Juvenile-onset OCD: clinical features in children, adolescents and adults.

OBJECTIVE: To examine clinical correlates of juvenile-onset OCD across the lifespan. METHOD: Data collected at the intake interview from 257 consecutive participants with juvenile-onset OCD (20 children, 44 adolescents and 193 adults) in a naturalistic study of the clinical course of OCD were examined. Participants and parents of juvenile participants completed a structured diagnostic interview, rater-administered severity measures and self-report questionnaires. RESULTS: Children and adolescents (i.e. juveniles) shared similar features with the exception of age at onset and OCD symptom expression. Clinically meaningful differences between juvenile and adult participants were also found. Compared with adults, juveniles were more likely to be male, recall an earlier age at OCD onset and have different lifetime comorbidity patterns. CONCLUSION: Juvenile-onset OCD symptom expression is remarkably similar across the lifespan. However, findings also suggest clinically meaningful differences between juveniles and adults. Future work using a prospective design will improve our understanding of course patterns of juvenile-onset OCD.

Specificity of Stroop interference in patients with pain and PTSD.

The authors investigated processing of threat words in motor vehicle accident survivors using a modified Stroop procedure. Three samples were included: 28 participants with comorbid posttraumatic stress disorder (PTSD) and pain, 26 participants with pain without PTSD, and 21 participants without pain or any psychiatric conditions. Four word categories were used: (a) accident words, (b) pain words, (c) positive words, and (d) neutral words. This study examined whether processing biases would occur to accident words only in participants with PTSD or if these biases would also be noted in the No PTSD/Pain sample. Additionally, this study examined whether processing biases would be noted to pain words in the 2 pain samples, irrespective of PTSD. Overall, color naming was significantly slower in the PTSD/Pain group in comparison with the other groups. As well, the PTSD/Pain sample showed significant response delays to both accident and pain-related words, whereas patients with No PTSD/Pain showed delays to pain stimuli only.

Anal intraepithelial dysplasia and squamous carcinoma in immunosuppressed patients.

OBJECTIVE: To describe a treatment and follow-up protocol for HIV patients with anal dysplasia or warts, which are at risk of malignant change. DESIGN: An ongoing study of highly selected patients referred to a single surgeon. SETTING: The Colorectal and HIV/AIDS Clinics, University of Ottawa, General Campus. PATIENTS: Ninteen young men who presented with suspicious anal lesions and were referred to the Colorectal Clinic by the HIV/AIDS Clinic, which sees approximately 800 patients per year. OUTCOME MEASURE: Significance of dysplasia or carcinoma. RESULTS: Of the 19 patients, 14 had dysplasia, carcinoma-in-situ or invasive carcinoma. All were treated with multiple mapped cold biopsies and local or wide excision as indicated. Two patients with invasive carcinoma received radiotherapy or chemotherapy, or both. CONCLUSIONS: The incidence of dysplasia or the sequence by which dysplasia progresses to invasive carcinoma is unknown. Surveillance of HIV patients, especially those with nodules or warts, by flexible sigmoidoscopy and Papanicolaou smears every 3 to 12 months is recommended, depending on the severity of the anal lesion.

Cognitive interference for trauma cues in sexually abused adolescent girls with posttraumatic stress disorder.

Investigated cognitive processing of fear-relevant information in sexually abused adolescent girls with posttraumatic stress disorder (PTSD) using a modified Stroop procedure (MSP). Participants were 20 sexually abused girls with PTSD, 13 sexually abused girls without PTSD, and 20 nonvictimized girls who served as controls, 11 to 17 years old. Word conditions included abuse-related threat, developmentally relevant (related to the experience of sexual abuse, e.g., trust, secrecy, and intimacy), general threat, positive, and neutral. Girls with PTSD were expected to show cognitive interference for trauma-related words as well as for developmentally relevant words, relative to adolescents without PTSD. Overall color naming was significantly slower in the PTSD group than in the nonabused controls. Contrary to expectation, all participants demonstrated cognitive interference for trauma-related words. Relevant theoretical and methodological issues are highlighted.

Rush to judgment? Child protective services and allegations of sexual abuse.

Two hundred and ninety-three randomly selected cases from a child protection service agency in a large western New York county were examined to test the hypothesis that sexual abuse allegations are investigated and processed more intensively than cases alleging other types of maltreatment. Contrary to the hypothesis, allegations of sexual abuse were substantiated at a lower rate, not investigated more intensively, and not offered more services than were other cases.

Weight loss after extended gastric bypass.

BACKGROUND: Gastric bypass (GBP) is the most effective method for controlling morbid obesity. Previously we showed that extending the length of the Roux limb increased weight loss. We have done over 400 obesity operations during the past 20 years. The current study consists of patients from the last 10 years of our experience and compares short to extended Roux-en-Y GBP. METHODS: Data from all patients operated at the Ottawa General Obesity Clinic were entered into a database on an ongoing basis, and those from the past 10 years were analyzed. All patients had standardized preoperative investigations and postoperative follow-up. Details of these and of the operative technique are provided in the manuscript. RESULTS: The preoperative weight and BMI were 129 +/- 2 kg, and 46 +/- 2 kg/m2, respectively. The mean weight loss prior to surgery was -2 +/- 21 kg. The results were classified, by percentage weight loss as: 'excellent' = > 35%; 'good' = 25-34%; 'poor' = 15-24%; and 'failure' = < 15%. Sixty-five patients (69%) were available for 2-year follow-up. At this time, mean percentage weight loss was 34 +/- 2 versus 40 +/- 1 for the short Roux (45-135 cm) and long Roux (180-225 cm) groups, respectively (P < 0.01). There were no deaths, leaks, splenectomies or intra-abdominal infections. The incidence of hernia and/or reoperation for bowel obstruction was 35/121 or 29%. The overall incidence of diarrhea was 16/121 (13%) and 6/121 (5%) at 12 and 24 months. Quality of life is significantly impaired in at least three of these patients, all with extended limbs. Major vitamin deficiencies, alterations in liver functions, or other metabolic complications did not occur. CONCLUSIONS: Gastric bypass is the procedure of choice for morbid obesity. Weight loss is marginally improved in proportion to the length of the Roux limb but at a risk of diarrhea, which occasionally may not manifest itself for 8 to 12 months. It is important that methods be devised to correct follow-up, incisional hernias and diarrhea.

Child age and caseworker attention in child protective services investigations.

Infants and toddlers are at increased risk for severe/fatal abuse, often at the hands of male perpetrators. This paper examined whether child maltreatment cases involving younger children receive more casework services, overall caseworker activity (e.g., home visits, phone contacts), and are more likely to be substantiated, particularly if a male perpetrator is involved. The randomly selected sample consisted of 293 child abuse and neglect reports in a large county in Western New York in 1993. Hierarchical regression analyses showed that younger children generally receive more overall services and caseworker activity, and that while age makes a significant contribution after the decision has been made to substantiate a case, it does not have the same effect on the initial decision of whether or not to substantiate. Gender of the perpetrator did not reliably predict caseworker attention.

Feeding jejunostomy: a safe adjunct to laparotomy.

It is well established that a feeding jejunostomy is an invaluable adjuvant for use in critically ill and malnourished patients. What is not well known are the complications of inserting these tubes. Some surgeons are reluctant to insert feeding tubes unless the indications are very clear. From their experience with the insertion of 133 feeding jejunostomy tubes during a 3-year period, the authors conclude that the complications associated with the insertion of such tubes are few and that the procedure is justified even if the tube is never used.

Comparison of Marlex and Gore-tex to repair abdominal wall defects in the rat.

Marlex and Gore-tex, two prosthetic materials used to close abdominal wounds, were compared with respect to strength and adhesion formation. A 2.5 X 3.5-cm full-thickness area of abdominal wall was excised in 32 CD rats. The defect was repaired using identically sized patches of Marlex or 1-mm Gore-tex, determined by alternate assignment, and sutured with continuous 4-0 Gore-tex. Adhesion formation was graded at necropsy and recorded photographically in each animal. The mean adhesion index (none = 0, maximal = 4) was 1.37 +/- 0.12 and 2.62 +/- 0.12 (mean +/- SEM) for Gore-tex and Marlex groups respectively (p less than 0.005, unpaired t-test). A template was used to fashion 2-cm coronal strips of abdominal wall for tensile-strength testing. The relative strengths were 2.67 +/- 0.14 and 3.02 +/- 0.16 kg/cm (mean +/- SEM) for the Gore-tex and Marlex groups respectively (NS). Histologically, there were more epithelioid giant cells and less collagen formation in the Gore-tex group. Abdominal wall reconstruction with Gore-tex resulted in wound strength equal to that of Marlex and fewer adhesions. Gore-tex is preferred when prosthetic material and viscera are in close proximity.

The use of endoscopy after gastric partitioning for morbid obesity.

Fiberoptic endoscopy is an important diagnostic modality for evaluating the patient with upper gastrointestinal tract symptoms following gastric restrictive operations. The specific indications for endoscopy after obesity surgery include stoma evaluation in patients who fail to lose adequate weight; stomal stenosis; esophagitis; surveillance of the excluded pouch; and suspicion of a marginal ulcer after gastric bypass.

Nonoperative management of stomal stenosis after gastroplasty for morbid obesity.

Over a period of six years, 33 of 172 (19 per cent) patients who had gastric partitioning had stomal stenosis develop which was defined as an inability to drink fluids or swallow saliva, or both. All were managed conservatively in the hospital or on an outpatient basis. This consisted of total parenteral nutrition and endoscopy to evaluate the stoma with or without dilation; Eder-Puestow dilaters and long term jejunostomy feeding were used. Thirteen of these patients were dilated a total of 36 times. Three required three to six dilations each, up to the maximum size (45F). There were no complications. Twenty-nine required repletion by combined parenteral and enteral nutrition. Three required jejunostomy insertion as a separate procedure. Patients were observed for six to 60 months. Thirty-two did well. Gastrogastrostomy was required in one patient with a stenosis after the second gastroplasty. Three patients who were dilated regained over 20 per cent of their ideal weight.

Serum alanine aminotransferase to aspartate aminotransferase ratio and degree of fatty liver in morbidly obese patients.

We evaluated the change in serum alanine aminotransferase (ALT; EC 2.6.1.2) to serum aspartate aminotransferase (AST; EC 2.6.1.; ALT/AST) ratio with the degree of fatty liver in morbidly obese patients. A total of 31 patients were included in the study. Fatty liver was graded as 0 to 4+. The mean and SD of AST and ALT were not significantly different between groups of patients with various grades of fatty liver. There was, however, a significant correlation between the ALT/AST ratio and the degree of fatty infiltration of the liver. This, we believe, implies damage mainly to the plasma membrane allowing loss of cytoplasmic enzymes rather than loss of mitochondrial enzymes.

Prevention of superficial phlebitis during peripheral parenteral nutrition.

Fifty-four patients receiving peripheral parenteral nutrition consisting of 3.5 percent amino acids in a 5 percent dextrose solution were randomly assigned in a double-blind fashion to receive this solution with or without an antiphlebitic mixture (1000 IU heparin, 5 mg hydrocortisone, and 1.8 mEq sodium hydroxide as a buffer). The addition of antiphlebitic mixture resulted in a marked and highly significant reduction in the incidence of phlebitis and a prolongation of the number of phlebitis-free hours during infusion of peripheral parenteral nutrition (p less than 0.005).

Long-term follow-up of concomitant band ligation and sclerotherapy for internal hemorrhoids.

From 1978 to 1983, 111 patients with symptomatic internal hemorrhoids were treated as outpatients by a modification of the Barron ligation technique. Each ligated hemorrhoid was injected with a sclerosant. Follow-up, available for 94 of the patients, ranged from 2 to 60 months (mean 18 months). Presenting symptoms were bleeding in 75 (80%) of the 94 patients, pain in 46 (49%), pruritus in 22 (23%) and prolapse in 24 (26%). Results were excellent in 51 (54%) patients, good in 20 (21%) and fair in 9 (10%). Fourteen (15%) patients had unsatisfactory results; only 4 of these required hemorrhoidectomy. The other 10 had residual symptoms but did not require further treatment. Nine patients had minor complications, which included pain lasting 24 to 72 hours in seven, bleeding in one and syncope in one. The addition of sclerotherapy to traditional band ligation for the management of internal hemorrhoids has the advantages of exciting a greater inflammatory reaction between the mucosa and submucosa and preventing premature slipping of the band. The authors conclude that this method of therapy is effective for symptomatic hemorrhoids and that surgical hemorrhoidectomy is seldom indicated.

Rate of weight loss after vertical banded gastroplasty in morbid obesity: relationship to serum lipids and uric acid.

The relationship between postoperative weight loss after vertical banded gastroplasty in morbidly obese patients and preoperative serum triglycerides, cholesterol, HDL-cholesterol, uric acid and fasting plasma glucose was evaluated. The rate of weight loss, calculated as a percentage of original weight, was determined at three and six months after surgery. There was a significant correlation between rate of weight loss at three months and preoperative serum uric acid (r = -0.60, p less than 0.01). and also with the total cholesterol: HDL-cholesterol ratio (r = 0.61, P less than 0.01). At six months, the rate of weight loss correlated with preoperative serum triglycerides (r = -0.54, p less than 0.02) and total cholesterol: HDL cholesterol ratio (r = 0.44, p less than 0.05). The reasons for the predictive value of these biochemical parameters is unknown and deserves further study.