Age-related changes in motor unit number estimates in adult patients with Charcot-Marie-Tooth type 1A.

BACKGROUND: Charcot-Marie-Tooth disease type 1A (CMT1A) is known as a demyelinating hereditary neuropathy. Secondary axonal dysfunction is the most important determinant of disease severity. In adult patients, clinical progression may be because of further axonal deterioration as was shown with compound muscle action potential (CMAP) amplitude reductions over time. The motor unit number estimation (MUNE) technique may be more accurate to determine the number of axons as it is not disturbed by the effect of reinnervation. The purpose of this study was to investigate the number and size of motor units in relation to age in patients and controls. METHODS: In a cross-sectional design, we assessed arm and hand strength and performed electrophysiological examinations, including CMAP amplitudes and MUNE of the thenar muscles using high-density surface EMG in 69 adult patients with CMT1A and 55 age-matched healthy controls. RESULTS: In patients, lower CMAP amplitudes and MUNE values were related to hand weakness. The CMAP amplitude and MUNE value of the thenar muscles were significantly lower in patients than in controls. CMAP amplitudes declined with age in controls, but not in patients. MUNE values declined with age in both patients and controls. CONCLUSIONS: The age-dependent decrease in the number of motor units was not significantly different between patients with CMT1A and controls, indicating that loss of motor units in adult patients is limited.

The effect of levosulpiride on in vitro motor patterns in the human gastric fundus, antrum, and jejunum.

BACKGROUND: Levosulpiride is a 5HT4 agonist/D2 antagonist prokinetic agent used to improve gastric emptying in patients with functional dyspepsia or gastroparesis. The aim of this study was to characterize its effect on the main in vitro motility patterns in the human fundus, antrum, and jejunum. METHODS: Circular muscle strips from human stomach (antrum and fundus) and jejunum, obtained from 46 patients undergoing bariatric surgery, were studied using organ baths. Enteric motor neurons (EMNs) were stimulated by electrical field stimulation (EFS). KEY RESULTS: Levosulpiride, caused an increase in the EFS-induced cholinergic contractions in the gastric antrum (+37 ± 15.18% at 100 µM, pEC50 = 4.46 ± 0.14; p < 0.05, n = 8) and jejunum (+45.4 ± 22.03% at 100 µM, pEC50 = 3.78 ± 6.81; p < 0.05, n = 5), but not in the gastric fundus. It also caused a slight decrease in tone and frequency of spontaneous contractions in the jejunum, but did not have any major effect on tone or spontaneous contractions in the stomach. It did not have any effect on EFS-induced relaxations mediated by nitric oxide (NO) in the stomach (antrum and fundus) and by NO and ATP in the jejunum. CONCLUSIONS & INFERENCES: Our results suggest that the prokinetic effects of levosulpiride in humans are mainly due to the facilitation of the release of acetylcholine by enteric motor neurons in the gastric antrum and the jejunum.

Portal vein thrombosis in liver transplantation.

In the initial experience of liver transplantation, complete thrombosis and portal vein occlusion were considered to be absolute contraindications for liver transplantation. The incidence of portal thrombosis in patients being prepared for transplantation varies between 5% and 15% according to published series. There are 2 surgical techniques to solve absent or low portal vein flow due to thrombosis. The most widely used technique is thrombectomy and the second technique is insertion of a shunt with a venous graft in the permeable portion of the superior mesenteric vein or in a vein in the splanchnic territory. Portal thrombosis recurrence rates vary among series, ranging from 0% to 25% or even 30%, depending on its extension and severity and also on time the transplantation was performed. Although overall survival is somewhat lower, there are no significant differences in most of the series when patients with portal thrombosis who underwent transplantation are compared with those without.

Cost/efficacy clinical trial about the use of T-tube in cadaveric donor liver transplant: preliminary results.

UNLABELLED: Biliary reconstruction is the most common cause of morbidity associated with orthotopic liver transplantation. Our objective was to assess the complications and hospital resources related to the use of a T-tube. MATERIAL AND METHODS: Among 95 liver transplants performed from October 2002 to November 2003, 84 patients were randomized to receive a T-tube or no T-tube. We analyzed all patients with a follow-up of at least of 3 months. RESULTS: Fifty-five transplants were analyzed with 8 months mean follow-up, including twenty eight with T-tube and twenty seven without a T-tube. No patient died during the follow-up. The overall rate of biliary complications was 45.4% (25/55) including 21/28 (75%) in the T-tube group and 4/27(14.8%) in the non-T-tube group (P < .0001). Complications related to T-tube extraction occurred in 48.2% (13/27), including 3 cholangitis and 10 leaks. The costs of hospital resources due to radiological studies were 5329 capital JE, Ukrainian for the T-tube group vs 5785 capital JE, Ukrainian for the non-T-tube group. The costs of hospital resources due to treatment were 28,280 capital JE, Ukrainian for the T-tube group vs 10,088 capital JE, Ukrainian for the non-T-tube group. CONCLUSIONS: Use of a T-tube during orthotopic liver transplantation does not seem justified. Biliary anastomosis stenting is followed by an increased incidence of complications, most of which are related to its use. Hospital stay, radiological studies, and cost of hospital resources are higher among the T-tube patients. Therefore its systematic use is not advisable.

One thousand liver transplants: the hospital clinic experience.

OBJECTIVES: Our goal was to study a consecutive series of 1000 liver transplants performed in our institution to evaluate the changes over time in donors, recipients, and results. PATIENTS AND METHODS: With the aim to evaluate differences between transplantation in the first period and the present period, the first consecutive 100 liver transplants performed from June 1988 to June 1990 (first period) were compared with the last consecutive 200 liver transplants performed from January 2001 to June 2003 (second period). RESULTS: Increased donor age, change in donor cerebral death etiology, and increasing numbers of grafts from alternative methods using cadaveric donors were observed in the second period. Piggy-back technique and the biliary anastomosis without a t-tube was also started in the second period. One-year actuarial patient survival was higher in the second period (84% vs 91.3%). The need for retransplantation in the overall series was 95%. One-, 5-, and 10-year actuarial retransplant survival was 67.7%, 51.3%, and 39.4%, respectively. CONCLUSIONS: Technical innovations, better understanding of donor and recipient aspects, and global improvements were the reasons for time-related improved results of liver transplantation.

Peritoneal mast cell degranulation and gastrointestinal recovery in patients undergoing colorectal surgery.

BACKGROUND: Degranulation of peritoneal mast cells (MCs) induced by intestinal manipulation has been proposed as a pathophysiological factor in postoperative ileus (POI). We aimed to explore the relationship between peritoneal and colonic MC degranulation and gastrointestinal (GI) recovery following colectomy. METHODS: Patients undergoing elective laparoscopic cholecystectomy (using a laparoscope and small abdominal incisions, n = 14), and elective laparoscopic (n = 32) or open partial colectomy (through a large abdominal incision, n = 10) were studied. MC protease tryptase and chymase were studied in peritoneal fluid at the beginning, middle, and end of each surgical intervention. Density of MCs in colectomy samples were examined and oro-caecal transit time by breath test, GI function recovery by clinical composite endpoint GI-2 and association between MC proteases and clinical recovery. KEY RESULTS: Open and laparoscopic colectomy caused greater peritoneal release of tryptase and chymase (323.0 ng/mL [IQR: 53.05-381.4] and 118.6 ng/mL [IQR: 53.60-240.3]), than cholecystectomy (41.64 ng/mL [IQR: 11.17-90.93]) at the end of the surgical intervention. However, there were no differences between laparoscopic and open colectomy. Increased peritoneal protease release during surgery was observed in patients who developed POI after colectomy. CONCLUSIONS & INFERENCES: Colorectal surgery causes protease release from peritoneal MCs. Protease release does not differ between both types of colectomy (laparoscopy vs laparotomy). However, MC activation is increased in colectomy patients developing POI. Therefore, degranulation of peritoneal MCs as a factor contributing to human POI after colectomy might be considered in future studies as a target to avoid POI.

Comparison of maximal voluntary isometric contraction and hand-held dynamometry in measuring muscle strength of patients with progressive lower motor neuron syndrome.

Context. Maximal voluntary isometric contraction, a method quantitatively assessing muscle strength, has proven to be reliable, accurate and sensitive in amyotrophic lateral sclerosis. Hand-held dynamometry is less expensive and more quickly applicable than maximal voluntary isometric contraction. Objective. To investigate if hand-held dynamometry is as reliable and valid as maximal voluntary isometric contraction in measuring muscle strength in patients with an adult-onset, non-hereditary progressive lower motor neuron syndrome. Design. Two testers performed maximal voluntary isometric contraction and hand-held dynamometry measurements in six muscle groups bilaterally in patients with progressive lower motor neuron syndrome to assess reliability and validity of both the methods. Setting. Outpatient units of an academic medical center. Patients. A consecutive sample of 19 patients with non-hereditary progressive lower motor neuron syndrome (median disease duration 32.5 months, range 10-84) was tested. Outcome measures. Comparison between maximal voluntary strength contractions as measured by hand-held dynamometry and maximal voluntary isometric contraction. Results. Low intra- and interrater variation in all muscle groups were found, intraclass correlation coefficients vary between 0.86 and 0.99 for both methods. Both methods correlated well in all muscle groups with Pearson's correlation coefficients ranged between 0.78 and 0.98. Scatter plots indicated a trend to under-estimate muscle strength above 250 N by hand-held dynamometry as compared with maximal voluntary isometric contraction. Conclusions. For longitudinal evaluation of muscle strength in patients with progressive lower motor neuron syndrome (i.e. between 0 and 250 N), muscle strength can be accurate quantified with both hand-held dynamometry and maximal voluntary isometric contraction. Hand-held dynamometry has the advantage of being cheap and quickly applicable. However, our results indicate that hand-held dynamometry is less sensitive than maximal voluntary isometric contraction in detecting subnormal muscle strength in strong muscle groups (i.e. >250 N), due to limited strength of the tester.

Gastrointestinal peptides, gastrointestinal motility, and anorexia of aging in frail elderly persons.

BACKGROUND: The mechanisms involved in anorexia in frail elderly people remain unclear. The objective of this study was to establish whether fasting and postprandial levels of gastrointestinal peptides, gastrointestinal motility, and hunger are modified by age and frailty. METHODS: Three groups of subjects were studied: (a) frail elderly (>70 years) persons, (b) non-frail elderly (>70 years) persons, and (c) healthy adults (aged 25-65 years). After an overnight fast, participants ingested a 400 Kcal liquid meal and appetite, hormonal, and gastrointestinal responses were monitored during early (0-60 min) and late (60-240 min) postprandial periods. KEY RESULTS: Frail persons showed poor nutritional status, sarcopenia, and almost absence of hunger during fasting and postprandial periods. Older persons presented higher levels of glucose and insulin during fasting, enhanced postprandial CCK release in early postprandial period and postprandial hyperglycemia and hyperinsulinemia, but similar ghrelin levels than younger adults. Ultrasound scan showed that the fasting antral area was higher and antral compliance lower in old persons. The paracetamol absorption test showed enhanced postprandial gastric emptying in the frail. Non-gallbladder contractors showed no CCK peak in younger and non-frail groups, but the same high CCK peak as contractors in the frail. CONCLUSIONS & INFERENCES: Frailty was associated with anorexia, risk of malnutrition, and sarcopenia. Frail persons showed impaired gastric motility (larger antral area at rest, impaired antral compliance, and enhanced postprandial emptying), impaired gallbladder motility, and fasting and/or postprandial alterations in CCK, glucose, and insulin release. Further studies are needed to determine if these factors may contribute to anorexia of aging in frail persons.

[The psychosomatic interview in diagnosis of functional voice disorders]. / Das psychosomatische Interview in der Diagnostik funktioneller Stimmstörungen.

For the psychosomatic diagnosis of functional voice disorders, the concept of a semistructured psychosomatic interview is presented which follows the principles of psychoanalytic interviewing and of deep-psychological biographical anamnesis. It also takes into account the special features of dysphonic patients as psychosomatic patients, the characteristics of functional voice disorders, and the interrelationship of voice and psychosocial biography. The psychosomatic interview consists of the components interviewing situation, voice symptomatology and voice genesis, psychosocial biographical anamnesis and indication to psychotherapy. Beginning and end of the interview are fixed, whereas in the further course the selection of elements is fitted to the conflict constellations of the patient.

[Symptom-centered psychotherapy in patients with functional voice disorders]. / Symptom-zentrierte Psychotherapie bei Patienten mit funktionellen Stimmstörungen.

As a disorder of an ego-function, functional voice disorders display a remarkable sensitivity and variability towards psychosocial factors and an often immediate connection with the underlying psychic conflict constellation. Being concentrated on their symptomatics, patients with functional voice disorders command a good capacity of observing their complaints and factors affecting them. Symptom-centered short-term psychotherapy makes use of the particular character of the voice symptom and of the patient's capacity in a focal treatment of the symptom. First, a symptom-focus is established on the basis of an analysis of speech conflict situations which contains essential psychosocial factors and is structured by a psychic conflict constellation. In the further course of psychotherapy, the symptom focus is used as a heuristic device in the treatment of material of the voice symptomatics. In working through present and past speech conflict constellations patients reach an understanding of the psychosocial conflict contained in the voice symptomatics and are enabled to develop alternatives for changing the maladaptive speech interaction patterns.

[Patient cooperation as a problem in inpatient psychosomatic rehabilitation]. / Die Mitwirkung des Patienten als Problem der stationären psychosomatischen Rehabilitation.

Patients insured under the pension insurance scheme are subject to a statutory obligation to cooperate in their remedial treatment. In in-patient psychosomatic rehabilitation, a number of problems arise in view of this cooperation, as the patients are hampered in their potential for compliance with this demanded cooperation due to the specific nature of their psychosomatic condition, their personality structure as well as their previous disease history. Moreover, cooperation in psychosomatic rehabilitation involves special requirements in terms of active participation, inner openness and readiness for psychosocial change. In psychosomatic rehabilitation, the patient's cooperation cannot be assumed as a matter of course, rather, it is a task of the treatment process itself, which by appropriate therapeutic means seeks to achieve the patient's motivation and a working alliance, hence to create the prerequisites for cooperation.

[The contribution of social work to psychosomatic rehabilitation in social insurance]. / Der Beitrag der Sozialarbeit zur psychosomatischen Rehabilitation in der Rentenversicherung.

Psychosomatic rehabilitation conducted by the social insurance system aims at improvement or restitution of the patient's impaired competence of leading a regular social life and in particular of taking part in the working process. Psychoanalytically based in-patient psychotherapy is focussed on the patient's psychosocial conflict constellations and tries to enable him to cope with his daily social tasks in a satisfying and self-reliant way. In the process of psychosomatic treatment the social worker has an important function in the comprehensive treatment plan due to his expert knowledge and counselling competence. In coordination with the treatment team the social worker makes a genuine contribution in examining and diagnosing the patient, motivating him/her, working out a treatment scheme, realising the treatment process, completing the treatment and arranging for further social and psychotherapeutic care.

[Handling indications for an initial psychotherapy interview]. / Der Umgang mit der Indikation in der psychotherapeutischen Erstuntersuchung.

The treatment of indication in the psychoanalytically oriented psychotherapeutic initial interview has been neglected by research on the initial interview as well as on indication. The indication discourse is a genuine part of the psychotherapeutic initial examination which is of great importance for the acceptance of the indication by the patient. The indication discourse has its own tasks, roles, and contents. In the treatment of indication in the interview phases of preparation, information, and working with the patient's reactions can be differentiated, each of which contains further elements. Further research in this field should be guided by an interest in the role of the patient in the reception of indication.

[Psychotherapeutic treatment of patients with functional voice disorders]. / Psychotherapeutische Behandlung von Patienten mit funktionellen Stimmstörungen.

Psychic factors in the development and maintenance of functional voice disorders call for a psychotherapeutic treatment of dysphonic patients. The voice symptom is considered as a creative achievement of the patient to cope with an internal conflict using the ego function of speaking in the social context. A large number of dysphonic patients require an orientation of psychotherapy towards their symptoms. Symptom-centered short-term psychotherapy on a psychoanalytic basis concentrates on a symptom focus which, being a generalized description of cognitive, affective and behavioural elements of speech-conflict situations, structures the psychotherapeutic work with the material of the manifestations of voice complaints in the psychosocial context. Working out the psychodynamic conflict constellation underlying the voice symptomatics enables the patients to develop alternatives of coping with the internal affective conflict and of arranging interaction patterns with emotionally significant persons.

[Aspects of process quality in quality assurance regarding inpatient psychosomatic rehabilitation]. / Aspekte der Prozessqualität in der Qualitätssicherung der stationären psychosomatischen Rehabilitation.

Quality assurance in in-patient psychosomatic rehabilitation is performed basically by an external, general, structure-oriented and outcome-oriented programme of quality assurance conducted by statutory insurance bodies. In contrast, the differentiation of quality assurance in special fields of rehabilitation as well as the elaboration of the dimension of process in quality assurance have been neglected. Particular conditions of treatment in in-patient psychosomatic rehabilitation highlight the importance of the quality of procedure. Among these are the relatively longer duration of treatment, the particular dynamics and liability to disturbances of psychotherapeutic interaction, the cooperation of different therapeutic fields within a comprehensive plan of treatment and the specificity of treatment goals for each individual patient. Such a kind of quality assurance relating to procedure is made feasible by two types of structural elements of quality of procedure in in-patient psychosomatic-psychotherapeutic treatment. Iterative structural elements of procedure (e.g. team conferences, supervision) serve to control the cooperation of the team by means of a random sample of patients. Sequential structural elements (e.g. admission conference, intermediate review conference, discharge conference) help in monitoring systematically the course of treatment in relation to each individual patient. As for the obtaining of information, sequential structural elements of assurance of quality of procedure make routine monitoring possible, whereas iterative elements create space for spontaneous notification of disturbances.

[Patient satisfaction as a criterion of quality assurance in inpatient psychosomatic rehabilitation]. / Die Patientenzufriedenheit als Kriterium der Qualitätssicherung in der stationären psychosomatischen Rehabilitation.

The investigation of patient satisfaction with treatment by means of simple standardised self-rating instruments is a focal point of monitoring and improvement of treatment quality in the programme of quality assurance of rehabilitation within the statutory social insurance system. In the field of psychosomatic rehabilitation this criterion contains a number of problems due to the individual traits of patients, the treatment institutions, and the rehabilitation process. A structural discrepancy between the patients' attitudes and the requirements of the rehabilitation measure causes a systematic potential of dissatisfaction of the patients throughout the whole rehabilitation procedure. The specific quality of psychosomatic rehabilitation requires differentiation in the assessment and interpretation of patient satisfaction as a criterion of quality assurance as well as in the deduction of subsequent measures for improvement. Doubts are also raised as to the usefulness of a simple and global reference to patient satisfaction as a criterion of quality assurance even beyond the field of psychosomatic rehabilitation.

[Partial inpatient treatment as a responsibility in psychosomatic rehabilitation]. / Teilstationäre Behandlung als Aufgabe der psychosomatischen Rehabilitation.

Day clinic rehabilitation is part of the development of the medical rehabilitation system. Psychosomatic rehabilitation faces the task of developing a concept of day treatment and of collecting experiences with such models in clinical practice. The basis of this task consists in regulations laid down by the social security insurance authorities which serve as a frame for the development. The main points of these regulations are presented and their relevance for psychosomatic rehabilitation is outlined. The institutional and conceptual establishment of day treatment presents psychosomatic rehabilitation with a number of problems that are particular in this area and which are discussed in detail. Besides that, consequent elaboration of day treatment could stimulate further development of psychosomatic rehabilitation in general and help to overcome prevailing shortcomings of this part of the rehabilitation system.

[Functions of the social worker in a multi-professional team in inpatient psychosomatic rehabilitation]. / Funktionen des Sozialarbeiters im multiprofessionellen Team der stationären psychosomatischen Rehabilitation.

The task of rehabilitation as defined by law and the concept of psychosomatic-psychotherapeutic treatment require cooperation of different professions in a clinical team. This approach implies a concept of interdisciplinary cooperation in which the contributions towards treatment to be made by the individual members of the multiprofessional team are defined by means of functions and tasks. Participation of the social worker is an integral element of psychosomatic teamwork. The social worker makes an important contribution towards the interdisciplinary arrangement of psychosomatic rehabilitation treatment by taking over functions for maintaining the ward setting, for the psychotherapy process and the rehabilitation task as well as for the working of the team. On the basis of his specific competence he provides independent knowledge, particular ways of interaction, and singular methods of intervention of social work for the psychosomatic treatment carried out by the multiprofessional team.

[Indications for psychotherapeutic treatment of functional dysphonias]. / Indikationen zur psychotherapeutischen Behandlung bei funktionellen Dysphonien.

Functional voice disorders require adequate psychiatric screening and treatment due to the complex etiologies of the psychic elements involved. While the diagnosis of dysphonia increasingly takes into account various emotional factors, considerations of indications for psychotherapy and for differing forms of psychotherapy are missing in the literature. To fill this gap, the aims and principles of a number of psychoanalytically based therapeutic methods are presented. Criteria for general indications for treatment and with respect to patients with functional voice disorders are outlined. Case reports of patients with functional voice disorders illustrate individual methods for diagnosis and treatment. Finally, the necessity, for the development of general criteria for differential indications for psychotherapy in functional voice disorders is pointed out.

[Conceptual development of partial inpatient psychosomatic rehabilitation]. / Konzeptionelle Entwicklung der teilstationären psychosomatischen Rehabilitation.

The conceptual development of partial hospitalization treatment is a present-day task for psychosomatic rehabilitation. For this task the general regulations of the pension insurance agencies as well as the conceptions existing in the field of psychosomatics and psychotherapy can serve as a sufficient basis for the conceptual development of partial hospitalization psychosomatic rehabilitation inspite of several differences between them. The elaboration of concrete outlines of this kind of psychosomatic rehabilitation takes place within a framework of structural models which encompasses different variants of institutional, organizational, functional and content forms of partial hospitalization rehabilitation. Moreover, the conceptual development of day treatment in rehabilitation raises several questions of the overall system of psychosomatic rehabilitation and offers possible solutions of general problems in psychosomatic rehabilitation. On this conceptual basis, in the further construction of partial hospitalization in psychosomatic rehabilitation concrete models should be designed and tested in clinical practice along with scientific evaluation.