W. R. D. Fairbairn (1889-1964) challenged the dominance of Freud's drive theory with a psychoanalytic theory based on the internalization of human relationships. Fairbairn assumed that the unconscious develops in childhood and contains dissociated memories of parental neglect, insensitivity, and outright abuse that are impossible the children to tolerate consciously. In Fairbairn's model, these dissociated memories protect developing children from recognizing how badly they are being treated and allow them to remain attached even to physically abusive parents. (...) Attachment is paramount in Fairbairn's model, as he recognized that children are absolutely and unconditionally dependent on their parents. Kidnapped children who remain attached to their abusive captors despite opportunities to escape illustrate this intense dependency, even into adolescence. At the heart of Fairbairn's model is a structural theory that organizes actual relational events into three self-and-object pairs: one conscious pair (the central ego, which relates exclusively to the ideal object in the external world) and two mostly unconscious pairs (the child's antilibidinal ego, which relates exclusively to the rejecting parts of the object, and the child's libidinal ego, which relates exclusively to the exciting parts of the object). The two dissociated self-and-object pairs remain in the unconscious but can emerge and suddenly take over the individual's central ego. When they emerge, the "other" is misperceived as either an exciting or a rejecting object, thus turning these internal structures into a source of transferences and reenactments. Fairbairn's central defense mechanism, splitting, is the fast shift from central ego dominance to either the libidinal ego or the antilibidinal ego-a near perfect model of the borderline personality disorder. In this book, David Celani reviews Fairbairn's five foundational papers and outlines their application in the clinical setting. He discusses the four unconscious structures and offers the clinician concrete suggestions on how to recognize and respond to them effectively in the heat of the clinical interview. Incorporating decades of experience into his analysis, Celani emphasizes the internalization of the therapist as a new "good" object and devotes entire sections to the treatment of histrionic, obsessive, and borderline personality disorders. (shrink)

Introduction: Early recognition of prediabetes may prevent progression to diabetes, yet not all adults are aware of their prediabetes risk. To reach all adults unaware of their risk, additional risk assessment strategies are warranted. Objectives: The objective of this study was to evaluate the potential scope of benefit from prediabetes risk assessment in the dental care setting and to identify characteristics of dental patients likely to unknowingly have prediabetes or diabetes. Methods: Data from 10,472 adults in the National Health and (...) Nutrition Examination Survey from 2013 to 2014 and 2015 to 2016 were analyzed for associations among prediabetes/diabetes risk factors, health care use, and hemoglobin A1C levels according to chi-square tests and multivariate logistic regression. Results: A total of 7.73% of US adults had seen a dentist but not a medical provider in the past 12 mo. The composition of this subpopulation was significantly different from that who saw a medical provider, in ways that might affect their diabetes risk. In addition, 31.27% of this subpopulation would be identified as being at high risk for prediabetes according to the CDC Prediabetes Screening Test, and 15.83% had hemoglobin A1C levels indicative of undiagnosed prediabetes or diabetes. Screening in a dental setting would have the highest odds of identifying someone unaware of his or her diabetes risk among those who were non-White, obese, or ≥45 y old. Conclusion: Extrapolation from this analysis indicates that screening for prediabetes at dental visits has the potential to alert an estimated 22.36 million adults of their risk for prediabetes or diabetes. Incorporating prediabetes or diabetes risk assessment into routine dental visits may enable 1) those with prediabetes to take action to decrease their risk of developing diabetes and 2) those with diabetes to engage in treatment to decrease their risk of diabetes-related complications. Knowledge Transfer Statement: Screening for prediabetes and diabetes during dental visits has the potential to raise patients’ awareness of diabetes risk and prevent prediabetes from progressing to diabetes. For some patients, the dental visit may be the only point of contact with the health care system, which heightens the importance of including diabetes risk assessment for patient well-being. (shrink)

Background In Switzerland, right-to-die organisations assist their members with suicide by lethal drugs, usually barbiturates. One organisation, Dignitas, has experimented with oxygen deprivation as an alternative to sodium pentobarbital. Objective To analyse the process of assisted suicide by oxygen deprivation with helium and a common face mask and reservoir bag. Method This study examined four cases of assisted suicide by oxygen deprivation using helium delivered via a face mask. Videos of the deaths were provided by the Zurich police. Dignitas provided (...) protocol and consent information. Results One man and three women were assisted to death by oxygen deprivation. There was wide variation in the time to unconsciousness and the time to death, probably due to the poor mask fit. Swiss law prevented attendants from effectively managing the face mask apparatus. Purposeless movements of the extremities were disconcerting for Dignitas attendants, who are accustomed to assisting suicide with barbiturates. None of the dying individuals attempted self-rescue. Conclusions The dying process of oxygen deprivation with helium is potentially quick and appears painless. It also bypasses the prescribing role of physicians, effectively demedicalising assisted suicide. Oxygen deprivation with a face mask is not acceptable because leaks are difficult to control and it may not eliminate rebreathing. These factors will extend time to unconsciousness and time to death. A hood method could reduce the problem of mask fit. With a hood, a flow rate of helium sufficient to provide continuous washout of expired gases would remedy problems observed with the mask. (shrink)

In this paper we examine the study of minerals from the Renaissance to the early nineteenth century in the light of the work of Michel Foucault on the history of systems of thought. In spite of a certain number of theoretical problems, Foucault's enterprise opens up to the historian of science a vast terrain for exploration. But this is the place neither for a general exegesis nor for a general criticism of his position; our aim here is the more modest (...) one of taking certain points from Foucault's study,The order of things, and seeing how far they can be extended into an area not explicitly considered in that work. (shrink)

Transplantation of vital organs has been premised ethically and legally on "the dead donor rule" (DDR)—the requirement that donors are determined to be dead before these organs are procured. Nevertheless, scholars have argued cogently that donors of vital organs, including those diagnosed as "brain dead" and those declared dead according to cardiopulmonary criteria, are not in fact dead at the time that vital organs are being procured. In this article, we challenge the normative rationale for the DDR by rejecting the (...) underlying premise that it is necessarily wrong for physicians to cause the death of patients and the claim that abandoning this rule would exploit vulnerable patients. We contend that it is ethical to procure vital organs from living patients sustained on life support prior to treatment withdrawal, provided that there is valid consent for both withdrawing treatment and organ donation. However, the conservatism of medical ethics and practical concerns make it doubtful that the DDR will be abandoned in the near future. This leaves the current practice of organ transplantation based on the "moral fiction" that donors are dead when vital organs are procured. (shrink)