ENACTMENT: SOME THOUGHTS ABOUT THE THERAPIST'S CONTRIBUTION

ABSTRACT This paper examines three instances of enactment, which occurred in the early stages of a thrice-weekly therapy. The emphasis is on both the origins and consequences of the therapist's contribution. Particular attention is paid to the unconscious nature of enactment, as a phenomenon that can precipitate both a refusal and an actualization of the patient's transference; the former, in this case, leading to further acting out and the latter to malignant regression.     

Therapy associated leukaemia.

A dose related risk of acute leukaemia, myelodysplasia and other cancers is seen in patients treated with certain drugs, particularly alkylating agents, and radiotherapy either alone or in combination. Treatment associated acute myeloid leukaemia (tAML) and myelodysplasia have biological and clinical features in common and are distinct from the corresponding de-novo disorders. tAML generally occurs between 2-11 years from administration of chemo/radiotherapy with few cases thereafter. Patients may present with myelodysplasia and severe cytopenia with abnormalities in all cell lines or as an acute leukaemia which may be difficult to classify because of multi-lineage involvement. Clonal cytogenetic abnormalities usually including either loss or interstitial deletion of the long arm of chromosomes 5 or 7 are frequently identified. Critical regions deleted in all patients with these lesions have been localised at 5q23-32 and 7q22-31; regions carrying the genes for several haemopoietic growth factors, receptors and oncogenes. The prognosis of patients with tAML is poor with low remission rates and a median survival of 6 months. Complex karyotypes or lesions of chromosomes 5 or 7 seen in the majority of cases are associated with a particularly poor outlook. The risks of this most serious complication of therapy should be weighed carefully against possible benefits.     

The favoured child?

This case conference concerns a child who has been in care following a diagnosis of emotional abuse and a serious incident of physical abuse. She wants to return home again, and her parents, who had previously scapegoated her, now blame the family''s previous ills on her sister instead. The Children Act 1989 gives considerable weight to the child''s wishes, but what if the child returns home and is re-abused? In this case conference a child psychiatrist, a philosopher and a lawyer discuss the issues of clinicians'' responsibilities, moral luck, and child care law.     

The effect of interleukin-2 administration on wound healing in adriamycin-treated rats

Adriamycin (doxorubicin hydrochloride), an effective chemotherapeutic drug, is also a potent inhibitor of wound healing. Conversely, certain polypeptide growth factors are capable of stimulating fibroblasts to secrete collagen, thus enhancing wound healing. The purpose of this study was to determine if interleukin-2 (IL-2), a T-cell growth factor, could reverse the wound healing deficit caused by Adriamycin. Adriamycin treatment caused a significant decrease in wound-breaking strength (P less than 0.005). IL-2 administration increased wound-breaking strength in Adriamycin-treated animals (2126 g vs 1549 g, P less than 0.005). In control animals, IL-2 did not increase wound-breaking strength significantly (2708 g vs 2608 g, P greater than 0.1). Histologically, wounds from Adriamycin-treated animals were less cellular, demonstrated less collagen in the dermis, and a lesser degree of capillary ingrowth. The number of fibroblasts in the dermal layer was increased in animals receiving IL-2. Control rats gained an average of 1.4% of their original body weight, while Adriamycin-treated rats lost an average of 19% of their original body weight (P less than 0.0005). IL-2 administration did not influence weight loss or gain. Hematologically, animals receiving Adriamycin had lower hemoglobin and hematocrit values and higher platelet counts. There were no differences in total white blood cell counts; however, animals receiving Adriamycin showed a predominance of polymorphonuclear leukocytes and a relative decrease in lymphocytes. Animals receiving IL-2 demonstrated a significant eosinophilia. (1) Adriamycin impairs normal wound healing. (2) Interleukin-2 administration improves the wound healing impairment caused by Adriamycin. (3) Interleukin-2 appears to increase infiltration of inflammatory cells, fibroblasts, and capillaries into the wound, which may account for the observed increase in wound breaking strength.     

Segmental intestinal muscular thinning: a possible cause of intestinal obstruction in the newborn

Intestinal obstruction proximal to a transition zone without an interposed physical barrier usually indicates Hirschsprung disease. The authors report one case of focal small bowel muscular thinning just distal to a transition zone that produced clinical and radiographic findings that simulated long-segment Hirschsprung disease in a 2-day-old infant.