[Influence of Depressive Symptoms on Group Therapeutic Psychoeducational Intervention in Psychiatric Patient Groups of Mixed Diagnosis]. / Einfluss depressiver Symptomatik auf gruppentherapeutische Wirkfaktoren diagnosenübergreifender Psychoedukation bei psychiatrischen Patienten.

OBJECTIVE: To analyse the extent of influence of depressive symptoms on the efficiency of group therapeutic psychoeducative intervention in psychiatric patients groups with mixed diagnoses, independently of the primary diagnosis. METHODS: 34 psychiatric inpatients with different diagnoses were allocated to two groups according to the severity of their depressive symptoms. After the psychoeducational group intervention, patients were asked about several parameters concerning the effectiveness of the intervention. RESULTS: Patients suffering from pronounced depressive symptoms seem to benefit less from the intervention. CONCLUSIONS: Psychoeducational intervention is less effective in patients with severe symptoms of depression. This should be taken into consideration concerning the time point when patients should be integrated in such a group, as well as concerning the intensity of the intervention itself.

[Willingness of Psychotherapists in Private Practice to Treat Patients With Complex Post-Traumatic Stress and Dissociative Disorders]. / Bereitschaft niedergelassener Therapeuten zur Behandlung von Patienten mit komplexen posttraumatischen und dissoziativen Störungen.

OBJECTIVE: Analyses of patient care with severe mental disorders. METHODS: Psychotherapists in private praxis were interviewed about their willingness to treat patients with a range of diagnoses in the context of post-traumatic disorders. RESULTS: Therapists were found more willing to treat "less severe" disorders, independent of years in practice, school of psychotherapy, a rural or urban practice setting. Therapists criticized the quality of their training and the health insurance review process. CONCLUSIONS: Therapists are generally willing to treat patients with severe mental disorders, but experience limits of competency attributed to training deficits. They further experience the bureaucratic procedures of the health insurance review process as barriers to accepting these patients into treatment.These results indicate that recently developed concepts of psychotherapy for these patient groups should be more intensively integrated into the existing training curricula. Furthermore, a simplified health insurance review process ought to be considered.

[Clinical prognosis of schizophrenic patients with cannabis addiction. Between nihilism and hope]. / Klinische Prognose schizophrener Patienten mit Cannabisabhängigkeit. Zwischen Nihilismus und Hoffnung.

Comorbid substance use disorders in schizophrenia are mostly associated with an unfavorable course of the disease and with difficulties in clinical management. Therefore, some therapists tend to react to these patients in a resigned manner. However, there is growing evidence for higher cognitive functioning and less severe deficits in brain morphology of these patients compared to patients without cannabis use. A common interpretation refers to relatively low vulnerability for psychosis in some of these patients, who mainly became schizophrenic because of the pro-psychotic properties of cannabis. Low vulnerability is reflected by a higher cognitive functioning; therefore, the pessimistic view of therapists seems unjustified for at least a subgroup of young patients. Provided that patients are treated in adequate therapeutic settings and that they stop using cannabis, a lower vulnerability may be associated with overall better socio-rehabilitative outcome parameters.

[Prevalence of psychosis/substance abuse comorbidity. Clinical-epidemiological findings from different treatment settings in a large German city]. / Prävalenz der Komorbidität Psychose und Sucht Klinisch-epidemiologische Ergebnisse aus verschiedenen Behandlungssettings in einer deutschen Grossstadt.

Comorbid substance use disorders in schizophrenia are of high clinical relevance, because they are common and they are mostly associated with an unfavourable long-term prognosis. Whereas the clinical impression suggests a continuous increase of substance use disorders in patients with schizophrenia over the last 10-20 years, results from epidemiological studies have been inconsistent. The aim of the present investigation was to study the prevalence of substance use disorders within a large sample of patients with schizophrenia in a large German city (Cologne). The prevalence data were examined in different treatment settings (outpatient vs inpatient, university hospital vs mental health hospital). Risk factors for substance use disorders and preferences for specific substances were analysed. The lifetime prevalence of comorbid substance use disorders in the entire sample of 2,337 patients with schizophrenia was 29.4%. However, the data varied substantially depending on the setting of treatment, with the highest comorbidity rates being prevalent in the inpatient sample. Alcohol and cannabis were the most commonly used substances. Commonly recognized risk factors for substance use disorders, such as being male and unmarried and having a low education level, were replicated.

Family functioning and metabolic control of school-aged children with IDDM.

The relationship of two aspects of family life to metabolic control were examined as part of a longitudinal study of school-aged children with newly diagnosed insulin-dependent diabetes mellitus (IDDM). Glycosylated hemoglobin level was the primary index of metabolic control; weight-adjusted insulin dosage served as an indirect index. Neither the quality of family life nor aspects of the parents' marriage predicted the child's metabolic control over the next 3-4 mo, and they were also unrelated to concurrent weight-adjusted insulin dosage. Longitudinal data spanning a 6-yr period of the child's diabetes also failed to reveal an association between aspects of family life and metabolic control. The significance of the findings are discussed in light of the sample's characteristics and possible methodological constraints.

Development of a self-inactivating, minimal lentivirus vector based on simian immunodeficiency virus.

In contrast to oncoviruses, lentiviruses do not require target cell division for integration into the host genome. Lentiviral vectors can therefore expand the spectrum of target cells susceptible to retroviral gene transfer. To analyze whether vectors based on simian immunodeficiency viruses (SIVs) could be used for gene transfer, a three-plasmid vector-packaging system was developed, in which Gag-Pol and the vector itself are of SIV origin, while Env is derived either from SIV, amphotropic murine leukemia virus (MuLV), or the G glycoprotein of vesicular stomatitis virus (VSV-G). To increase the safety of the SIV vector system, a self-inactivating SIV vector was constructed. After optimization of the SIV gag-pol expression plasmid, a minimal SIV vector, which contained only SIV sequences present on the multiply spliced nef transcript, could still be produced at titers of 2 x 10(5) infectious units/ml. Growth-arrested cells could be transduced with this vector even if vif, vpr, vpx, and nef had been deleted from the packaging construct and the vector.

There are no reliable symptoms for erosive oesophagitis and Barrett's oesophagus: endoscopic diagnosis is still essential.

AIMS: To evaluate the sensitivity and specificity of different symptoms in erosive reflux oesophagitis and Barrett's oesophagus. METHODS: The presence of reflux symptoms was compared between a case population of 306 patients with endoscopically determined erosive reflux oesophagitis, 235 patients with biopsy-proven Barrett's oesophagus and a control population of 198 subjects without reflux disease. RESULTS: Heartburn at any time and heartburn at night represented the only two symptoms to be simultaneously sensitive and specific. Symptoms that were induced by various foods, such as fat, tomato, chocolate, citrus or spices, tended to cluster in the same sub-group of patients. Similarly, heartburn induced by exercise, lying down or bending over tended to occur in the same sub-groups. The frequency of symptoms was influenced more by the presence of mucosal erosions than by the presence of Barrett's oesophagus. Reflux symptoms occurred more frequently in the presence rather than the absence of Barrett's oesophagus, and in long segment rather than short segment of Barrett's mucosa. CONCLUSIONS: Endoscopic inspection of the oesophageal mucosa remains the only certain method by which to reliably diagnose erosive reflux oesophagitis and Barrett's oesophagus.

Walking and chewing reduce postprandial acid reflux.

BACKGROUND: Gastro-oesophageal reflux is worse after meals, and antacids are usually consumed after dietary indiscretion. AIM: To investigate whether walking or gum chewing affect meal-induced gastro-oesophageal reflux. METHODS: The study population comprised 12 case subjects with gastro-oesophageal reflux disease and 24 healthy controls. Each subject was studied using pH-metry for 5 h on 3 separate days. After baseline recording of pH for 1 h, all subjects were fed a standard breakfast over a 20-min period. On one of the days, oesophageal pH was recorded after the 20-min eating period for an additional 4 h in the sitting position. On another day, postprandial oesophageal pH was recorded for the first hour whilst walking, and for 3 subsequent hours whilst sitting. During a third day, oesophageal pH was recorded for the first postprandial hour whilst gum-chewing, followed by 3 h of sitting. RESULTS: Food intake promoted gastro-oesophageal reflux in case subjects with GERD as well as in healthy controls, although postprandial reflux was more pronounced amongst the refluxers than amongst the controls. Chewing gum for 1 h after the meal reduced the acid contact time in both groups, with a more profound effect in refluxers than in controls. Whilst the beneficial effect of 1-h of gum-chewing lasted for up to 3 h in both groups, the beneficial effect of 1-h of walking was apparent only in refluxers, only to a mild degree, and only for a short duration. CONCLUSIONS: Chewing gum after a meal helps to reduce postprandial oesophageal acid exposure.

Inguinal hernia is not a sign of colon cancer: results of a prospective screening trial.

BACKGROUND: It has been suggested that patients with an inguinal hernia harbour an increased risk for colorectal cancer. METHODS: In a prospective clinical trial, we compared the prevalence of colonic neoplasms in 100 cases with inguinal hernia and 100 controls without inguinal hernia. The number, size, histology type, and the location of all colorectal lesions found during a screening flexible sigmoidoscopy were recorded. RESULTS: Not a single case of colorectal cancer was detected in the patients with inguinal hernia pending surgical repair. In the asymptomatic control subjects, one Dukes A and one Dukes B1 colon cancer were detected. Polypectomy was performed in 15% and 17% of the case and control subjects, respectively. During a 5-year period following the initial screening procedure, none of the case or control subjects was diagnosed with colon cancer. CONCLUSIONS: The decision for or against performing an endoscopic procedure in a patient with inguinal hernia should be guided by the general principles of screening for colorectal cancer. The mere presence of an inguinal hernia does not automatically increase the risk of colorectal cancer.

Lansoprazole heals erosive reflux oesophagitis in patients with Barrett's oesophagus.

BACKGROUND: Barrett's oesophagus is thought to be a complication of severe gastro-oesophageal reflux. AIM: To determine whether the proton pump inhibitor, lansoprazole, is effective in healing erosive reflux oesophagitis in patients with Barrett's oesophagus. METHODS: An 8-week, randomized, double-blind study was conducted using patients with both erosive reflux oesophagitis and Barrett's oesophagus. Erosive reflux oesophagitis was defined as grades 2-4 oesophagitis; Barrett's oesophagus, as specialized columnar epithelium obtained by biopsy from the tubular oesophagus; and healing, as a return to grade 0 or 1 oesophageal mucosa (complete re-epithelialization). One-hundred and five (105) patients from one centre were randomized to receive either lansoprazole 30 mg daily or ranitidine 150 mg twice daily. Unhealed or symptomatic lansoprazole patients at week 4 were randomized to receive the same 30 mg dose daily or an increased dose of 60 mg daily. Endoscopy was performed at baseline and at weeks 2, 4, 6 and 8. RESULTS: The treatment groups were similar in regards to baseline characteristics, erosive reflux oesophagitis grades and length of Barrett's oesophagus. At each 2-week interval, lansoprazole patients had significantly greater healing rates and less day and night heartburn and regurgitation than ranitidine patients. There were no significant differences between treatment groups in antacid use, quality of life parameters, or rate of reported adverse events. Median values for fasting serum gastrin levels remained within the normal range for both groups. CONCLUSION: In patients with both Barrett's oesophagus and erosive reflux oesophagitis, lansoprazole is significantly more effective than ranitidine in relieving reflux symptoms and healing erosive reflux oesophagitis.

Fecal occult blood testing: a false sense of security?

BACKGROUND: Recent screening studies with fecal occult blood testing (FOBT) report that one of three patients with colorectal cancer (CRC) can be cured of the disease; minimal attention has been given to the two of three patients who despite repeated screening go on to die of silent CRC. We report the known "miss rate" (known false negatives) of our 14-year ongoing program of FOBT that was organized in 1979 to detect early CRC. METHODS: From October 1979 through December 1993, 36,034 FOBT kits were distributed to patients who were without gastrointestinal complaints at Hines Veterans Affairs Hospital. The test was considered positive if at least one result of the six tests was positive and negative if the test result was equivocal. Patients with negative FOBT received a new test kit each year by mail. A positive test was followed by full colonoscopy or an air contrast barium enema if a full colonoscopy was not possible. RESULTS: The overall return rate was 47.8%. CRC was detected in 115 patients: 94 had a favorable and 21 had an unfavorable Duke's C or D or lymphoma prognosis. Of 21 patients 13 (62%) had initially tested FOBT negative (missed lesion). Of the 21 cases of advanced CRC 15 (71.43%) were in the descending, sigmoid, or rectosigmoid colon or rectum. CONCLUSIONS: (1) The majority (82%) of all CRC detected by FOBT screening are diagnosed at a favorable stage. (2) The majority of known advanced CRC (62%) escape early detection with FOBT. (3) Five (62.5%) of eight of the advanced CRC cases discovered on initial FOBT and 10 (76.9%) of 13 of advanced CRC cases missed on initial FOBT but detected in subsequent years were in the left colon and most likely in the range of the flexible sigmoidoscope. (4) FOBT as a sole screening test may provide a false sense of security, especially in patients with advanced left-side CRC.

Risk factors of oesophagitis in arthritic patients.

BACKGROUND: The risk factors that precipitate the occurrence of oesophageal mucosal injury in patients on continuous nonsteroidal anti-inflammatory drug (NSAID) therapy are unknown. METHODS: Outpatients who regularly consumed NSAIDs for osteoarthritis were recruited from a rheumatology clinic into a prospective case-control study. All patients answered a structured interview and underwent upper gastrointestinal endoscopy. RESULTS: Of 450 eligible patients, 195 (43%) consented to be interviewed and undergo upper gastrointestinal endoscopy. Oesophagitis was diagnosed in 41 of these 195 patients (21%). The occurrence of gastric or duodenal ulcer in individual patients did not predict the concomitant damage of the oesophageal mucosa. Young age (odds ratio: 1.79 per decade of life; 95% confidence interval: 1.11-2.86) and hiatus hernia (odds ratio: 3.72; 95% confidence interval: 1.63-8.49) both increased the risk of developing oesophagitis. When questioned, all oesophagitis patients revealed at least one gastrointestinal symptom, heartburn being named most frequently (odds ratio: 4.78; 95% confidence interval: 2.04-11.17). The type of anti-inflammatory medication, the use of alcohol and the use of nicotine were not associated with any significant risk for erosive oesophagitis. CONCLUSIONS: Patients on chronic NSAID therapy for rheumatological disease suffer frequently from erosive oesophagitis. While the risk may be higher in patients with a pre-existing tendency for gastro-oesophageal reflux, any concomitant history of NSAID-induced peptic ulcer disease does not add to the risk. Erosive oesophagitis should be considered especially in patients on NSAIDs who complain of heartburn.

Barrett's esophagus. The cytology of dysplasia in comparison to benign and malignant lesions.

Barrett's esophagus (BE) is the replacement of esophageal squamous epithelium by columnar-lined mucosa and carries an increased risk of carcinoma. Endoscopic surveillance has been suggested, but esophageal brush cytology (BC) has not been widely utilized. Cytologic descriptions of BE, especially dysplasias, are sparse. We studied matched cytologic and histologic materials from 26 patients with BE and 4 patients with concurrent BE and adenocarcinoma. In six patients without dysplasia on biopsy, BE was recognized on BC by the presence of goblet cells within clusters of uniform columnar cells with vesicular nuclei. Dysplasia in 18 BC samples revealed small clusters of haphazardly oriented, mildly pleomorphic cells. Their larger nuclei had thickened membranes, evenly dispersed chromatin and occasional multiple nucleoli. The cytologic differentiation of histologically graded low- and high-grade dysplasia was difficult. The carcinoma cases displayed numerous isolated cells exhibiting flagrant malignant features. We conclude that BE lesions are cytologically distinctive and suggest that BC may play a role in surveillance.

Performance, carcass, and palatability traits for cull cows fed high-energy concentrate diets for 0, 14, 28, 42, or 56 days.

Cull cows, thin to moderate in initial condition scores, were randomly assigned within breed to slaughter groups and fed a high-concentrate diet for 0, 14, 28, 42 or 56 d (n = 40). Carcass data were collected, and one side of each carcass was fabricated into boneless subprimals, lean trimmings, fat, and bone. Live and carcass weights, ADG, and dressing percentage increased through 28 d of feeding (P < .05), and lean firmness increased (P < .05) through 42 d of feeding. Adjusted preliminary yield grades and final yield grades increased (P < .05) with feeding, but not to levels requiring knife trimming of fat. Fat color became whiter (P < .05) but marbling was not affected (P > .05) by feeding. Weights of fat-free lean, fat, and bone and percentages of fat in soft tissues of cow carcasses increased (P < .05) by 28 d on feed. Overall steak tenderness was higher (P < .05) for cows fed 56 d than for cows fed 0 or 14 d. Warner-Bratzler shear force was not affected by feeding. Amounts of soluble collagen increased (P < .05) in the longissimus muscle between 0 and 28 d on feed, and total collagen decreased (P < .05) in the biceps femoris muscle between 0 and 42 d on feed. Continental European cow carcasses yielded more fat-free lean and less fat (P < .05) and dairy cows generally provided the most tender product across all slaughter periods. In general, sensory tenderness and yields of cow carcass components increased without requiring excessive trimming of fat by feeding cull beef and dairy cows for periods up to 56 d.

Porcine bone marrow: extraction procedure and characterization by bone type.

Data on porcine and bovine bone marrow composition indicate high calcium content, which may be erroneously elevated owing to the marrow recovery process. A method of bone marrow recovery was developed that involved passing marrow extracted from bone through a filter-press mechanism to remove very fine bone particles and dust, allowing a more accurate analysis of marrow. Calcium values were reduced approximately 90% and ash values reduced more than 50% compared to other reported data. The new recovery method did not require sawing away the hard bone and it removed particulate that may have interfered with analyses. Bone marrow was characterized by bone type. Rib bone marrow had higher protein, iron, non-heme iron and total pigment than scapula, aitch/hip bone or vertebrae marrow. Fat ranged from 17·81 to 26·76% and calcium ranged from 27·25 to 44·33mg 100g(-1) among bone types. The pH of bone marrow ranged from 7·14 to 7·53. Bone marrow appears to contribute to some of the properties of meat obtained from advanced meat recovery systems.

Maintenance therapy for peptic ulcer disease: an overview of medical treatment.

Peptic ulcer disease is a chronic disorder that manifests as recurrent episodes of pain or complications such as bleeding or perforation. Current medical therapy with H2-receptor blockers or sucralfate effectively prevents most recurrences and, according to clinical trials, may prevent complications. Since this treatment does not alter the natural history of peptic ulcer disease, continued therapy is needed. Surgical treatment does permanently alter the history of recurrence. Medical therapy aimed at eradicating Helicobacter pylori infection is an exciting new development and shows promise of a medical "cure" for peptic ulcer disease. However, many questions remain unanswered about this treatment. This review examines the natural history and long-term treatment of peptic ulcer disease.

Adenocarcinomas arising in tongues or short segments of Barrett's esophagus.

The diagnosis of Barrett's esophagus is established when the esophageal mucosa is lined by 2-3 cm of columnar epithelium or when specialized (intestinal type) columnar epithelium of any length is present. Emphasis is frequently placed on long segments of Barrett's because these patients reportedly are at higher risk of developing adenocarcinoma than patients with shorter segments. We present four cases of adenocarcinoma that arose in tongues or short segments (less than 2 cm) of specialized columnar epithelium near the gastroesophageal junction. We emphasize the need for biopsy of minimal appearing abnormalities in this area, and we suggest that histologic subtype, rather than length of involvement, be the major criterion for establishment of Barrett's esophagus.

No association between gallstones and gastroesophageal reflux disease.

OBJECTIVES: Gallstones and hiatal hernia reportedly have been linked to similar dietary factors prevalent in western countries, and patients with cholelithiasis or previous cholecystectomy have been reported to have more duodenogastric reflux than healthy controls. Nonetheless, the contribution of duodenogastric reflux to the development of gastroesophageal reflux disease (GERD) remains controversial. The present study was aimed to assess the association between gallstone disease and GERD. METHODS: Outpatients from general medical clinics who underwent upper GI endoscopy and abdominal ultrasonography were recruited into a case-control study. A case population of 790 patients with various grades of GERD was compared to a control population of 407 patients without GERD. In a multivariate logistic regression, the presence of GERD served as the outcome variable, whereas the presence of gallstones, hiatal hernia, social habits, and demographic characteristics served as predictor variables. RESULTS: No associations were found between the presence of cholelithiasis or previous cholecystectomy and GERD or between the presence of cholelithiasis or previous cholecystectomy and hiatal hernia. The severity of GERD also remained unaffected by the presence of gallstones. The occurrence of GERD was influenced only by hiatal hernia (odds ratio [OR] = 3.15, 95% CI = 2.44-4.08), alcohol consumption (OR = 1.47, CI = 1.08-1.99), and not by cholelithiasis (OR = 1.02, CI = 0.68-1.51), or cholecystectomy (OR = 0.90, CI = 0.64-1.28). The frequency of GERD among hiatus hernia patients with gallstones (437/592 = 74%) was similar to the frequency of GERD among hiatus hernia patients without gallstones (168/220 = 76%, p = 0.516). CONCLUSIONS: Neither cholelithiasis nor cholecystectomy poses a risk for the occurrence of GERD or hiatal hernia. Gallstone disease does not seem to influence the integrity of the esophageal mucosa through GERD.

Mucosal reactive oxygen species production in oesophagitis and Barrett's oesophagus.

Reactive oxygen species (ROS) produced by inflammatory cells can contribute to tissue destruction. ROS have been implicated in various gastrointestinal abnormalities, including the acid related peptic diseases. Although the development of oesophagitis and Barrett's columnar epithelium is associated with prolonged reflux of gastric acid, the exact mechanism by which tissue damage occurs is not known. To discover if ROS are involved in damage to the oesophageal mucosa, this study measured in vitro the mucosal ROS concentrations of biopsied mucosal samples taken from patients with reflux oesophagitis using luminol enhanced chemiluminescence (LECL). Mucosal biopsy specimens were taken from 83 patients: 19 with normal oesophageal mucosa (group I); 20 with macroscopic oesophagitis (group II); 20 with biopsy confirmed Barrett's epithelium without macroscopic oesophagitis (group III); and 24 with Barrett's epithelium with macroscopic oesophagitis (group IV). The mucosa from patients exhibited significantly higher LECL values than the mucosa from controls. But, there were no significant differences between groups II, III, and IV. Addition of the myeloperoxidase inhibitor, azide, or the hydrogen peroxide scavenger, catalase, to the tissue suspension caused a decrease in LECL values of 32% and 45%, respectively, suggesting that neutrophils--although important--are not the only source of mucosal LECL. These data are consistent with the proposal that ROS play an important part in the tissue injury associated with oesophagitis and Barrett's columnar epithelium.