Clinical Diary Research Articles

Completing the clinical governance cycle in dietetic gastroenterology outpatients

Background: To overcome high rates of non‐attendance, inappropriate referrals and long waiting times, an audit was undertaken of a dietetic outpatients clinic for gastroenterology patients in 2003 and then repeated in 2007. The aim of the first audit was to identify referral source, types of patient, attendance rates and if dietary advice had a positive outcome. This study aimed evaluated changes since 2003.Method: The clinic diary was used to identify patients booked to attend in 2003 and 2007. Information was retrieved from the patient's record on source of referral, types of referral, waiting times, attendance rates and dietary goals achieved. The results were compared to determine if changes had improved service delivery. The data were analyzed in Microsoft Excel (2003) and the attendance rates were compared using chi‐squared statistics.Results: There were 92 new patients in 2003 and 69 patients in 2007; data were obtained for n = 77 in 2003 and n = 55 in 2007. There was an increase in referrals from gastroenterologists (n = 31, 55%) in 2007 compared with 2003 (n = 23, 34%). Waiting times improved between the two audits with 44% being seen within 3 months in 2003 compared to 51% in 2007. Attendance rates improved by 30% when the two audits were compared and in both years 2003 and 2007 (p = 0.009), a positive outcome was recorded for the majority of patients who had completed their treatment episodes 78% and 63% respectively. Types of patients referred to Gastroenterology clinic Type of referral 2003 2007 Irritable bowel syndrome 4 (5) 12 (21) Inflammatory bowel disease 15 (19) 7 (12) Bariatric surgery 0 11 (20) Pancreatitis 13 (16) 9 (16) Gastric surgery 7 (9) 1 (2) General GI 28 (36) 13 (23) Non‐gastro 10 (12) 2 (3) Discussion: The literature on the audit cycle in dietetic outpatients is limited. The baseline results in 2003 lead to the production of guidelines and the subsequent audit in 2007 demonstrated an improvement in clinical effectiveness. There was incomplete retrieval of records for the 2007 audit that led to missing data.Conclusion: Guidelines for the clinic improved appropriateness of referrals and the focus of the clinic. The procedural changes have decreased non‐attendance and improved waiting times for patients. The changes implemented have improved service delivery for the patients and maximised the resources available for a specialist clinic by effectively utilising the skills of a Specialist gastroenterology dietitian.

Daily stress and pain sensitivity in chronic tension‐type headache sufferers

AbstractThe aim was to examine interactions between daily stress, pain sensitivity, and headache activity in Chronic Tension‐Type Headache sufferers. We measured daily hassles, pericranial muscle tenderness, pressure pain threshold at finger, headache history (years of headache) and prospective headache activity (in a two‐week clinical diary), in headache sufferers and healthy Controls. Headache sufferers had increased daily hassles scores, increased muscle tenderness, and decreased pain threshold compared to Controls. Daily hassles were correlated with increased muscle tenderness and reduced pain threshold in the CTH group. In regression analyses, daily hassles predicted muscle tenderness when accounting for headache history, headache severity and pain threshold. Muscle tenderness and daily hassles predicted headache severity when accounting for headache history and pain threshold. Muscle tenderness predicted pain threshold when accounting for headache history, headache severity and daily hassles. The results indicate daily stress is related to increased pain sensitivity and headache activity in Chronic Tension‐Type Headache sufferers, accounting for significant variance in these factors additional to that accounted for by clinical factors (headache history and severity). Although only correlational, the results support the proposition that daily stress affects Chronic Tension‐Type Headache through hyperalgesic effects on already sensitized pain pathways in headache sufferers. Copyright © 2007 John Wiley & Sons, Ltd.

Die heilsame Kraft der Beziehung bei Sándor Ferenczi

WITHOUT SYMPATHY NO HEALING, so Ferenczi's key thesis. Freud accused Ferenczi of THERAPEUTIC ENTHUSIASM, Ferenczi Freud of lacking interest in the THERAPEUTIC DIMENSION OF PSYCHOANALYSIS. Every entry in Ferenczi's CLINICAL DIARY attempts to come to terms with his teacher, friend and analyst, Freud. For his patients Ferenczi wanted to discover something, which he had wished that Freud might have discovered for him. For Ferenczi healing comprised the elimination of repression, a more highly developed SENSE OF REALITY, an anxiety-free view of UNFULFILLED LONGING and the discovery of the TRUTH OF ONE’S UNIQUE LIFE HISTORY, whose maieutic companion is the doctor. - The worst early trauma is for Ferenczi to simultaneously experience FATHER'S THREATENING und MOTHER'S ABANDONMENT. For a child, that means that it has no chance to have a good cry over its anguish or to complain. The feelings of injustice and hopelessness are so absolute that the ego retreats from reality and takes recourse to a frightfilled splitting in the absence of the ego. For Ferenczi “overflowing healing sympathy” is the most original POSTULATE OF THERAPEUTIC RATIONALITY. The influx of PURE SYMPATHY, “a love cleansed of every ambivalence” enwraps the soul fragmented by trauma in a PROTECTIVE MANTEL, so that the fragments, indeed the whole ego, again attain to UNIFICATION WITH ITSELF. The emotional closeness of the therapist makes possible the conversion of emotional upheavals into memory images and body sensations. - Genuine human COMPASSION at times of real schock is for Ferenczi the BEGINNING OF HEALING ITSELF. For Ferenczi true therapy involves the bodily and psychic “reviving of the dead soul fragments”. He is of the same mind as Fichte and Hegel: The sense of personality (the feeling for one's own importance, form, esteem) is “the product of recognition”! The more the early approval and recognition are undermined, the greater is the demand on the therapist to enclose the ego in the mantel of affectionate caring. FAILURE OF ORIGINAL AFFECTION generates a basic mistrust and makes it virtually impossible to persue later relationships in eros, philia, agape. - Ferenczi's KEY DIAGNOSTIC PSYCHOSOMATIC THESIS: When the psyche, the soul-ego, is “catastrophied”, the organism, the body-ego, begins to think! The THERAPEUTIC COUNTERPART to this is: “Only sympathy cures (healing)”! Ferenczi declaims the crowning moment of therapy with moral-religious approval: “Mutual forgiveness!! - Final success.” The resume of the entire clinical diary is: Without sympathy no healing - at most insight into the genesis of suffering.

Patient Diaries: Charting the Course

Clinical diaries are a way for patients to assess their own health status without clinician bias or interpretation. Diaries are especially useful in understanding symptoms' temporal dynamics, including triggers that exacerbate symptoms; they also help individuals to evaluate the impact of their treatment. Diary format should be patient-specific, with thoughtful consideration given to rating scales, symptom descriptors, number of daily entries required, and the duration of diary recording. While compliance, recall biases, and diary fatigue affect data quality, a diary's potential for individualizing treatment strategies is tremendous.

Development and cross-sectional validation of the Childhood Asthma Control Test

For children younger than 12 years old with asthma, there are several quality-of-life instruments, clinical diaries, and questionnaires assessing symptoms; however, a validated tool for assessing asthma control is currently lacking. To develop and validate the Childhood Asthma Control Test (C-ACT), a self-administered tool for identifying children aged 4-11 years whose asthma is inadequately controlled. A 21-item questionnaire was administered to 343 patients with asthma and their caregivers, randomly assigning 75% (n = 257) for development and cross-sectional validation of the tool and 25% (n = 86) to a confirmatory sample. Stepwise logistic regression was used to reduce the 21 items to those best able to discriminate control as defined by the specialist's rating of asthma control. Seven items were selected from regression analyses of the development sample to comprise the C-ACT. The scores of each item were summed for a total score (0-27), with lower scores indicating poorer control. Summed scores discriminated between groups of patients differing in the specialists' rating of asthma control (F = 36.89; P < .0001), the need for change in patients' therapy (F = 20.07; P < .0001), and % predicted FEV(1) (F = 2.66; P = .0494). A score of 19 indicated inadequately controlled asthma (specificity 74%, sensitivity 68%). These analyses were confirmed in the confirmatory sample. The C-ACT is a validated tool to assess asthma control and identify children with inadequately controlled asthma. The C-ACT can be valuable in clinical practice and research based on its validation, ease of use, input from the child and caregiver, and alignment with asthma guidelines.

In prison: A clinical diary.

In prison: A clinical diary.

On the Patient's Becoming an Individual: The Importance of the Analyst's Personal Response to a Deprived Patient and Her Dreams

What patients mainly want—which Ferenczi noted as early as 1932 in his clinical diary and which Bion later expressed in his Cogitations (1992)—and what some patients need, is to experience how the analyst lives and processes the interpersonal events that lie at the origin of their affective and mental suffering. This is especially true with schizoid patients who were profoundly emotionally deprived in childhood. In this paper, the author investigates this crucial aspect of the intersubjective analytic relationship in his treatment of just such a patient, an extremely silent and inert young woman. Through a detailed examination of clinical material from various stages of her analysis, he explores how the analyst's unconscious emotional response serves as both a tool for comprehension and a key element of environmental facilitation—a “new beginning,” to use Balint's phrase—that may help the patient attain a level of development and emancipation that he or she has never experienced before.

Trauma and daimonic reality in Ferenczi's later work.

Jung and Ferenczi made independent discoveries of an 'archaic' (Jung) or 'primordial' (Ferenczi) layer of the psyche that shone through the 'basic fault' in the psyche opened by childhood trauma. This paper explores those parallels through an extended vignette of Ferenczi's work with Elizabeth Severn, known as 'R. N.' in the Clinical Diary. A remarkable inner object known as 'Orpha' appeared in the patient's trauma experience and saved a seed of personality from total annihilation. Ferenczi's speculation about this 'daimonic' object is cited along with his discussion of a transpersonal immaterial reality that Orpha makes visible, and that links the patient's ego-experience with a spiritual/material unity not ordinarily available to consciousness.

PREVENTING AGEISM IN NURSING STUDENTS: AN ACTION THEORY APPROACH

Australia has an ageing population and increased longevity has resulted in a larger proportion of the older population surviving to be 75 years and older. As a result of demographic trends, nurses are more likely to come into contact with older people. Ageism existsin Australian society and can unfortunately be found in some practicing nurses. ‘Ageism’ is a term used to describe a process of systematic stereotyping and discrimination against older people because they are very old, in a similar vein as racism and sexismaccomplish this with skin colour and gender. The aim of this study was to explore final year Bachelor of Nursing (BN) students’ attitudes toward ageism and emancipate them to come to terms with these issues to prevent replication of ageism in their future practice as registered nurses (RNs). Critical social theory (Fay 1987) combined with Stringer’s (1996) model of Participatory Action Research (PAR) provided the theoretical directions forthis study. Nine final year BN students at the University of Southern Queensland (USQ) volunteered to participate. Data were collected by focus group meetings and clinical diaries over a duration of six months. Findings of this study revealed an acute self-awareness of what ageism was and a personal fear of the ageing process itself. Identified issues are discussed and re-framed in the form of recommendations so they can offer potential for renewed critical consciousraising to prevent ageism.

Ferenczi's Concept on Trauma, Connected with the Katonadolog - 'Soldiers Can Take It' Concept

Although Ferenczi did not write his Clinical Diary - neither most of his late works - in Hungarian, he uses the term katonadolog in Hungarian even in the German text, and later translations apply the original Hungarian word annotated in a footnote as 'soldiers can take it'. Ferenczi connects the term katonadolog to the concept of biphasic trauma and to the interpretation of trauma as a moral shock. The paper investigates how this can be connected to the idea of intersubjective self theories stating that commonly constructed meanings in the early mother-child interactions, meaningful inner contents and common experiences are of utmost importance. Further, it analyses how the child, who may be exposed to parental interpreting power, can create a distorted image of reality that has nothing or little to do with his own real experiences. However, due to the deviant parental mirroring the 'transcription of reality', the formation of 'false and robbed self' (Winnicott and Schibbye) can already start in preverbal age. According to the biphasic trauma, it is the parental denying and interpreting power that is really traumatogenic, and this is complemented by the interpretation of the child's pain as katonadolog.

Childhood Lost and Recovered

The author is trying to grasp the significance of two antagonistic concepts in order to understand life, as trauma and resilience-bouncing back ("orpha" in the Ferenczi-Severn sense in Ferenczi's Clinical Diary); with references to recent research in- and out-side psychoanalysis.

A Visit to the Budapest School

Within the past ten years, there has been a growing interest among American psychoanalysts in the work of Sandor Ferenczi and his followers, the so-called Budapest School. Several collections of essays on Ferenczi have appeared, while his correspondence with Freud and his Clinical Diary were finally published and translated. In this paper, I will give an overview of the historical importance of the Budapest School analysts, and then focus on three overlapping areas of their interest that have been and will continue to be particularly challenging. First, their exploration, stimulated by Ferenczi, of clairvoyance and telepathy, as these relate to the analytic situation, to transference and countertransference. Second, the mother-child dyad in the first year of life and the importance of trauma in early development. Third, the theory of psychosis.

Threshold and Impasse: Excavating the Maternal Defense in Sandor Ferenczi'sClinical Diary

Three dramatic conflicts emerge from Sandor Ferenczi’s Clinical Diary, when the Diary is analyzed as if it were a literary text. Using the interlocking symbols of the threshold and the impasse as an Ariadne’s thread to guide us through the Diary’s complexities, we can trace Ferenczi’s journey to intense self-awareness in the penultimate year of his life. These three conflicts are (1) the conflict between Freud and Ferenczi, (2) the conflicts experienced by Ferenczi and his patients in his work in mutual analysis, and (3) Ferenczi’s internal conflicts uncovered in the process of mutual analysis, resulting in his discovery of what I call “the maternal defense.” “The maternal defense” is an elaborate constellation, developed by Ferenczi over the course of his life to protect him from acknowledgment of his unconscious hatred and fear of women. Excavation of this defense created space ample enough to contain ambivalent feelings toward both women and Freud. Traditionally, the threshold is a “symbol of transition and transcendence . . . the function of the threshold is clearly to symbolize both the reconciliation and the separation of the two worlds of the profane and

Prospective randomized multicentre trial comparing stapled with open haemorrhoidectomy

The aim of this study was to compare the results of conventional open haemorrhoidectomy as currently practised in Italy (group 1) with stapled haemorrhoidectomy using a 33-mm circular stapling device (group 2). One hundred patients with symptomatic third- and fourth-degree haemorrhoids were enrolled by five hospitals. Patients were allocated to the two groups according to a centralized randomization scheme featuring five permutated blocks of 20. Preoperative clinical examination and anorectal manometry demonstrated no features of anal incontinence. Patients had a clinical and manometric re-evaluation after operation and were asked to complete a clinical diary. After a median of 16 (range 8-19) months patients were administered a standardized questionnaire by telephone. Postoperative bleeding requiring haemostatic procedures occurred in three patients in each group. Patients in group 1 complained of moderate pain for a median of 5.3 (range 0-19) days compared with 3.1 (range 0-10) days in group 2 (P = 0.01), while severe pain was present for 2.3 (range 0-24) days in group 1 but only for 1 (range 0-14) day in group 2 (P = 0.03). The median hospital stay was 2 days in group 1 compared with 1 day in group 2 (P = 0.01). In the early days after operation, patients in group 2 had greater difficulty in maintaining normal continence to liquid stools (P = 0.01), but after 30 days the continence score was better in group 2 (P = 0.04). Stapled haemorrhoidectomy is as effective as conventional haemorrhoidectomy. Reduced postoperative pain, shorter hospital stay and a trend toward earlier return to work suggest short-term advantages for the stapled technique.

The use of public education in practice.

1. Miriam E. Bar-on, MD* 1. 2. *Professor of Pediatrics, Ronald McDonald Children’s Hospital, Loyola University Stritch School of Medicine, Maywood, IL Dr Bar-on also is Chair, Committee on Public Education, American Academy of Pediatrics. Objectives After completing this article, readers should be able to: 1. Describe the primary goals of patient handouts. 2. Describe the primary goals of group education for patients who have specific disease processes. 3. Delineate the advantages of pediatrician involvement in the community. 4. Describe quality issues related to patient education on the Internet. 5. List the advantages of developing media contacts and providing information to them. Public or patient education is one means of attaining the optimal physical, mental, and social health and well-being for infants, children, adolescents, and young adults, as stated in the American Academy of Pediatrics’ (AAP) mission statement. By definition, patient education is the process of influencing patient behavior and producing changes in knowledge, attitudes, and skills required to maintain or improve health. This usually is addressed on an individual basis and includes teaching and counseling to enable patients to stay healthy and manage illness better when it occurs. Public education, on the other hand, is a broader term that includes the pediatrician’s role in influencing the health status of the public through involvement with community groups and the media. Both types of education are important and merit pediatrician involvement. Questions arise as to the best and most effective ways to provide this education within the constraints of busy practices or other commitments. Public education can be incorporated into pediatricians’ daily activities in a variety of ways both inside and outside the office. Studies in the medical literature have reviewed the outcomes of public/patient education programs and their effectiveness in practice. This article examines various methods of public/patient education that may enhance pediatricians’ promotion of health and well-being for their patients. Although many of the methods discussed will be familiar, there is evidence in the literature that public/patient education is not adequately provided to patients. The office is the primary …

The Meaning of the Clinical Learning Experience of Korean Nursing Students

ABSTRACT Clinical learning is the major component of nursing education. Since nursing is a practice discipline, experiential learning in clinical practice is vital in a nursing student's education. Moreover, it is within the structure of clinical practice that nursing students are inducted into the profession of nursing. The purpose of this phenomenological study was to understand the meanings embedded in the clinical learning experience of Korean nursing students. Informants were 25 junior baccalaureate nursing students in their first clinical rotation who volunteered to participate in extended, unstructured audiorecorded interviews, and to submit clinical diaries for six months. The patterns of the lived experience of clinical learning that emerged from this research are illustrated with descriptive data and provide useful insights for nursing faculty and students involved in nursing education.

Infantile Spasms: Hypothesis-Driven Therapy and Pilot Human Infant Experiments Using Corticotropin-Releasing Hormone Receptor Antagonists

Background and Rationale: Infantile spasms (IS) are an age-specific seizure disorder occurring in 1:2,000 infants and associated with mental retardation in ∼90% of affected individuals. The costs of IS in terms of loss of lifetime productivity and emotional and financial burdens on families are enormous. It is generally agreed that the seizures associated with IS respond poorly to most conventional anticonvulsants. In addition, in the majority of patients, a treatment course with high-dose corticotropin (ACTH) arrests the seizures completely within days, often without recurrence on discontinuation of the hormone. However, the severe side effects of ACTH require development of better treatments for IS. Based on the rapid, all-or-none and irreversible effects of ACTH and on the established physiological actions of this hormone, it was hypothesized that ACTH eliminated IS via an established neuroendocrine feedback mechanism involving suppression of the age-specific endogenous convulsant neuropeptide corticotropin-releasing hormone (CRH). Indeed, IS typically occur in the setting of injury or insult that activate the CNS stress system, of which CRH is a major component. CRH levels may be elevated in the IS brain, and the neuropeptide is known to cause seizures in infant rats, as well as neuronal death in brain regions involved in learning and memory. If ‘excess’ CRH is involved in the pathogenesis of IS, then blocking CRH receptors should eliminate both seizures and the excitotoxicity of CRH-receptor-rich neurons subserving learning and memory. Patients and Methods: With FDA approval, α-helical CRH, a competitive antagonist of the peptide, was given as a phase I trial to 6 infants with IS who have either failed conventional treatment or who have suffered a recurrence. The study was performed at the Clinical Research Center of the Childrens Hospital, Los Angeles. The effects of α-helical CRH on autonomic parameters (blood pressure, pulse, temperature, respiration) were determined. In addition, immediate and short-term effects on ACTH and cortisol and on electrolytes and glucose were examined. The potential efficacy of α-helical CRH for IS was studied, using clinical diaries and video EEG. Results: α-Helical CRH, a peptide, did not alter autonomic or biochemical parameters. Blocking peripheral CRH receptors was evident from a transient reduction in plasma ACTH and cortisol. No evidence for the compound’s penetration of the blood-brain barrier was found, since no central effects on arousal, activity or seizures and EEG patterns were observed. In addition, a striking resistance of the patients’ plasma ACTH to the second infusion of α-helical CRH was noted. Conclusions: Peptide analogs of CRH do not cross the blood-brain barrier, and their effects on peripheral stress hormones are transient and benign. Nonpeptide compouds that reach CNS receptors are required to test the hypothesis that blocking CRH receptors may ameliorate IS and its cognitive consequencs.

Time‐Series Analyses of General Arousal and Headache Activity in the Natural Environment

A naturalistic longitudinal study was conducted to examine temporal relationships between subjective dimensions of general arousal and headache activity. The "tense arousal" dimension of Thayer's biopsychological model of mood and arousal (The Biopsychology of Mood and Arousal. New York: Oxford University Press; 1989) was recorded using the Activation-Deactivation Adjective Check List (ADACL). Recordings were made eight times daily, every 2 hours from awakening, in conjunction with a clinical diary recording head pain intensity and duration. Three time series of daily, half-daily, and bihourly headache and tension scores were modeled and cross-correlated. Results indicated moderate positive same-time correlations, but revealed large interindividual and intraindividual variation in temporal relationships.

"Orpha Reviving": Toward an Honorable Recognition of Elizabeth Severn

This paper attempts to reassess Elizabeth Severn's place in the history of psychoanalysis. It does so by focusing on her three out of print books, which until now have been overlooked in discussions of the patient Ferenczi called ?RN? in the Clinical Diary. Her first two books, written in 1913 and 1917, provide the reader with valuable glimpses into what was the pre-analytic mind and person of Elizabeth Severn before she began what would be a ground breaking eight year analysis with Ferenczi. A key to understanding Elizabeth Severn, her writings, as well as many of our traumatized patients lies in a what Ferenczi and Severn called ?Orpha?. The paper suggests that an appreciation of this obscure phenomenon is critical in the treatment of trauma. After investigating her first two books in light of Orpha, the paper will compare and contrast them with her last book, The Discovery of Self, written toward the end of her analysis, and published shortly after Ferenczi's death in 1933. The tone, texture and content of this third book is strikingly different from her first two books, suggesting a depth of healing in Severn not previously reported in the literature.

Ferenczi's Contribution to the Concept of Countertransference

On the basis of a historical survey of Ferenczi's contributions to the concept of countertransference, the author highlights the most important theoretical shifts present in each of his contributions, from Freud's initial formulation in 1910 to the ?Clinical Diary?. Besides pointing to some key concepts and characteristics in Ferenczi's thinking, such as ?the control of the countertransference?, ?The transference-countertransference interaction?, ?the analyst's narcissism?, and in particular the view of countertransference as a useful therapeutic tool in itself rather than as an obstacle for the cure. The author discusses Ferenczi's significant influence on some later analysts, especially on Heimann, Winnicott, Racker and Searles who stood out precisely for, among other reasons, their contributions to the question of countertransference.