ia-reactive cells. These results suggested that the anti-class II autoreactive cell associated with syngeneic GVHD either recognizes a common class II determinant ("public" epitope) shared by multiple strains of rats, or was polyspecific with respect to "private" class II determinants.

"PALS for life!" A required trauma-oriented pediatric advanced life support course for pediatric and emergency medicine housestaff

While advanced cardiac life support (ACLS) and advanced trauma life support (ATLS) courses have become accepted standards for physicians who care for the critically ill and injured patient, only recently have pediatric advanced life support (PALS) courses been developed. The American Academy of Pediatrics has shown renewed interest in pediatric cardiopulmonary arrest after impressive gains made in adult resuscitation. The American Heart Association filled a void by including new chapters on Pediatric and Neonatal Resuscitation in the Textbook of Advanced Cardiac Life Support, 1981. A joint committee of AHA and AAP is seeking to unify course objectives and materials for standard curriculum. Because trauma is the most common cause of death and disability in children, pediatric trauma life support measures should be incorporated into any program directed toward emergency physicians and pediatricians who function in an emergency department or rural primary care setting. The Department of Pediatrics and Surgery and its division of Emergency Medicine has developed and implemented a PALS curriculum which is different from most other programs in that emphasis has been placed on pediatric trauma in addition to traditional cardiac (ACLS) resuscitation. This 20-hour program combines a modified ACLS curriculum with specific pediatric trauma lectures and laboratory sessions. It includes a canine surgical procedure lab and modified ATLS skill stations. At the completion of the course, students are eligible for ACLS certification. In the two years in which the course was given, 39 pediatric houseofficers were enrolled in the course.(ABSTRACT TRUNCATED AT 250 WORDS)

Bystander CPR in prehospital coarse ventricular fibrillation

Prehospital bystander cardiopulmonary resuscitation (CPR) was studied to determine if it affected the outcome of defibrillation. Four hundred twenty-one consecutive witnessed cardiopulmonary arrests presenting with the initial rhythm of coarse ventricular fibrillation treated by the Milwaukee County Paramedic System from January 1980 to June 1982 were analyzed. Pediatric, trauma, and poisoning patients and those receiving intravenous or endotracheal medications before defibrillation (58) were excluded. Immediate professional bystander CPR (physician, nurse, EMT) and citizen bystander CPR were compared to a control group receiving no bystander CPR until arrival of EMS personnel. A successful defibrillation occurred if defibrillation prior to administration of medication produced an effective cardiac rhythm with pulses. Eighty-eight of the 363 remaining patients (24%) converted with initial defibrillations. While the group receiving professional bystander CPR had a higher successful defibrillation rate than did the no-CPR group (35% vs 22%, P less than .04), citizen bystander CPR and no-CPR groups had similar successful defibrillation rates (24% vs 22%, no significant difference). One hundred eighty-six of the 363 patients (51%) were transported to a hospital with a rhythm and a pulse (a successful resuscitation). Ninety-seven of the 363 patients (27%) were discharged alive from the hospital (a save). Patients who were converted successfully using initial "quick-look" defibrillations were far more likely to be successfully resuscitated (79/88 [90%] vs 107/275 [39%], P greater than .0001) and to be discharged alive from the hospital (54/88 [61%] vs 43/275 [16%], P greater than .0001) than were those who required further advanced cardiac life support techniques.(ABSTRACT TRUNCATED AT 250 WORDS)

The precordial thump

The American Heart Association (AHA) currently recommends the precordial thump as the initial maneuver in treatment of ventricular tachycardia (VT) and monitored ventricular fibrillation (VF). These recommendations are based largely on anecdotal reports of successful "thump-version" of asystole, VF, and VT. The Milwaukee County Paramedic System follows the AHA guidelines in the treatment of VT and VF. The precordial thump is included in the advanced cardiac life support (ACLS) paramedic training program, and has been used in our approach to the pulseless, nonbreathing patient. During an eight-month period, 50 pulseless, nonbreathing patients received precordial thumps during ACLS resuscitative attempts. Twenty-seven patients who developed monitored VT and 23 patients with monitored VF were thumped. Three of 27 patients (11%) with VT were thumped into a supraventricular rhythm, 12 of 27 patients (44%) remained in VT, and 12 of 27 patients were thumped from VT into more malignant rhythms: three, into asystole; eight, into VF; and one, into an idioventricular/electromechanical dissociation rhythm. A total of 23 patients were thumped without effect. Subsequently, using countershock and medications, 12 of these 23 patients were successfully resuscitated. In the prehospital setting the precordial thump is usually not beneficial, and may be detrimental. Thus its use as the initial maneuver in treating the cardiac arrest patient with VT or VF in this setting cannot be supported. The presence of acidosis and hypoxia may explain why prehospital precordial thump responses differ from those seen in the hospital environment.

Cobra envenomation: an uncommon emergency

An unusual case involving a cobra snake envenomation is presented. The patient developed transient neurological sequelae during air evacuation to a regional trauma center and required endotracheal intubation. He developed a hypersensitivity reaction to cobra antivenin which responded to diphenhydramine. The bite wound became edematous and necrotic, but responded to conservative therapy. He was discharged on the fifth hospital day and did well.