Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience.

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

[Bi-directional ventricular tachycardia and pheochromocytoma: a case report]. / Tachycardie ventriculaire bidirectionnelle et phéochromocytome: a propos d'un cas.

We present the case of a 48 year old woman who was admitted to our university hospital in cardiogenic shock with bi-directional ventricular tachycardia degenerating into polymorphic venricular tachycardia which resolved spontaneously. Investigation revealed healthy coronary arteries but severe left ventricular dysfunction due to akinesia involving the entire base. There was a rapid improvement within several days. The diagnosis of bilateral phaeochromocytoma was made on the biochemistry and CT scan of the adrenals.

[Septal alcoholisation of hypertrophic obstructive cardiomyopathy in childhood]. / Alcoolisation septale d'une cardiomyopathie hypertrophique obstructive de l'enfant.

The authors report a case of septal alcoholisation in a 6 year old child with hypertrophic obstructive cardiomyopathy responsible for congestive cardiac failure despite optimal betablocker therapy. The indication was retained in a context of mucoviscidosis complicated by multiresistant bacterial infection. At catheterisation, the dominant septal artery was identified and an alcoholisation was performed by the classic technique described in adults. The immediate result was satisfactory with regression of the signs of cardiac failure and reduction of 70 mmHg of the maximal instantaneous pressure gradient (from 160 to 90 mmHg). However, 10 months later, the signs of right heart failure reappeared with a partial increase in the maximal instantaneous pressure gradient (100 mmHg) leading to surgical myectomy while the patient's condition had considerably improved from the pulmonary point of view. Septal alcoholisation would appear to be a therapeutic alternative in children especially in cases with a temporary or permanent contraindication to conventional surgery.

Six-month and one-year followup of 23 weeks of aerobic exercise for individuals with fibromyalgia.

OBJECTIVE: To measure mood and physical function of individuals with fibromyalgia, 6 and 12 months following 23 weeks of supervised aerobic exercise. METHODS: This is a followup report of individuals who were previously enrolled in 23 weeks of land-based and water-based aerobic exercise classes. Outcomes included the 6-minute walk test, Beck Depression Inventory (BDI), State-Trait Anxiety Inventory, Arthritis Self-Efficacy Scale (ASES), Fibromyalgia Impact Questionnaire (FIQ), tender point count, patient global assessment score, and exercise compliance. Outcomes were measured at the start and end of the exercise classes and 6 and 12 months later. RESULTS: Analyses were conducted on 29 (intent-to-treat) or 18 (efficacy) subjects. Six-minute walk distances and BDI total scores were improved at followup (all analyses). BDI cognitive/affective scores were improved at the end of 23 weeks of exercise (both analyses) and at the 12-month followup (efficacy analysis only). BDI somatic scores were improved at 6-month (both analyses) and 12-month followup (intent-to-treat only). FIQ and ASES function were improved at all followup points. ASES pain was improved in efficacy analyses only (all followup points). Tender points were unchanged after 23 weeks of exercise and at followup. Exercise duration at followup (total minutes of aerobic plus anaerobic exercise in the preceding week) was related to gains in physical function (6- and 12-month followup) and mood (6-month followup). CONCLUSION: Exercise can improve physical function, mood, symptom severity, and aspects of self efficacy for at least 12 months. Exercising at followup was related to improvements in physical function and perhaps mood.

Measuring exercise-induced mood changes in fibromyalgia: a comparison of several measures.

OBJECTIVE: To compare scales measuring exercise-induced changes in mood. METHODS: Mood changes in a randomized, 23-week controlled trial of exercise were assessed using the Beck Depression Inventory (BDI), Center for Epidemiologic Studies Depression Scale (CES-D), State Trait Anxiety Inventory (STAI), Fibromyalgia Impact Questionnaire, and the Mental Health Inventory (MHI). Effect sizes and t-tests were computed on 23-week change scores. Scales were deemed to be confounded if items addressed sleep disturbances, fatigue, or effort (symptoms of both mood disturbances and fibromyalgia). RESULTS: Efficacy (15 exercise subjects) and intent-to-treat analyses (27 exercise subjects) generated medium effects for BDI (total, cognitive), MHI depression (efficacy only), and CES-D (intent-to-treat only) scales. BDI (total, cognitive), MHI (depression, positive affect, total [MHI-5]), and STAI scales distinguished exercise from control subjects at 23 weeks in all analyses. BDI somatic and CES-D scales were deemed to be confounded. CONCLUSION: We recommend the BDI cognitive, STAI, and MHI-5 scales to measure depression, anxiety, and general mood, respectively, in patients with fibromyalgia.

Illness intrusiveness among survivors of autologous blood and marrow transplantation.

BACKGROUND: Illness-induced disruptions to lifestyles, activities, and interests (i.e., illness intrusiveness) compromise subjective well-being. The authors measured illness intrusiveness in autologous blood and bone marrow transplantation (ABMT) survivors and compared the results with survivors of solid organ transplants. METHODS: Forty-four of 64 consecutive ABMT survivors referred to the University of Toronto ABMT long-term follow-up clinic completed the Illness Intrusiveness Ratings Scale (IIRS), the Affect Balance Scale (ABS), the Atkinson Life Happiness Rating (ATKLH), the Beck Hopelessness Scale (BHS), and the Center for Epidemiologic Studies Depression (CES-D) Scale. Mean time from ABMT to evaluation was 4.6 +/- 2.8 years. All patients were in remission or had stable disease at the time of evaluation. Autologous blood and bone marrow transplantation patients' IIRS scores were compared with scores reported by recipients of kidney (n = 357), liver (n = 150), lung (n = 77), and heart (n = 60) transplants. RESULTS: Mean IIRS score for the 44 ABMT patients was 37.2 +/- 17 (maximum possible score, 91; minimum possible score, 13). Higher IIRS scores correlated with lower scores on the ABS (r = -0.54; P < 0.0001), and ATKLH (r = -0.44; P = 0.004), and with higher scores on the BHS (r = 0.58; P < 0.0001) and CES-D (r = 0.48; P < 0.0001). The authors compared IIRS scores from the ABMT survivors with scores from recipients of solid organ transplants. Scores were corrected for age, gender, and time from transplant to evaluation. Corrected mean IIRS scores for the marrow (37.5), kidney (38.9), heart (40.0), lung (30.1), and liver (32.3) transplant recipients differed significantly (P < 0.0001 by analysis of covariance). Higher scores among marrow, kidney, and heart transplant survivors were caused by increased scores in the instrumental domain of the IIRS that measures disruptions in health, work, financial situation, and active recreation. CONCLUSIONS: Despite achieving a remission after ABMT, patients continue to experience illness intrusiveness compromising subjective well-being.

Effect of a randomized, controlled trial of exercise on mood and physical function in individuals with fibromyalgia.

OBJECTIVE: To evaluate the effect of exercise on mood and physical function in individuals with fibromyalgia. METHODS: Subjects were randomly assigned to an exercise (EX) or control (CTL) group. EX subjects participated in 3 30-minute exercise classes per week for 23 weeks. Subjects were tested at entry and at 6, 12, and 23 weeks. Tests included the Beck Depression Inventory (BDI), 6-minute walk, State-Trait Anxiety Inventory (STAI), Mental Health Inventory (MHI), Fibromyalgia Impact Questionnaire (FIQ), Arthritis Self-Efficacy Scale (ASES), and a measure of tender points and knee strength. RESULTS: Fifty subjects (27 EX, 23 CTL) completed the study, and 31 (15 EX, 16 CTL) met criteria for efficacy analyses. In efficacy analyses, significant improvements were seen for EX subjects in 6-minute walk distances, BDI (total, cognitive/ affective), STAI, FIQ, ASES, and MHI (3 of 5 subscales) scores. These effects were reduced but remained during intent-to-treat analyses. CONCLUSION: Exercise can improve the mood and physical function of individuals with fibromyalgia.

Gender and psychosomatic aspects of ischemic heart disease.

While women and their doctors have traditionally worried about mortality from breast and gynecological malignancies, over the past 5 years they have come to realize that ischemic cardiac disease (IHD) is the number one killer of women in most Western countries. This has led to public and professional education campaigns and a new emphasis on gender and gender-specific research in IHD. Unfortunately, this literature remains poorly developed and much work remains to be done. Even in samples in which there may be sufficient numbers to allow for the evaluation of gender and gender differences, these important analyses have often been overlooked. This article provides a review of what is known about gender and gender differences in psychosocial and behavioral issues in IHD.

Somatization, illness attribution and the sociocultural psychiatry of chronic fatigue syndrome.

In addition to epidemiological and neurobiological perspectives on the relationship between chronic fatigue syndrome (CFS) and psychiatric disorders there has been increasing interest in the role of cognitive-behavioural, psychological, psychodynamic and social factors in the psychiatric aspects of this syndrome. These factors may be important in the initiation and/or maintenance of CFS and play important roles in the misdiagnosis of primary psychopathology as CFS. They may be important targets for intervention and treatment. This paper examines the relevance of the following issues for better understanding the relationship between CFS and the results of psychiatric studies: (1) the concepts of somatization and abnormal illness behaviour; (2) the role of patients' illness attributions; (3) psychological and psychodynamic constructs such as depressive vulnerability occurring in individuals dependent upon achievement for the maintenance of self-esteem and euthymic mood, perfectionism, and helplessness; (4) the role of personality characteristics and styles; (5) the potential iatrogenic role of the health care system in producing disability in individuals with a diagnosis of CFS; (6) the role of the media and other sociocultural forces in the patient's choice of the CFS label; and (7) the impact of the CFS label on the patient. The importance of differentiating between initiating and maintaining or perpetuating factors is emphasized.

Assessment of regional cerebral perfusion by 99Tcm-HMPAO SPECT in chronic fatigue syndrome.

Chronic fatigue syndrome (CFS) is a severely disabling illness of uncertain aetiology. It is characterized by a chronic, sustained or fluctuating sense of debilitating fatigue without any other known underlying medical conditions. It is also associated with both somatic and neuropsychological symptoms. Both physical and laboratory findings are usually unremarkable. Regional cerebral blood flow (rCBF) was assessed in 60 clinically defined CFS patients and 14 normal control (NC) subjects using 99Tcm-hexamethylpropyleneamine oxime (99Tcm-HMPAO) single photon emission computed tomography (SPECT). Compared with the NC group, the CFS group showed significantly lower cortical/cerebellar rCBF ratios, throughout multiple brain regions (P < 0.05). Forty-eight CFS subjects (80%) showed at least one or more rCBF ratios significantly less than normal values. The major cerebral regions involved were frontal (38 cases, 63%), temporal (21 cases, 35%), parietal (32 cases, 53%) and occipital lobes (23 cases, 38%). The rCBF ratios of basal ganglia (24 cases, 40%) were also reduced. 99Tcm-HMPAO brain SPECT provided objective evidence for functional impairment of the brain in the majority of the CFS subjects. The findings may not be diagnostic of CFS but 99Tcm-HMPAO SPECT may play an important role in clarifying the pathoaetiology of CFS. Further studies are warranted.

Neurasthenia and chronic fatigue syndrome: the role of culture in the making of a diagnosis.

Chronic fatigue syndrome is an increasingly popular diagnosis consisting of multiple psychiatric and somatic symptoms. It bears a striking resemblance to the nineteenth-century diagnosis of neurasthenia. Both disorders arose during periods characterized by a preoccupation with commerce and material success and major changes in the role of women. They illustrate the role of culture in the development of a new diagnosis that emphasizes a "medical" rather than "psychiatric" etiology. The authors argue that chronic fatigue syndrome will meet the same fate as neurasthenia--a decline in social value as it is demonstrated that the majority of its sufferers are experiencing primary psychiatric disorders or psychophysiological reactions and that the disorder is often a culturally sanctioned form of illness behavior.

Chronic fatigue syndrome and depression: cause, effect, or covariate.

Depressed mood and the psychiatric diagnosis of major depressive episode (MDE) are common findings in patients with chronic fatigue syndrome (CFS). The relationship between depression and CFS is unclear and may be explained by one of four models: (1) CFS is an atypical manifestation of MDE; (2) depression is the result of CFS as either an organic mood syndrome or an adjustment reaction; (3) CFS and MDE are covariates; and (4) the diagnosis of MDE is artifactual. The evidence for these models is discussed. The potentially confounding effect of depression on tests of immune function and neuropsychological testing is described. The implications of these different models for the design of studies of CFS are examined.

Chronic fatigue syndrome and the psychiatrist.

The number of patients who are identified as having chronic fatigue syndrome (CFS) has increased, and as a result, chronic fatigue syndrome has received widespread attention. Research has demonstrated that cognitive, affective and behavioural symptoms are prominent in CFS. Psychiatrists are therefore being asked to participate in the assessment and management of patients with this syndrome. This paper will provide an overview of the clinical characteristics of CFS and the current empirical findings related to its pathology, and will conclude with a discussion of the management of these patients.

Self-report symptoms that predict major depression in patients with prominent physical symptoms.

The diagnosis of depression in patients presenting with both depressive and physical symptoms is potentially confounded and problematic. The present study of 271 patients with four types of illness all with prominent physical symptoms--end-stage renal disease (n = 99), irritable bowel syndrome (n = 21), post-infectious neuromyasthenia (n = 25) and eating disorders (n = 126)--investigates if there are a group of symptoms on the Beck Depression Inventory (BDI) which predict the diagnosis of major depressive episode (MDE) made using the Diagnostic Interview Schedule (DIS). Discriminant function analysis of BDI responses yielded a four item function--self-hate, indecisiveness, loss of appetite and suicidal thoughts--which maximally discriminated between patients with and without a current MDE and correctly classified 75 percent of subjects.

The neuropsychological dimensions of postinfectious neuromyasthenia (chronic fatigue syndrome): a preliminary report.

Postinfectious neuromyasthenia (PIN) is a clinical syndrome of protracted and incomplete recovery after an apparent viral-like illness. Medical investigation yields few abnormalities which might account for the symptomatology. A substantial number of PIN patients complain of cognitive changes. Specific complaints include impaired attention, concentration and abstraction skills. This study was designed to systematically investigate whether the aforementioned subjective complaints could be quantified objectively using standard neuropsychological instruments. Results indicated that on all tests but one, the subjects' performances were significantly higher than those of their age matched groups in the normative data. Specifically, PIN patients scored significantly better than their age matched norms on tests of concentration, attention and abstraction. What is most striking is the discrepancy between the subjective complaints of cognitive impairment and the objective results of the subjects' performances on all tests. These findings suggest that psychological factors may play an important role in the cognitive functioning of individuals diagnosed with postinfectious neuromyasthenia.

Secretion of plasminogen activators by human colorectal and gastric tumor explants.

Conditioned media from explants of human colorectal and gastric tumors in short-term organ culture were analysed for plasminogen activator activity, activity toward the synthetic urokinase substrate, Spectrozyme-UK, and for the presence of urokinase antigen using monospecific goat antibody, by enzyme-linked immunosorbent assay. Comparisons were made between primary tumors, adjacent normal mucosa and metastatic lesions. These analyses were carried out on unfractionated culture fluids and on fractions obtained by fast protein liquid chromatography separation using Superose 6 gels. Plasminogen activator activity, tested by azocaseinolysis in the presence of added plasminogen, was restricted to peaks of 55 kD and 155 kD. These were of the urokinase type as shown by specific immunoinhibition and by absorption by an antiurokinase antibody-Affigel 10 column. Spectrozyme-UK, in addition to these peaks, detected a series of higher molecular weight activities, the largest of which appeared in the void volume, and were therefore of greater than 10(6) molecular weight. These activities were greatly increased by inclusion of trace plasmin indicating that these components were mostly in their proenzyme forms. The characteristics of these very large enzymes were similar to those isolated earlier from a human lung cancer cell line. Comparison of the primary and metastatic tumors confirmed earlier observations showing that urokinase secretion by the metastatic tumors was greatly reduced in comparison with the primary tumors: in the colon carcinomas it was 10 per cent of the value for the primary, in the gastric tumors 3 per cent, whether means or medians were compared (P less than 0.0001). This large difference was characteristic only of plasminogen activator secretion assayable by azocaseinolysis; activities toward Spectrozyme-UK, and antigen reacting with anti-urokinase antibody, were considerably less different in the two groups. In individual tissues, no correlation was found between the amount of extractable plasminogen activator and amounts secreted, or between the latter and the amount of lactic acid released. It is postulated that the greatly reduced plasminogen activator secretion by explants of metastatic tumors may be a phenotypic characteristic of distinct advantage for cancer cells destined to initiate metastatic foci, and may contribute to the ability of circulating cancer cells to lodge in the blood vessels of the target organ.