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This issue of Psychoanalytic Inquiry has been designed to address the new directions that have emerged in self-psychology after Kohut, and the product has demonstrated just how alive and well, how ...

From the beginning, self psychology has been criticized for failing to adequately address aggression. This critique is explored beginning with Heinz Kohut’s position on aggression and then moving t...

This discussion of Dr. Kathy Marks’s paper, In the Nick of Time: Motherhood and the Analytic Pair, centers on a patient’s need to probe the analyst’s subjectivity. Clinical processes involving the ...

One of the essential features of a therapeutic change process is the ability to establish, within the therapeutic relationship, a sense of safety from which patients can engage and explore the many issues that bring them into therapy. Efforts to gain our patients’ trust so that they feel safe enough to expose their vulnerabilities and engage in a healing process remain at the center of the analytic enterprise, no matter the theoretical position of the therapist. In fact, in an otherwise diverse and sometimes fractious psychoanalytic field, the importance of safety is one of the few areas of near consensus. In our approach, we acknowledge the intersubjective nature of all relational experience and appreciate the powerful processes of mutual influence that reverberate between the analytic couple. As we see it, clinical engagement requires both partners to take risks, tolerate a sense of danger, learn to trust each other, and seek emotional safety through connection and understanding. In this article...

The purpose of this retrospective study was to report the peritoneal fluid lactate (PFL) levels in horses diagnosed with nonstrangulating small intestinal (NSSI) lesions and to compare those values to horses diagnosed with strangulating small intestinal (SSI) lesions. Medical records between 2005 and 2016 were reviewed. Subject details, presenting clinical findings, and disease category (strangulating/NSSI lesion) were obtained. Comparison of SSI lesions to NSSI lesions revealed no significant difference in PFL values. However, horses with SSI lesions had significantly higher peritoneal fluid lactate:blood lactate ratios and were more likely to have serosanguinous peritoneal fluid color than those with NSSI lesions.

Robert Emde describes the appealing qualities of playfulness and aliveness that Daniel Stern brought to living and to his life’s work. Having been both a friend and a collaborator, Emde summarizes ...

Objective: The aim of this study was to introduce new approaches to conduct qualitative research that may provide valuable insight into issues related to education, training and patient care in psychiatry. Conclusions: A variety of data-collection tools is available for researchers and practitioners in psychiatry. These can be used independently or in conjunction with other quantitative and qualitative methods.

We are very grateful to the contributors of “The Many Faces of Self Psychology” for providing a group of articles which, individually and collectively, honor Kohut’s original contributions while of...

In the 1960s, after completing medical school, Dan Stern conducted psychopharmacology research at the National Institutes of Health in Bethesda, MD, and then completed his psychiatry residency and ...

Myodural bridges have been described in various species as connective tissue structures “bridging” small cranio-cervical muscles to the dura. Myodural bridges are thought to stabilize the dural sac during head and neck movements and promote cerebrospinal fluid motion; however, their role in neurological diseases has not yet been established. We report ultrasonographic visualization, necropsy, histopathologic and ultrastructural findings of myodural bridges in horses with hereditary equine regional dermal asthenia (HERDA), an equine model of Ehlers-Danlos syndromes. Five HERDA and 5 control horses were studied. Post-mortem examination and ultrasonographic studies (3 HERDA and 4 controls) demonstrated that the atlanto-occipital and atlanto-axial myodural bridges are dynamic structures “moving” the dura. En block resection of the myodural bridges (4 HERDA and 5 controls) was accomplished and histopathology showed myofiber degeneration in 3 HERDA horses and 1 control. Ultrastructural examination revealed loosely packed collagen fibrils with abnormal orientation in all HERDA horses compared to mild abnormalities in 2 controls. Our study provides necropsy and ultrasonographic evidence of the dynamic aspect of the myodural bridges as dural sac stabilizers. Myodural bridges may be pathologically altered in connective tissue disease as evidenced by the ultrastructural morphology in the HERDA myodural bridge.

The aim of this study was to discover how an active learning classroom (ALC) influenced the teaching and learning of dental radiology with dental hygiene students through a mixed-methods approach. A year-long observation of a dental hygiene professor who was teaching two consecutive courses in an ALC was conducted in 2015-16. Nineteen classes were recorded and transcribed, and observational notes on classroom activities were taken. Towards the end of the academic year, the professor was interviewed with use of a 13-question guide, and the students were surveyed with a 25-question survey. Moreover, five-year grades in the same two courses, including four-year historical grades earned in the traditional classrooms (TCs) and one year from the ALC, were collected along with demographic and prior academic performance data. Thirty-two of the 38 students responded to the survey, for a response rate of 84%. The results showed that 63% of the students preferred to take classes in the ALC rather than TC. They especially enjoyed the ALC’s spaciousness, mobility, unobstructed views, and ease of information-sharing and engagement in class. However, the ALC presented both the faculty and students with sensory and technique challenges. The analysis of students’ grades suggested that GPA was one of the strongest predictors for both courses’ final grades in the TCs but had weaker predicting significance in the ALC setting. Overall, the majority of students enjoyed taking classes in the ALC due to its physical charm and dynamic collaboration. Sensory and technique challenges coexisted with benefits.

Nutritional support is an important adjunct to medical therapy in the sick, injured, or debilitated equine patient. What is not clear is the optimal route, composition, or amounts of support. The enteral route should be chosen whenever possible to maximize the benefits to the gastrointestinal tract and the patient as a whole. Complete or partial parenteral nutrition is most useful as a bridge during recovery and transition to enteral feeding in the horse. The reader is encouraged to consider nutritional support whether enteral or parenteral in any anorexic, chronically debilitated, or sick equine patient.

The purpose of this article is to provide a quick reference for field triage of the sick neonatal foal. Therefore, information is focused toward diagnostics and treatments that can be performed in the field. When evaluating a weak, recumbent, or lethargic foal on a farm, it is often difficult to make a definitive diagnosis. Therefore, the approach should be to treat what is treatable and prevent what is preventable. In many cases, the goal will be to stabilize a foal before referral to a tertiary care facility where more intensive and continuous treatment can be performed.

Background: Equid herpesvirus-1 (EHV-1) reactivation and shedding can occur in latently infected, asymptomatic animals. Risk factors for reactivation include stress and illness. The risk of asymptomatic shedding in hospitalized, critically ill horses with acute abdominal disease is unknown. This information is important to assess the need for additional biosecurity protocols to prevent spread of EHV-1 in hospitalized critically ill horses with acute abdominal disorders. Objectives: To determine the frequency of reactivation and nasal shedding of EHV-1 in hospitalized critically ill horses. Animals: One hundred twenty-four client-owned horses admitted to the Veterinary Teaching Hospital with acute abdominal disorders were included in the study. Methods: Cross-sectional study examining the risk of reactivation of EHV-1 in horses admitted with acute, severe, gastrointestinal disease. Whole blood and nasal secretions were collected throughout hospitalization. In addition, mandibular lymph nodes were collected from 9 study horses and 26 other Michigan horses. All samples were tested for the presence of EHV-1 nucleic acid by real-time PCR assays targeting the glycoprotein B gene and the polymerase (ORF 30) gene. Results: One hundred and twenty-four horses met the inclusion criteria. None of the samples were positive for EHV-1 DNA. Conclusion and Clinical Importance: These results suggest that nasal shedding and viremia of EHV-1 in hospitalized critically ill horses with acute abdominal disorder is extremely rare. Implementation of additional biosecurity protocols to limit aerosol spread of EHV-1 among horses with acute abdominal disease and other hospitalized horses is not necessary.

A 3-year-old Thoroughbred gelding presented with a history of neurological signs, including incoordination in his hindlimbs, of about 7 months' duration. On initial examination, the horse exhibited ataxia and paresis in all limbs with more severe deficits in the hindlimbs. Cervical radiographs displayed severe osteoarthritis of the articular processes between C5 and C6. On subsequent cervical myelography the dorsal contrast column was reduced by 90% at the level of the intervertebral space between C5 and C6. Cervical vertebral canal endoscopy, including epidural (epiduroscopy) and subarachnoid endoscopy (myeloscopy), was performed under general anaesthesia. A substantial narrowing of the subarachnoid space at the level between C6 and C7 was seen during myeloscopy, while no compression was apparent between C5 and C6. Epiduroscopy showed no abnormalities. After completion of the procedure, the horse was subjected to euthanasia and the cervical spinal cord submitted for histopathological examination. Severe myelin and axon degeneration of the white matter was diagnosed at the level of the intervertebral space between C6 and C7, with Wallerian degeneration cranially and caudally, indicating chronic spinal cord compression at this site. Myeloscopy was successfully used to identify the site of spinal cord compression in a horse with cervical vertebral stenotic myelopathy, while myelography results were misleading.

Age-related macular degeneration (AMD) is a progressive degenerative disease which leads to blindness, affecting the quality of life of millions of Americans. More than 1.75 million individuals in the United States are affected by the advanced form of AMD. The etiological pathway of AMD is not yet fully understood, but there is a clear genetic influence on disease risk. To date, the 1q32 (CFH) and 10q26 (PLEKHA1/ARMS2/HTRA1) loci are the most strongly associated with disease; however, the variation in these genomic regions alone is unable to predict disease development with high accuracy. Therefore, current genetic studies are aimed at identifying new genes associated with AMD and their modifiers, with the goal of discovering diagnostic or prognostic biomarkers. Moreover, these studies provide the foundation for further investigation into the pathophysiology of AMD by utilizing a systems-biology-based approach to elucidate underlying mechanistic pathways.

Summary Reasons for performing study: Despite modern medical diagnostic imaging, it is not possible to identify reliably the exact location of spinal cord compression in horses with cervical vertebral stenotic myelopathy (CVSM). Vertebral canal endoscopy has been successfully used in man and a technique for cervical vertebral canal endoscopy (CVCE) has been described in equine cadavers. Objective: To determine the feasibility and safety of CVCE in healthy mature horses. Methods: Six healthy mature horses were anaesthetised. A flexible videoendoscope was subsequently introduced via the atlanto-occipital space into the epidural space (epiduroscopy, Horses 1-3) or the subarachnoid space (myeloscopy, Horses 4-6) and advanced to the 8th cervical nerve. Neurological examinations were performed after surgery and lumbosacral cerebrospinal fluid (CSF) analysed in horses that had undergone myeloscopy. Results: All procedures were completed successfully and all horses recovered from anaesthesia. Anatomical structures in the epidural space (including the dura mater, nerve roots, fat and blood vessels) and subarachnoid space (including the spinal cord, blood vessels, arachnoid trabeculations, nerve roots and the external branch of the accessory nerve) were identified. During epiduroscopy, a significant increase in mean arterial pressure was recognised, when repeated injections of electrolyte solution into the epidural space were performed. In one horse of the myeloscopy group, subarachnoid haemorrhage and air occurred, resulting in transient post operative ataxia and muscle fasciculations. No complications during or after myeloscopy were observed in the other horses. CSFanalysisindicatedmildinflammationonDay7withvalues approaching normal 21 days after surgery. Conclusions: Endoscopic examination of the epidural and subarachnoid space from the atlanto-occipital space to the 8th cervical nerve is possible and can be safely performed in healthy horses. Potential relevance: Cervical vertebral canal endoscopy might allow accurate identification of the compression site in horses with CVSM and aid diagnosis of other lesions within the cervical vertebral canal.

Summary Three mature Thoroughbred horses were prepared surgically with ultrasonic sonomicrometer crystals affixed to their ventricular pericardia. Signals from crystals recorded dimensions of axes across the left ventricle. Cubic algorithms were fitted to dimensional data to generate volume estimates that matched stroke volumes simultaneously measured using the Fick principle. As horses stood at rest or exercised at various intensities (approx 7, 12, 24, 47 and 100% maximal rate of O2 consumption [Vo2max]), left ventricular dimensions were recorded and 20 consecutive diastolic and systolic volumes calculated. Although Fick estimates detected no difference in stroke volume at different exercise intensities, sonomicrometer measurements of stroke volume were significantly lower at rest and higher at Vo2max. These differences mirrored changes in end-diastolic volume, although end-systolic volume did not change. At all exercise intensities, stroke volume was most variable and end-diastolic volume the least. The pattern conforms to the Frank-Starling mechanism, and indicates that at high exercise intensities ventricular myocytes generate high pressures with higher myocardial wall stress due to the increased size of the chamber.

Summary Reasons for performing study: Although subclinical airway inflammation is thought to be common in horses, there is little information on its prevalence and none on risk factors. Objective: To determine the prevalence and risk factors for an increased number of inflammatory cells and for mucus accumulation in the trachea of pleasure horses. Methods: Horses (n = 266) in stables (n = 21) in Michigan were examined endoscopically, once in winter and once in summer 2004. Visible tracheal mucoid secretions were graded 0–5 and inflammatory cell numbers counted in a tracheal lavage sample. Information collected about each horse included age, gender, presence of cough, percent time indoors and source of roughage. The repeated measures were analysed by generalised estimating equations and linear mixed models. Results: Horses eating hay, especially from round bales, had the most neutrophils, whereas horses feeding from pasture had the fewest. Being female and being outdoors in winter were associated with increased numbers of inflammatory cells. Older horses had fewer macrophages than young horses. More than 70% of horses had >20% neutrophils in tracheal lavage. Twenty percent of horses had a mucus accumulation score >1; 17% had both a mucus score >1 and >20% neutrophils. The significant risk factors for mucus accumulation >1 were age >15 years, feeding on hay as compared to pasture, and being outdoors for more than 80% time in winter. Even though mucus accumulation score >1 was a risk factor for cough, only half of such horses coughed. Cough and mucus accumulation were associated with increased number of neutrophils. Conclusions: In comparison to pasture feeding, hay feeding, particularly from round bales, was associated with an increased number of neutrophils in the airway. Being outdoors in winter was associated with increased numbers of inflammatory cells and with mucus accumulation. Because 70% of horses have >20% neutrophils, this value should not be used as the sole indicator of airway inflammation. Potential relevance: The study reinforces the importance of hay feeding and older age as risk factors for inflammatory airway disease. Horses that do not have ‘heaves’ may be best kept indoors when winters are cold.

Summary Reason for performing study: Accumulations of mucus within the trachea are often found during endoscopic examinations of the airways of poorly performing racehorses, but the clinical importance of this finding is unknown. Objectives: To determine the effect of tracheal mucus, pharyngeal lymphoid hyperplasia (PLH) and cytological indices of tracheal aspirate on racing performance in Thoroughbred horses assessed by race place and whether the horse was raced. Methods: Endoscopic examination of the nasopharynx, larynx and trachea was performed, and a tracheal aspirate obtained monthly at Thistledown racetrack from April to December, 2002 and 2003. Horses received a score of 0–4 for the degree of PLH and 0–4 for the amount of mucus visible in the trachea. The tracheal aspirate was assessed for turbidity, and total and differential cell counts. Generalised estimating equations models were used as repeated measures models for each risk factor and the level of association assessed through the risk factor's P value in the model. Results: Moderate to severe tracheal mucus (2–4) was a risk factor for poor racing performance. There was no association between degree of PLH, cell counts or turbidity of tracheal wash fluid and racing performance. However, horses that raced had higher total neutrophil counts in tracheal wash aspirates than horses that did not race. Conclusions: Grades 2–4 tracheal mucus should be considered a potential cause of poor racing performance in Thoroughbred horses. Clinical relevance: Because moderate to severe tracheal mucus accumulation, and not increased tracheal neutrophils, was a risk factor for poor racing performance, functionally significant airway inflammation may best be confirmed by the presence of mucus rather than increased number of neutrophils in the trachea.

Nutritional supplementation is becoming the standard of practice in equine medicine, although there are minimal data on nutritional support in critically ill horses and its association or effect on morbidity and mortality or length of hospital stay. Horses can be fed orally and when that is not possible, intravenously or parenterally. Enteral feeding is less expensive, more physiologic, improves immunity, and is easier and safer. This article reviews available information on the development of a nutritional plan for critically ill horses, and describes methods for and complications of enteral and parenteral feeding.

A 3-day-old alpaca cria presented for progressive weakness and dyspnea since birth. Complete bloodwork, thoracic radiographs, and endoscopic examination of the nasal passages and distal trachea revealed no significant findings. Echocardiogram and contrast study revealed a single artery overriding a large ventricular septal defect (VSD). A small atrial septal defect or patent foramen ovale was also noted. Color flow Doppler and an agitated saline contrast study revealed bidirectional but primarily right to left flow through the VSD and bidirectional shunting through the atrial defect. Differential diagnosis based on echocardiographic findings included common arterial trunk, Tetralogy of Fallot, and pulmonary atresia with a VSD. Postmortem examination revealed a large common arterial trunk with a quadricuspid valve overriding a VSD. Additionally, defect in the atrial septum was determined to be a patent foramen ovale. A single pulmonary trunk arose from the common arterial trunk and bifurcated to the left and right pulmonary artery, consistent with a Collet and Edwards’ type I common arterial trunk with aortic predominance. Although uncommon, congenital cardiac defects should be considered in animals presenting with clinical signs of hypoxemia, dyspnea, or failure to thrive.