Moments of tension and strain in psychotherapy and how they promote a good alliance and outcome

It is well established that the therapeutic relationship contributes about as much to therapy outcome as ‘technical’ intervention. Furthermore, it follows clear prescriptive concepts in the same manner as technical interventions do. ‘Motive Oriented Therapeutic Relationship’ is such a concept for establishing a solid basis for whatever therapeutic work the patients’ problems require (Grawe, 1980, 1992; Caspar, 1996). Yet, the therapeutic relationship doesn’t explain everything because other factors play a significant role too. Previous studies showed that outcome is clearly better when therapists achieved a generally high quality of a therapeutic relationship when they did not shy away from possibly threatening interventions such as confrontations. This ratio of a fruitful alliance and marginally present confrontations in the same session also showed significant correlations with patient’s assessment of alliance and progress in therapy (Figlioli et al., 2009). The current state of research in the field, however, does not give any answers to questions like how good and bad confrontations can be characterized or what role does the intensity, respectively frequency of confrontations play in the process of psychotherapy. Therefore, we analyzed a sample of 80 therapies of 3 sessions each representing either good or bad outcome. Independent raters judged moment by moment how therapists used confrontative interventions. 20 cases, which showed an excellent or a very poor outcome, as well as an unexpected pattern were analyzed in further quantitative details. We found that confrontations are correlated to good outcome when they are uttered implicitly, related to an important topic of the patient (e.g. one of the defined therapy goals), long but weak, embedded in prior complementarity and not in the first three sessions of a therapy, as well as not an interactional discrepancy between the patient and the therapist.

First outbreak of sleeping disease in Switzerland: disease signs and virus characterization.

Sleeping disease is a contagious disease mainly of freshwater farmed rainbow trout, caused by salmonid alphavirus (SAV) Subtype 2. Here we describe the first case in Switzerland. Pathological changes ranged from acute pancreas necrosis to more chronic lesions with complete loss of exocrine pancreas and simultaneous degenerative, inflammatory and regenerative heart and muscle lesions. The partial sequencing of SAV E2 and nsp3 genes placed the Swiss SAV variant within the Subtype 2 clustering together with freshwater isolates from UK and continental Europe. Although mortality stayed low, growth rates were significantly reduced, making the disease economically relevant.

A Possible Case of Möller-Barlow Disease in Northwestern Switzerland (7th Century)

The excavation site Reigoldswil is located at 550 m above sea level on the Jura chain hillside in north-western Switzerland. The mountains divide the Rhine valley from an agriculturally rich region. The origin of the village lies in the early medieval time. Until now the skeletons of one cemetery have been morphologically studied. Around 216 individuals were excavated from under the foundation walls of a church and in the open field. They date to the 7/8th up to the 10th century. The striking part is the high amount of subadult (0-18 years) individuals with 58% (n=126). One of these children, an approximately 1.5 year old toddler from the 7th century, was buried in a stone cist. Its bones show morphological traces like porotic lesions of the greater wings of the sphenoidale, the squama, the mandibule and the scapula as new bone formation on both femora and tibiae. These signs could be an indicator for Möller-Barlow disease (Ortner 2003, Brickley and Ives 2008, Stark in press). As scurvy is associated with an insufficient intake of vitamin C, malnutrition must be assumed. A reason might be the geographic location or/and a harsh climat with crop failure and famine the first settler had to face. Besides the morphological diagnose amino acids of the bone collagen have been analyzed (Kramis et. al.). Further examinations, such as radiocarbon dating and stable isotope ratios (C, N, O, S) to specify nutrition, are planned.

In vivo compatibility of Dynesys(®) spinal implants: a case series of five retrieved periprosthetic tissue samples and corresponding implants

PURPOSE To determine whether particulate debris is present in periprosthetic tissue from revised Dynesys(®) devices, and if present, elicits a biological tissue reaction. METHODS Five Dynesys(®) dynamic stabilization systems consisting of pedicle screws (Ti alloy), polycarbonate-urethane (PCU) spacers and a polyethylene-terephthalate (PET) cord were explanted for pain and screw loosening after a mean of 2.86 years (1.9-5.3 years). Optical microscopy and scanning electron microscopy were used to evaluate wear, deformation and surface damage, and attenuated total reflectance Fourier transform infrared spectroscopy to assess surface chemical composition of the spacers. Periprosthetic tissue morphology and wear debris were determined using light microscopy, and PCU and PET wear debris by polarized light microscopy. RESULTS All implants had surface damage on the PCU spacers consistent with scratches and plastic deformation; 3 of 5 exhibited abrasive wear zones. In addition to fraying of the outer fibers of the PET cords in five implants, one case also evidenced cord fracture. The pedicle screws were unremarkable. Patient periprosthetic tissues around the three implants with visible PCU damage contained wear debris and a corresponding macrophage infiltration. For the patient revised for cord fracture, the tissues also contained large wear particles (>10 μm) and giant cells. Tissues from the other two patients showed comparable morphologies consisting of dense fibrous tissue with no inflammation or wear debris. CONCLUSIONS This is the first study to evaluate wear accumulation and local tissue responses for explanted Dynesys(®) devices. Polymer wear debris and an associated foreign-body macrophage response were observed in three of five cases.

Predicting Psychotherapy Dropouts: A Multilevel Approach

The role of therapeutic processes in predicting premature termination of psychotherapy has been a particular focus of recent research. The purpose of this study was to contrast outpatients who completed therapy and those who dropped out with respect to their self-reported in-session experiences of self-esteem, mastery, clarification and the therapeutic alliance. The 296 patients with mixed disorders were treated with an integrative form of cognitive–behavioural therapy without pre-determined time limit (M = 20.2 sessions). Multilevel analyses indicated that patients who did not completetreatment reported, on average, lower levels of self-esteem, mastery and clarification and lower ratings of their therapeutic alliance in treatment in contrast to patients who completed therapy. Patient-reported change in self-esteem experiences over the course of treatment turned out to be the strongest predictor of dropout from psychotherapy or successful completion. When dropout occurred before the average treatment length was reached, patients reported fewer clarifying experiences as early as the first session and their ratings of the therapeutic alliance were characterized by an absence of positive development. Both of these aspects seem to be involved in patients' decisions to leave treatment early. The findings underscore the importance of the therapeutic process in understanding the mechanisms behind treatment dropout. Copyright © 2014 John Wiley & Sons, Ltd.

First report of a multidrug-resistant Klebsiella pneumoniae of sequence type 11 causing sepsis in a free-ranging beaver (Castor fiber).

Klebsiella pneumoniae of sequence type (ST) 11 is a hyper-epidemic nosocomial clone spreading worldwide among humans and also emerging in pets. In this report, we describe a clinical case of fatal sepsis due to this multidrug-resistant (MDR) pathogen in a Eurasian beaver. The isolate showed resistance to six different classes of antimicrobials including third generation cephalosporins and fluoroquinolones. This is the first report describing the detection of a MDR K. pneumoniae ST11 in a free-ranging animal. Our finding highlights the potential for environmental dissemination of hyper-epidemic clones of K. pneumoniae and possible spread in wildlife and cause epizootics.

The first batteryless, solar-powered cardiac pacemaker

BACKGROUND: Contemporary pacemakers (PMs) are powered by primary batteries with a limited energy-storing capacity. PM replacements because of battery depletion are common and unpleasant and bear the risk of complications. Batteryless PMs that harvest energy inside the body may overcome these limitations. OBJECTIVE: The goal of this study was to develop a batteryless PM powered by a solar module that converts transcutaneous light into electrical energy. METHODS: Ex vivo measurements were performed with solar modules placed under pig skin flaps exposed to different irradiation scenarios (direct sunlight, shade outdoors, and indoors). Subsequently, 2 sunlight-powered PMs featuring a 4.6-cm2 solar module were implanted in vivo in a pig. One prototype, equipped with an energy buffer, was run in darkness for several weeks to simulate a worst-case scenario. RESULTS: Ex vivo, median output power of the solar module was 1963 μW/cm2 (interquartile range [IQR] 1940-2107 μW/cm2) under direct sunlight exposure outdoors, 206 μW/cm2 (IQR 194-233 μW/cm2) in shade outdoors, and 4 μW/cm2 (IQR 3.6-4.3 μW/cm2) indoors (current PMs use approximately 10-20 μW). Median skin flap thickness was 4.8 mm. In vivo, prolonged SOO pacing was performed even with short irradiation periods. Our PM was able to pace continuously at a rate of 125 bpm (3.7 V at 0.6 ms) for 1½ months in darkness. CONCLUSION: Tomorrow's PMs might be batteryless and powered by sunlight. Because of the good skin penetrance of infrared light, a significant amount of energy can be harvested by a subcutaneous solar module even indoors. The use of an energy buffer allows periods of darkness to be overcome.

Biogeochemical indicators of peatland degradation – a case study of a temperate bog in Northern Germany

Organic soils in peatlands store a great proportion of the global soil carbon pool and can lose carbon via the atmosphere due to degradation. In Germany, most of the greenhouse gas (GHG) emissions from organic soils are attributed to sites managed as grassland. Here, we investigated a land use gradient from near-natural wetland (NW) to an extensively managed (GE) to an intensively managed grassland site (GI), all formed in the same bog complex in northern Germany. Vertical depth profiles of δ13C, δ15N, ash content, C / N ratio and bulk density as well as radiocarbon ages were studied to identify peat degradation and to calculate carbon loss. At all sites, including the near-natural site, δ13C depth profiles indicate aerobic decomposition in the upper horizons. Depth profiles of δ15N differed significantly between sites with increasing δ15N values in the top soil layers paralleling an increase in land use intensity owing to differences in peat decomposition and fertilizer application. At both grassland sites, the ash content peaked within the first centimetres. In the near-natural site, ash contents were highest in 10–60 cm depth. The ash profiles, not only at the managed grassland sites, but also at the near-natural site indicate that all sites were influenced by anthropogenic activities either currently or in the past, most likely due to drainage. Based on the enrichment of ash content and changes in bulk density, we calculated the total carbon loss from the sites since the peatland was influenced by anthropogenic activities. Carbon loss at the sites increased in the following order: NW < GE < GI. Radiocarbon ages of peat in the topsoil of GE and GI were hundreds of years, indicating the loss of younger peat material. In contrast, peat in the first centimetres of the NW was only a few decades old, indicating recent peat growth. It is likely that the NW site accumulates carbon today but was perturbed by anthropogenic activities in the past. Together, all biogeochemical parameters indicate a degradation of peat due to (i) conversion to grassland with historical drainage and (ii) land use intensification.

Neuralgia of the glossopharyngeal nerve in a patient with posttonsillectomy scarring: recovery after local infiltration of procaine-case report and pathophysiologic discussion

We describe a patient with a three-year history of severe progressive left-sided glossopharyngeal neuralgia (GPN) that failed to adequately respond to various drug therapies. The application of lidocaine spray to the posterior pharyngeal wall provided no more than short-term relief. Apart from a large hypertrophic tonsillectomy scar on the left side all clinical and radiologic findings were normal. In terms of therapeutic local anaesthesia, the hypertrophic tonsillectomy scar tissue was completely infiltrated with the local anaesthetic (LA) procaine 1%. The patient has been almost completely pain-free ever since, and the lidocaine spray is no longer needed. Six weeks after the first treatment a repeat infiltration of the tonsillectomy scar led to the complete resolution of all symptoms. The patient has become totally symptom-free without the need to take any medication now for two and a half years. This is the first report of a successful therapeutic infiltration of a tonsillectomy scar using an LA in a patient with GPN that has been refractory to medical treatment for several years. A possible explanation may be that the positive feedback loop maintaining neurogenic inflammation is disrupted and "sympathetically maintained pain" resolved by LA infiltration.

Neurogenic thoracic outlet syndrome due to subclavius posticus muscle with dynamic brachial plexus compression: a case report.

BACKGROUND Neurogenic thoracic outlet syndrome is an underestimated cause of brachial weakness and pain. The subclavius posticus muscle (SPM) is an aberrant muscle originating from the medial aspect of the first rib reaching to superior border of the scapula, which may cause, depending on its activation, dynamic compression of the brachial plexus. CASE PRESENTATION In the present study, we report about a 32-year-old male caucasian patient with weakness in radial deviation of his left hand. An isolated macrodactyly of his left middle finger had been operated twice. Electroneurography showed a carpal-tunnel-syndrome (CTS) on the left side. MRI of the brachial plexus revealed an additional muscle in the costoclavicular space, identified as SPM. To our knowledge, this is the second case report of a neurogenic thoracic outlet syndrome due to SPM, and the first case described with isolated macrodactyly and CTS in the same patient. CONCLUSION If complaints about hand weakness are only reported in cases of distinct hand positions, a dynamic compression of the brachial plexus by SPM may be the cause. A neurogenic thoracic outlet syndrome may facilitate the development of CTS.

Does a reference to evaluations contribute to discourse quality? The case of Swiss direct-democratic campaigns on school policy: a conceptual framework

This article examines how references to evaluations in school policy debates contribute to discourse quality. The article consists of two parts: First, it presents a descriptive overview of the references to evidence in direct-democratic campaigns. These results are based on a quantitative content analysis of the newspaper coverage and governmental information documents of 103 direct-democratic Swiss school policy votes. In a second step, it discusses these findings in view of the question of whether the incorporation of evaluation results in policy debates contributes to discourse quality. It presents a conceptual framework, including hypotheses and a research design to answer this question.

Provenance analysis using Raman spectroscopy of carbonaceous material: A case study in the Southern Alps of New Zealand

Detrital provenance analyses in orogenic settings, in which sediments are collected at the outlet of a catchment, have become an important tool to estimate how erosion varies in space and time. Here we present how Raman Spectroscopy on Carbonaceous Material (RSCM) can be used for provenance analysis. RSCM provides an estimate of the peak temperature (RSCM-T) experienced during metamorphism. We show that we can infer modern erosion patterns in a catchment by combining new measurements on detrital sands with previously acquired bedrock data. We focus on the Whataroa catchment in the Southern Alps of New Zealand and exploit the metamorphic gradient that runs parallel to the main drainage direction. To account for potential sampling biases, we also quantify abrasion properties using flume experiments and measure the total organic carbon content in the bedrock that produced the collected sands. Finally, we integrate these parameters into a mass-conservative model. Our results first demonstrate that RSCM-T can be used for detrital studies. Second, we find that spatial variations in tracer concentration and erosion have a first-order control on the RSCM-T distributions, even though our flume experiments reveal that weak lithologies produce substantially more fine particles than do more durable lithologies. This result implies that sand specimens are good proxies for mapping spatial variations in erosion when the bedrock concentration of the target mineral is quantified. The modeling suggests that highest present-day erosion rates (in Whataroa catchment) are not situated at the range front but around 10 km into the mountain belt.

Recurrent Nicolau syndrome associated with subcutaneous glatiramer acetate injection--a case report.

BACKGROUND Glatiramer acetate is worldwide used as first line treatment in relapsing remitting multiple sclerosis. Local skin reactions associated with glatiramer acetate are common, however, only isolated cases of severe local injection site reactions known as Nicolau Syndrome have been reported so far. CASE PRESENTATION We describe the case of a recurrent Nicolau Syndrome occurred during longstanding glatiramer acetate treatment in a woman with multiple sclerosis. The haemorrhagic patch necrotized and was treated locally as a deep second degree burn with excision of dead skin tissue and was healed. Treatment with glatiramer acetate was definitely suspended. CONCLUSIONS GA injections can be complicated by isolated or recurrent Nicolau Syndrome, a potentially life-threatening condition of which neurologists should be aware.

Association of hormone therapy and incident gout: population-based case-control study

OBJECTIVE This study aims to assess the odds of developing incident gout in association with the use of postmenopausal estrogen-progestogen therapy, according to type, timing, duration, and route of administration of estrogen-progestogen therapy. METHODS We conducted a retrospective population-based case-control analysis using the United Kingdom-based Clinical Practice Research Datalink. We identified women (aged 45 y or older) who had a first-time diagnosis of gout recorded between 1990 and 2010. We matched one female control with each case on age, general practice, calendar time, and years of active history in the database. We used multivariate conditional logistic regression to calculate odds ratios (ORs) with 95% CIs (adjusted for confounders). RESULTS The adjusted OR for gout with current use of oral formulations of opposed estrogens (estrogen-progestogen) was 0.69 (95% CI, 0.56-0.86) compared with never use. Current use was associated with a decreased OR for gout in women without renal failure (adjusted OR, 0.71; 95% CI, 0.57-0.87) and hypertension (adjusted OR, 0.62; 95% CI, 0.44-0.87) compared with never use. Tibolone was associated with a decreased OR for gout (adjusted OR, 0.77; 95% CI, 0.63-0.95) compared with never use. Estrogens alone did not alter the OR for gout. CONCLUSIONS Current use of oral opposed estrogens, but not unopposed estrogens, is associated with a decreased OR for incident gout in women without renal failure and is more pronounced in women with hypertension. Use of tibolone is associated with a decreased OR for incident gout. The decreased OR for gout may be related to the progestogen component rather than the estrogen component.

Acute hemorrhagic edema of young children: a prospective case series.

Acute hemorrhagic edema of young children is a rare leukocytoclastic vasculitis that has been reported exclusively in small retrospective cases series, case reports, or quizzes. Considering that retrospective experience deserves confirmation in at least one observational prospective study, we present our experience with 16 children (12 boys and 4 girls, 5-28 months of age) affected by acute hemorrhagic edema. The patients were in good general conditions and with a low-grade or even absent fever. They presented with non-itching red to purpuric targetoid lesions not changing location within hours, with non-pitting and sometimes tender indurative swelling, and without mucous membrane involvement or scratch marks. Signs for articular, abdominal, or kidney involvement were absent. Antinuclear or antineutrophil cytoplasmic autoantibodies were never detected. The cases were managed symptomatically as outpatients and fully resolved within 4 weeks or less. No recurrence or familiarity was noted. CONCLUSION This is the first prospective evaluation of hemorrhagic edema. Our findings emphasize its distinctive tetrad: a well-appearing child; targetoid lesions that do not change location within hours; non-pitting, sometimes tender edema; complete resolution without recurrence. What is known • Acute hemorrhagic edema of young children is considered a benign vasculitis. • There have been ≈100 cases reported in small retrospective case series. What is new • The first prospective evaluation of this condition emphasizes its features: febrile prodrome; well-appearing child; targetoid lesions not changing location within hours; non-pitting, sometimes tender indurative edema; absent extracutaneous involvement; resolution within 3 weeks. • Antineutrophil cytoplasmic autoantibodies do not play a pathogenic role.