Incidence and treatment of positive pelvic sidewall lymph nodes in patients with rectal cancer.

AIM: The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. METHODOLOGY: This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. RESULTS: There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. CONCLUSIONS: This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.

Stress-induced changes in the aged-rat adrenal cortex. Histological and histomorphometric study.

BACKGROUND: Stress exposure exerts direct effects on the morphology and functionality of the adrenal cortex. In addition, ageing effects growth, differentiation, apoptosis and cellularity of the cortex. The missing data is the combined effect of stress and ageing on the adrenal cortex. The aim of this study was to demonstrate the structural changes in the adrenal cortex following the exposure to stress in the adult and aged albino rats. MATERIALS AND METHODS: Forty rats were divided into groups I and II (adult and senile). Each group was further subdivided into subgroups a and b (control and stressed). Light and electron microscopic studies were done. Area per cent of collagen fibres (Masson's trichrome-stained sections), number of proliferating cells (optical density immunoreactivity in the Ki67 stained sections) and thickness of the three adrenal zones were also measured. RESULTS: Lamellar separation of the capsule with subcapsular spindle cell hyperplasia and areas of ghost cells were observed in zona glomerulosa (ZG) and zona fasciculata (ZF) in group I-b. Separation and indentation of the capsule with its lamellar separation were observed in group II-a with the existence of multiple scattered degenerative foci in ZF and zona reticularis (ZR). Similar and aggressive was the architectural pattern of ZF in group II-b with the presence of areas of homogenous degeneration. The nuclei of ZG had marginated chromatin in group I-b and were pyknotic with deformed irregular outlines in group II-b. Multiple lysosomes and vacuolar degeneration mitochondria were also seen in group I-b. The nuclei of ZF were irregular with condensed marginated heterochromatin in group I-b, irregular with scattered chromatin in group II-a and indented with areas of chromatin destruction in group II-b. Mitochondria with disrupted cristae and cristolysis were also detected in group I-b. Numerous lipofuscin granules and dilated smooth endoplasmic reticulum were revealed in group II-b. The mean collagen fibre area per cent and the mean number of the proliferating cells in group II-b were significantly higher by 39% and 23%. The thickness of ZG decreased significantly by 20% in group I-b. Contrary, the thickness of both ZF and ZR increased significantly by 10% in group I-b. CONCLUSIONS: Histological alterations occurred in the adrenal cortex in response to stress, especially when coupled with the advance of age. This was accompanied by increase in the area per cent of collagen fibres and increase in the mean number of the proliferating cells in the adrenal cortex.

Pelvic exenteration for advanced malignancy in elderly patients.

BACKGROUND: Pelvic exenteration is an aggressive surgical procedure reserved for highly selected patients. Surgery in the elderly is often associated with increased morbidity and mortality. The aim of this study was to review outcomes following exenteration for advanced pelvic malignancy in this subgroup of patients. METHODS: All patients aged 70 years and over who underwent pelvic exenteration between 1999 and 2014 were included in the study. This comprised all primary rectal, gynaecological and bladder tumours. The primary outcome measure was 5-year overall survival. Secondary endpoints were postoperative morbidity and 30-day mortality. RESULTS: A total of 94 patients were included, with a median age of 76 (range 70-90) years. There were 65 rectal, 20 gynaecological and nine bladder tumours. The administration of neoadjuvant therapy was significantly different among tumour types (P = 0·002). A total of 32 patients (34 per cent) developed postoperative complications, and there were six deaths (6 per cent) within 30 days of surgery. Median survival was 64 months for patients with rectal cancer, 30 months for those with gynaecological tumours and 15 months for those with bladder cancer. Five-year survival rates in these groups were 47, 31 and 22 per cent respectively (P = 0·023). CONCLUSION: Given the possibility of long-term survival, pelvic exenteration should not be withheld on the grounds of advanced age alone.

Social deprivation in patients requiring pelvic exenterative surgery.

AIM: Pelvic exenteration is an aggressive operation for locally advanced rectal cancer. Social deprivation has been shown to reduce life expectancy and has been linked to a poorer outcome in patients with colorectal cancer. The aim of this study was to analyse the effect of social deprivation scores on the outcome in these complex patients. METHOD: A retrospective review of all patients undergoing pelvic exenteration for primary rectal cancer between 2006 and 2014 was performed. Deprivation scores were calculated for all patients using the Welsh Index of Multiple Deprivation. Patients were then grouped into quartiles, from Q1 (most deprived) to Q4 (least deprived). The primary outcome measure was 5-year survival. RESULTS: In all, 120 patients were included (65 female) with a median age of 64 (31-90) years. No differences between quartiles were identified for neoadjuvant therapy (P = 0.687) or type of exenteration (P = 0.690). The median length of stay was significantly higher in the most deprived groups (Q1-Q2; P = 0.023). There was a significant difference in survival between the groups, with lowest 5-year survival rates (53%) in the most deprived quartile (Q1) (P = 0.015). CONCLUSION: Social deprivation is significantly associated with postoperative length of stay and survival in patients undergoing pelvic exenteration for primary rectal cancer.

Determinants of survival following pelvic exenteration for primary rectal cancer.

BACKGROUND: Pelvic exenteration is a potentially curative treatment for locally advanced primary rectal cancer. Previous studies have been limited by small sample sizes and heterogeneous data. A consecutive series of patients was studied to identify the clinicopathological determinants of survival. METHODS: All patients undergoing pelvic exenterative surgery for primary rectal cancer (1992-2014) at this hospital were analysed. The primary outcome measure was 5-year overall survival. Secondary endpoints included length of hospital stay, complication rate, 30-day mortality and disease recurrence rate. Statistical analysis was performed using Kaplan-Meier and Cox regression analysis. RESULTS: A total of 174 patients with a median age of 65 (range 31-90) years were included. Ninety-six patients underwent posterior pelvic exenteration and 78 had total pelvic exenteration. Median follow-up was 48 (range 1-229) months. Two patients (1.1 per cent) died within 30 days of surgery and 16.1 per cent returned to the operating theatre. The 5-year survival rate following complete resection (R0) was 59.3 per cent. In univariable analysis, adverse survival was associated with advanced age (P = 0.003), metastatic disease (P = 0.001), pathological node status (P = 0.001), circumferential resection margin (P = 0.001), local recurrence (P = 0.015) and the need for neoadjuvant therapy (P = 0.039). CONCLUSION: Pelvic exenteration is an aggressive treatment option with a high morbidity rate that provides favourable long-term outcomes in patients with locally advanced primary rectal cancer.

Quality-of-life outcomes following pelvic exenteration for primary rectal cancer.

BACKGROUND: For patients with locally advanced tumours and contiguous organ involvement, pelvic exenteration (PE) can offer cure with relatively low mortality. The literature surrounding quality of life (QoL) in patients undergoing PE is limited. Furthermore, there are no matched comparisons of QoL between abdominoperineal resection (APR) and PE. The aim of this study was to compare differences in long-term QoL for patients with primary rectal cancer undergoing APR versus PE. METHODS: All patients who underwent either APR or PE between January 2011 and December 2012 were identified. Patients were asked to complete the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire before surgery and 2 weeks afterwards. Subsequent questionnaires were requested at 3, 6, 12 and 24 months after operation. RESULTS: A total of 110 patients were included in the study (54 APR, 56 PE). Median length of stay following operation was 11 (range 3-70) days for APR and 15 (7-84) days for PE. Patients undergoing PE experienced lower physical (mean score 42 versus 56; P = 0.010), role (20 versus 33; P = 0.047), emotional (57 versus 73; P = 0.010) and social (34 versus 52; P = 0.005) functional levels 2 weeks after surgery. Long-term dyspnoea and financial worries were experienced only after PE. Patients undergoing PE had a lower overall global health status at 2 weeks after operation (40 versus 53; P = 0.012). Levels were comparable between groups from 3 months after surgery. CONCLUSION: QoL recovery following PE was equivalent to that after APR alone. Patients should not be denied exenterative surgery based on perceived poor QoL.

Is the follow-up of small renal angiomyolipomas a necessary precaution?

AIM: To investigate the natural history and rationalize follow-up of renal angiomyolipomas (AMLs). MATERIALS AND METHODS: A prospectively gathered radiology database was scrutinized to identify patients with renal AMLs over a 3 year period (January 2006 to December 2008). Radiological investigations were examined to identify those AMLs exhibiting change during surveillance. RESULTS: A total of 135 patients were identified. Mean age at first detection was 49.6 years and patients were followed up for a median 21.8 months (6-85.3 months). Small AMLs (≤20 mm) were less likely to grow than their larger counterparts [odds ratio 13.3, confidence interval (95% CI) 1.4-123.9, p = 0.02] and exhibited a slower growth rate (0.7 versus 9.2 mm/year). Patients with AMLs that increased in size were significantly younger (median age 43 versus 52 years, p < 0.001). Multiple AMLs or those associated with genetic conditions grew at a significantly greater rate (3 versus 0.1 mm/year, p < 0.001). AMLs with a large extra-renal component are less reliably measured on ultrasound (median error 7 versus 1 mm, p < 0.001). CONCLUSION: This is the first study with the primary purpose to investigate growth of small AMLs (≤20 mm). Small, solitary AMLs (≤20 mm) do not require follow-up due to their low probability of growth. Patients with multiple AMLs and younger patients require closer monitoring due to their comparatively greater AML growth rate. Ultrasound-detected AMLs with an extra-renal component may require computed tomography (CT) to confirm their size.

How safe is it to manage diverticular colovesical fistulation non-operatively?

AIM: Colovesical fistula (CVF) is an uncommon condition. Diagnosis and management varies according to presentation and aetiology. The identification of patients suitable for conservative management and their outcome following this approach has not been well documented. METHODS: The clinical outcomes of all patients diagnosed with a CVF over a 7-year period from an uro-radiological database were reviewed. Cases secondary to diverticular disease were analysed with respect to the approach by which they were managed: those treated surgically and those managed conservatively. RESULTS: Sixty-two patients (32 men) were diagnosed with CVF of whom 53 (85%) had diverticular disease. Twenty-seven (mean age 69 years, range 42-90) underwent surgery (with a stoma in 59%) with a 30-day mortality of 15%. Those managed conservatively (n = 26) were older (mean age 76 years, range 39-87) and frailer (62% American Society of Anesthesiologists Grades III and IV). At 1 and 3 years following diagnosis there was no difference in mortality between these two groups and only one death was as a consequence of urosepsis. CONCLUSION: Many patients with CVF secondary to diverticular disease can be safely managed non-operatively.

24-Epibrassinolide regulates photosynthesis, antioxidant enzyme activities and proline content of Cucumis sativus under salt and/or copper stress.

Brassinosteroids have been extensively used to overcome various abiotic stresses. But its role in combined stress of salt and excess copper remains unexplored. Seeds of two cultivars (Rocket and Jumbo) of Cucumis sativus were grown in sand amended with copper (100 mg kg(-1)), and developed seedlings were exposed to salt stress in the form of NaCl (150 mM) at the 30-day stage of growth for 3 days. These seedlings were subsequently sprayed with 0 or 0.01 µM of 24-epibrassinolide (EBL) at the 35-day stage. The plants exposed to NaCl and Cu in combination exhibited a significant decline in fresh and dry mass of plant, chlorophyll content, activities of carbonic anhydrase, net photosynthetic rate and maximum quantum yield of the PSII primary photochemistry followed by NaCl and Cu stress alone, more severely in Jumbo than in Rocket. However, the follow-up treatment with EBL to the stressed and nonstressed plant improved growth, chlorophyll content, carbonic anhydrase activity and photosynthetic efficiency, and further enhanced the activity of various antioxidant enzymes viz. catalase, peroxidase and superoxide dismutase and content of proline at the 40-day stage of growth, and the response of the hormone was more effective in Rocket than in Jumbo. The elevated level of antioxidant enzymes as well as proline could have conferred tolerance to the NaCl- and/or Cu-stressed plants resulting in improved growth, water relations and photosynthetic attributes. Furthermore, antioxidant enzyme activity and proline content were more enhanced in Rocket than in Jumbo cultivar.

Structure, dynamics, and binding thermodynamics of the v-Src SH2 domain: implications for drug design.

SH2 domains provide fundamental recognition sites in tyrosine kinase-mediated signaling pathways which, when aberrant, give rise to disease states such as cancer, diabetes, and immune deficiency. Designing specific inhibitors that target the SH2 domain-binding site, however, have presented a major challenge. Despite well over a decade of intensive research, clinically useful SH2 domain inhibitors have yet to become available. A better understanding of the structural, dynamic, and thermodynamic contributions to ligand binding of individual SH2 domains will provide some insight as to whether inhibitor development is possible. We report the first high resolution solution structure of the apo-v-Src SH2 domain. This is accompanied by the analysis of backbone dynamics and pK(a) values within the apo- and peptide-bound states. Our results indicate that the phosphotyrosine (pY) pocket is tightly structured and hence not adaptable to exogenous ligands. On the other hand, the pocket which accommodates residues proximal and C-terminal of the pY (pY + 3) or so-called specificity determining region, is a large dynamic-binding surface. This appears to allow a high level of promiscuity in binding. Binding of a series of synthetic, phosphotyrosyl, peptidomimetic compounds designed to explore interactions in the pY + 3 pocket further demonstrates the ability of the SH2 domain to accommodate diverse ligands. The thermodynamic parameters of these interactions show dramatic enthalpy/entropy compensation. These data suggest that the v-Src SH2 domain does not have a highly specific secondary-binding site, which clearly presents a major hurdle to design selective inhibitors.

Computed tomography as a first-line investigation for elderly patients admitted to a surgical assessment unit.

Background Increases in life expectancy has meant that a higher proportion of patients presenting to surgical assessment units are now elderly. Abdominal computed tomography (CT) can provide early and accurate diagnosis in the elderly, even in the presence of incomplete clinical and biological findings. The aim of this study was to investigate the use of early CT imaging in elderly patients presenting directly to the surgical assessment unit. Materials and methods All consecutive patients aged 65 years and over admitted directly to the surgical assessment unit between January 2017 and April 2017 were identified. Data were collected on demographics, laboratory investigations, radiological investigations and hospital admission. The primary outcome measure was overall length of stay. Results A total of 200 consecutive patients were identified and included over a six-month period. This comprised 110 women and 90 men with a median age of 78 years (range 64-98 years). A total of 83 patients underwent CT on admission to the surgical assessment unit. White cell count (WCC) and C-reactive protein (CRP) results were significantly higher in patients undergoing CT (P = 0.001). Median length of stay for patients undergoing CT was 5 days (range 1-19 days). This was significantly lower than those patients not receiving CT imaging, at 6 days (range 1-105 days; P = 0.034). Discussion CT should be considered as a first-line investigation when elderly patients with an acute abdomen are admitted to surgical assessment units. Early CT can accelerate hospital discharge and decrease overall length of hospital stay.

Benefits of pre-emptive analgesia by local infiltration at day-case general anaesthetic open inguinal hernioplasty.

Introduction The open prosthetic repair of inguinal hernias under local anaesthesia (LA) is well established, with the concept of intraoperative 'pre-emptive analgesia' evolving so that patients are as comfortable as possible. We used a peri-incisional LA solution in patients undergoing day-case inguinal hernioplasty under general anaesthesia (GA) and recorded use of analgesia in the immediate postoperative period. Methods In this observational cohort study, 100 consecutive unselected men underwent open inguinal hernia repair as a day case. Of these, 75 underwent repair under GA and 25 with peri-incisional LA solution (equal mixture of 0.5% bupivacaine and 1% lignocaine with 1:200,000 adrenaline). Analgesia prescribed at induction, for maintenance and after cessation of anaesthesia was scored in accordance with the World Health Organization (WHO) analgesic ladder. Results The median age in the GA group was 59 years (range: 25-89 years) and in the GA+LA group, it was 62 years (range: 27-88 years). Of the 100 patients, 82 underwent a mesh plug repair by seven surgeons whereas 18 underwent a flat (Lichtenstein) mesh repair by two surgeons. WHO analgesic induction and postoperative scores were significantly lower in the GA+LA group (p=0.034 and p<0.001 respectively). There was also a significant difference in use of postoperative antiemetics (23% vs 0% in the GA only and GA+LA cohorts respectively, p=0.020). Six patients (8%) in the GA group failed day-case discharge criteria. Conclusions Patients undergoing contemporary day-case GA inguinal hernioplasty with pre-emptive LA solution infiltration require lower levels of postoperative opioid analgesia and antiemetics. These cases are less likely to fail discharge criteria for planned day surgery.

Inguinal hernias associated with a single strenuous event.

INTRODUCTION: There is debate regarding the role of physical activity and, in particular, a single strenuous event (SSE) in the development of inguinal hernia. This study aims to identify the incidence and associated features of hernias perceived to be due to a single strenuous event and to compare their features with published guidelines. MATERIALS AND METHODS: All consecutive patients surgically treated for primary inguinal hernia at a single NHS trust between April 2010 and April 2011 were identified and contacted to participate in a questionnaire. Clinical details from operative records and case notes were compared with patients' responses to identify features of their presentation attributable to a single strenuous event according to previously published guidelines. RESULTS: Three hundred and thirty five eligible patients were contacted with a response rate of 292 (87 %). 41/292 (14 %) of patients reported an SSE associated with the onset of their hernia. Only 2 of 41 (5 %) patients reporting a hernia associated with SSE met published criteria for association of the hernia with SSE, and this represented less than 1 % of all patients treated for inguinal hernia at a single centre in a 1-year period. CONCLUSION: The relationship between physical activity and development of inguinal hernia is under debate; however, we find that inguinal hernia that can be attributed to SSE is a rare event, despite the fact that many patients present with acute symptoms. Updated guidelines for the assessment of 'cause' in industrial claims for the association of hernia with workplace activity are required.

Therapeutic amnioinfusion for intrapartum fetal distress using a pediatric feeding tube.

OBJECTIVE: To evaluate the role of therapeutic amnioinfusion using a pediatric feeding tube in cases of intrapartum fetal distress. METHODS: A randomized clinical trial including 438 women admitted in labor at Assiut University Hospital with nonreassuring fetal heart rate tracing. Using sealed opaque envelopes, the women were randomized to 2 groups. In the amnioinfusion group they underwent transcervical amnioinfusion (1000 mL of warmed sterile saline solution) in addition to conventional treatment. In the control group they received conventional treatment only. The primary outcome was cesarean section rate for fetal distress. The secondary outcomes were neonatal and maternal complications. RESULTS: The amnioinfusion group showed a significant reduction in the rate of cesarean section for fetal distress (relative risk [RR], 0.7; 95% confidence interval [CI], 0.6-0.83), and a 30% reduction in abnormal fetal heart rate patterns (RR, 0.7; 95% CI, 0.6-0.83). Significantly fewer newborns had Apgar scores less than 7 at 1 and 5 min in the amnioinfusion group than in the control group (RR, 0.38; 95% CI, 0.26-0.55 and RR, 0.31; 95% CI, 0.15-0.64, respectively). Significantly fewer newborns had meconium below the vocal cords in the amnioinfusion group than in the control group (RR, 0.36; 95% CI, 0.13-0.97). Moreover, 14 newborns in the amnioinfusion group needed admission to the intensive care unit vs. 31 newborns in the control group. There were no significant differences between the 2 groups regarding the incidence rates of uterine hypertonus and maternal temperature higher than 38 degrees C. CONCLUSION: Therapeutic amnioinfusion is a simple and effective intervention that reduces the rates of cesarean section for intrapartum nonreassuring fetal heart tracing. In under-resourced settings, it can be performed using inexpensive catheters.

Apolipoprotein E polymorphism and lipoprotein levels in a Gulf Arab population in Kuwait: a pilot study.

BACKGROUND: APOE polymorphism is believed to confer susceptibility to coronary heart disease (CHD) and Alzheimer's disease. It is well known that patterns of APOE polymorphisms differ between populations and ethnic groups, although most of the data available so far have been in whites. SUBJECT AND METHODS: We evaluated the frequencies of APOE genotypes and their relationships with serum levels of lipids, lipoproteins and apolipoproteins in two groups of Gulf Arab citizens: a control population of healthy voluntary blood donors (n=106), and a group of patients presenting to the lipid clinic for the first time with combined hyperlipidaemia (CH) (n=41). In both groups, fasting serum total cholesterol (TC), triglycerides (TG), HDL, LDL and apolipoprotein A1 and B levels were measured by routine autoanalyzer methods, and APOE genotyping was performed by validated PCR methods. The lipid and lipoprotein levels were related to the specific APOE allele frequencies. RESULTS: Allele frequencies were 5.7% for *E2, 85.4% for *E3, and 9.0% for *E4 in the healthy blood donor group. An essentially similar pattern was seen in the patients with CH. This APOE allelic distribution conforms to patterns described in Chinese, whites and South Asians. In both the blood donor and CH groups there were no consistent links between specific APOE pattern and serum lipoproteins, as would have been predicted from APO *E2 and APO *E4 frequencies. CONCLUSIONS: We conclude that APOE allelic patterns in healthy Kuwaiti blood donors and a smaller group of patients with CH do not satisfactorily predict circulating blood levels of lipids and lipoproteins.

Insulin-like growth factor (IGF)-I, IGF-II and IGF-binding protein (IGFBP)-3 levels in Arab subjects with coronary heart disease.

OBJECTIVE: Insulin-like growth factors (IGF-I, IGF-II) and their binding protein (IGFBP-3) may be risk markers for coronary heart disease (CHD). This study aimed to assess the levels and determinants of the serum levels of IGF-I, IGF-II and IGFBP-3 in Arab patients with established CHD. MATERIAL AND METHODS: Two groups of subjects were matched for age, gender, BMI and waist-hip ratio (WHR): (i) CHD (n = 105), median age 51.0 (range 40.0-60.0) years; (ii) controls (n = 97) aged 49.0 (range 37.0-60.0) years. We measured fasting serum levels of glucose and lipoproteins (total cholesterol, triglycerides, LDL, HDL, apo B), insulin, HOMA-IR, IGF-I, IGF-II and IGFBP-3 and compared the results between groups. The effects of body mass and the metabolic syndrome (MS) on IGF levels were also examined, and linear correlations were sought between the various parameters. RESULTS: The levels of IGF-I, IGF-II and IGFBP-3 were significantly lower (all p<0.01) for the CHD group than for the control group. These differences were not influenced by BMI or with the presence of MS. In CHD, there were no significant correlations between levels of IGF-I and IGF-II and age, BMI, WHR, lipoprotein concentrations and insulin sensitivity, although IGFBP-3 had weakly significant relationships with some of the lipoproteins. CONCLUSIONS: Levels of IGF-I, IGF-II and IGFBP3 are reduced in male Arab patients with CHD, and did not appear influenced by traditional CHD risk factors such as age, BMI, insulin sensitivity and presence of MS. Perturbations in the IGF/IGFBP-3 axis may be potential additional targets for pharmacological manipulation in CHD.

Short-term treatment in a general hospital following a suicide attempt.

The authors discuss the value of short-term psychiatric treatment in the nonpsychiatric wards of a general hospital for patients who attempt suicide. During 1974 a total of 124 such patients were seen in the emergency room of Meir General Hospital in Kfar Saba, Israel. Following an initial psychiatric examination, 110 of the patients were admitted to the internal medicine or surgical wards. After further observation 30% were transferred to psychiatric hospitals, and the rest were treated in the general hospital's nonpsychiatric wards for an average of three days. There were no suicide attempts during hospitalization. The authors emphasize the usefulness of a short hospitalization to separate the patient from his traumatic home environment until his return to it becomes feasible.