A review of teen-tot programs: comprehensive clinical care for young parents and their children.

Comprehensive clinical programs for teenage mothers and their children, also known as teen-tot programs, have been a promising intervention to improve outcomes of teenage childbearing and parenting. However, much remains unknown regarding the efficacy of such programs. We reviewed four published evaluations of programs that provided medical care, counseling, contraception, guidance for parenting, and assistance with staying in school. The evaluations reported moderate success in preventing repeat pregnancies, helping teen mothers continue their education, and improving teen and infant health over 6 to 18 months. However, the evaluations had limitations that may have reduced or accentuated observed effectiveness. Teen-tot programs will continue to face the challenges of sustaining adequate long-term interventions and evaluations, and reducing the high attrition rate among program participants. It is concluded that increased support and funding for teen-tot programs and more complete evaluations are warranted.

Is colonoscopic surveillance reducing colorectal cancer mortality in ulcerative colitis? A population based case control study.

BACKGROUND: Colonoscopic surveillance is a standard procedure in many patients with long standing, extensive ulcerative colitis (UC), in order to avoid death from colorectal cancer. No conclusive proof of its benefits has been presented however. AIMS: To evaluate the association between colonoscopic surveillance and colorectal cancer mortality in patients with UC. PATIENTS: A population based, nested case control study comprising 142 patients with a definite UC diagnosis, derived from a study population of 4664 patients with UC, was conducted. METHODS: Colonoscopic surveillance in all patients with UC who had died from colorectal cancer after 1975 was compared with that in controls matched for age, sex, extent, and duration of the disease. Information on colonoscopic surveillance was obtained from the medical records. RESULTS: Two of 40 patients with UC and 18 of 102 controls had undergone at least one surveillance colonoscopy (relative risk (RR) 0.29, 95% confidence interval 0.06 to 1.31). Twelve controls but only one patient with UC had undergone two or more surveillance colonoscopies (RR 0.22, 95% confidence interval 0.03 to 1.74), indicating a protective dose response relation. CONCLUSION: Colonoscopic surveillance may be associated with a decreased risk of death from colorectal cancer in patients with long standing UC.

Is there an excess risk for colorectal cancer in patients with ulcerative colitis and concomitant primary sclerosing cholangitis? A population based study.

BACKGROUND: Patients with ulcerative colitis have an increased risk of colorectal cancer. Duration, age, and extent of the disease at diagnosis are the only established risk factors. Patients with ulcerative colitis and concomitant primary sclerosing cholangitis (PSC) have been reported to have a higher frequency of colonic DNA aneuploidy and/or dysplasia than expected, findings indicating an increased risk of colorectal cancer compared with other patients with ulcerative colitis. METHODS: A population based cohort consisting of 125 patients with a verified diagnosis of PSC was followed up by linkage to the Swedish Cancer Registry for the occurrence of colorectal cancer. RESULTS: There were 12 colorectal cancers. Six cancers were diagnosed prior to the diagnosis of PSC. Among the 104 patients with an intact colon at the time of the diagnosis of PSC there was a cumulative risk for colorectal cancer of 16% after 10 years. Among the 58 patients with a diagnosis of ulcerative colitis and colorectal cancer prior to the diagnosis of PSC, there were five colorectal cancers corresponding to a cumulative risk of 25% after 10 years. CONCLUSIONS: Patients with ulcerative colitis and concomitant PSC seem to constitute a subgroup with a high risk for colorectal cancer.

Pregnancy outcomes in women with inflammatory bowel disease--a population-based cohort study.

OBJECTIVE: Our purpose was to assess the frequency of adverse pregnancy outcomes in women with inflammatory bowel disease compared with the general population. STUDY DESIGN: Of all 239,773 pregnant women with single births in Sweden from 1991 to 1992, 756 women with inflammatory bowel disease could be analyzed for late fetal and infant death, preterm birth, low birth weight, small for gestational age, and cesarean section. Logistic regression analyses was used to estimate the odds ratios. RESULTS: Pregnancies in women with inflammatory bowel disease were associated with an increased risk of preterm birth at < 33 weeks (odds ratio 1.81, 95% confidence interval 1.06 to 3.07) and at 33 to 36 weeks (odds ratio 1.48, 95% confidence interval 1.10 to 1.99); low birth weight < 1500 gm (odds ratio 2.15, 95% confidence interval 1.11 to 4.15) or 1500 to 2499 gm (odds ratio 1.57, 95% confidence interval 1.12 to 2.22); small for gestational age (odds ratio 1.40, 95% confidence interval 0.97 to 2.02); and cesarean section (odds ratio 1.51, 95% confidence interval 1.27 to 1.89). CONCLUSIONS: Inflammatory bowel disease in pregnant women is associated with an increased frequency of adverse pregnancy outcomes.

Survival and risk of cholangiocarcinoma in patients with primary sclerosing cholangitis. A population-based study.

BACKGROUND: Endoscopic retrograde cholangiopancreatography was introduced in the early 1970s, making a more reliable diagnosis of primary sclerosing cholangitis (PSC) possible. Since then decreased survival and increased risk of cholangiocarcinoma have been reported. However, no population-based studies have quantified these outcomes. METHODS: A population-based cohort of 125 patients with a verified PSC diagnosis was followed up through linkage to the Swedish Death Registry and the Swedish Cancer Registry for occurrence of death and cholangiocarcinoma. RESULTS: The diagnosis of PSC was associated with a substantially decreased survival, with an overall 10-year survival of 68.8%. Patients with a diagnosis of inflammatory bowel disease (IBD) had a somewhat better prognosis, 71.8%, compared with 60% for patients without. Fourteen subsequent cholangiocarcinomas yielded a cumulative risk of 11.2% 10 years after diagnosis. Sex, duration of IBD, and colectomy influenced neither the survival nor the cholangiocarcinoma risk. CONCLUSION: Patients with PSC have a substantially decreased survival, which is most pronounced among patients without IBD.

Consultation-liaison psychiatry and the practice of medicine. The Thomas P. Hackett Award lecture given at the 42nd annual meeting of the Academy of Psychosomatic Medicine, 1995.

The contributions of consultation-liaison psychiatrists have significantly influenced the practice of medicine. The author reviews the pertinent literature that substantiates this observation as well as suggests areas that hold promise for such contributions in the future.

Group psychotherapy during radiotherapy: effects on emotional and physical distress.

OBJECTIVE: The purpose of this study was to ascertain whether group psychotherapy during radiotherapy for cancer significantly decreases patients' emotional and physical distress. METHOD: Twenty-four patients receiving radiotherapy were randomly selected for group psychotherapy (six patients per group, 90-minute weekly sessions for 10 weeks). Another 24 patients served as control subjects. Each patient was given the Schedule for Affective Disorders and Schizophrenia (SADS) at the onset of radiotherapy, midway through radiotherapy, at the end of radiotherapy, and 4 and 8 weeks after radiotherapy ended. RESULTS: The combined SADS items for depression, pessimism and hopelessness, somatic preoccupation and worry, social isolation and withdrawal, insomnia, and anxiety and agitation were used as a measure of emotional distress. The combined SADS items for anorexia, nausea and vomiting, and fatigue were used as a measure of physical distress. By 4 weeks after the end of radiotherapy, the patients who received group psychotherapy showed significant decreases in both emotional and physical symptoms, and the decreases were greater than those for the control patients. The subjects who initially seemed unaware of their cancer diagnoses had the lowest baseline levels of emotional and physical distress, but 4 weeks after the end of radiotherapy they had high distress levels. CONCLUSIONS: Group therapy may enhance quality of life for cancer patients undergoing radiotherapy by reducing their emotional and physical distress. The degree to which patients acknowledge the diagnosis of malignancy may be a factor in their initial distress level and their response to radiotherapy and group therapy.

Role of emotional factors in adults with atopic dermatitis.

BACKGROUND: The role of anger in the onset or perpetuation of episodes of atopic dermatitis in adults has long been considered an important factor. The objective was to investigate whether atopic patients feel ineffective in dealing with anger and assertiveness when compared with psoriasis patients and control patients. METHODS: Thirty-four adult patients with atopic dermatitis were compared to 28 patients with psoriasis and 32 controls, dental patients without major skin disease. Standard measures of anxiety, anger, assertion, depression, and locus of control as well as a measure of anger effectiveness, designed for this study, were used. RESULTS: There were significant differences between atopic dermatitis patients and controls in that atopics felt angry more readily but were less likely to express it, were more anxious and less assertive, and felt less effective in expressing anger. The only difference between psoriasis patients and controls was less ability to express anger. Atopic patients were more chronically anxious than those with psoriasis. CONCLUSIONS: Adult atopic dermatitis patients are often chronically anxious and feel ineffective in handling anger which suggests that psychological interventions may prove helpful.

Connective tissue-activating peptide-III and its derivative, neutrophil-activating peptide-2, release histamine from human basophils.

Connective tissue-activating peptide-III (CTAP-III) is a 9 kd platelet alpha-granule-derived growth factor. It stimulates the synthesis of DNA, hyaluronic acid, glycosaminoglycans, and proteoglycan core protein in human fibroblasts. Human mononuclear cell-derived proteases have been previously demonstrated to digest the N-terminal 15 residues of CTAP-III (total, 85 residues) to produce neutrophil-activating peptide-2 (NAP-2). CTAP-III and NAP-2 belong to a class of proteins (platelet factor 4, interleukin-8/NAP-1, etc.) associated with inflammation and wound repair. In our efforts to purify human mononuclear cells and platelet-derived histamine-releasing factors, we had previously discovered that mixtures of CTAP-III and NAP-2 released histamine from human basophils. We have now developed simple protocols for the purification of CTAP-III and NAP-2, independently, from calcium ionophore (A23187)-stimulated platelet supernatants by affinity chromatography and have established their identity by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and N-terminal sequence analysis. Each of these related histamine between 2 and 10 micrograms/ml, a range identical to that obtained with CTAP-III/NAP-2 mixtures that we reported earlier. Thus, our data suggest that CTAP-III and NAP-2 independently release histamine from human basophils in dose ranges similar to ranges required for fibroblast stimulation by each.

IL-8 inhibits histamine release from human basophils induced by histamine-releasing factors, connective tissue activating peptide III, and IL-3.

We have previously purified and partially characterized histamine releasing factors (HRF), which were derived from a mixture of human mononuclear cells and platelets. We now report the effect of IL-8 upon HRF-, connective tissue activating peptide III (CTAP III)-, and IL-3-induced histamine release from human basophils. We determined that IL-8 itself, at concentrations between 10(-7) to 10(-11) M, does not release histamine from basophils, although positive results are observed in two of 26 subjects at 10(-7) M. Unfractionated (crude) HRF released histamine in 25 of 26 donors, in the range of 6.7% to 100% of total basophil histamine stores. When basophils were preincubated with IL-8 (10(-7) to 10(-11) M) for 5 min, followed by a 40-min incubation with HRF, histamine release was significantly inhibited in 20 of 25 donors. Inhibition was observed at as little as 10(-11) M IL-8, with maximal inhibition being attained at 10(-9) M. HRF-containing supernatants contain a mixture of different histamine-releasing moieties. To better define which factor(s) may be inhibited by IL-8, fractionated supernatants, purified CTAP III, and IL-3 were studied. Histamine release produced by two different HRF-containing chromatographic fractions (HRFvoid and HRFpeak 2) and purified CTAP-III (5 micrograms/ml) was inhibited by IL-8 in 10 of 12 donors, three of three donors, and seven of 10 donors, respectively. IL-3 (5000 U/ml)-dependent histamine release was inhibited by IL-8 in all subjects tested. In contrast, histamine release by anti-IgE and FMLP was not affected by IL-8. Thus, IL-8 appears to be an inhibitor of cytokine-like molecules that induce histamine release and may represent the previously described 8-kDa histamine release inhibitory factor present in mononuclear cell supernatants.

Biobehavioral variables and mortality or cardiac arrest in the Cardiac Arrhythmia Pilot Study (CAPS).

The frequency of ventricular premature complexes and the degree of impairment of left ventricular ejection fraction are major predictors of cardiac mortality and sudden death in the year after acute myocardial infarction. Recent studies have implicated psychosocial factors, including depression, the interaction of social isolation and life stress, and type A-B behavior pattern, as predictors of cardiac events, controlling for known parameters of disease severity. However, results tend not to be consistent and are sometimes contradictory. The present investigation was designed to test the predictive association between biobehavioral factors and clinical cardiac events. This evaluation occurred in the context of a prospective clinical trial, the Cardiac Arrhythmia Pilot Study (CAPS). Five-hundred two patients were recruited with greater than or equal to 10 ventricular premature complexes/hour or greater than or equal to 5 episodes of nonsustained ventricular tachycardia, recorded 6 to 60 days after a myocardial infarction. Baseline behavioral studies, conducted in approximately 66% of patients, included psychosocial questionnaires of anxiety, depression, social desirability and support, and type A-B behavior pattern. In addition, blood pressure and pulse rate reactivity to a portable videogame was assessed. The primary outcome was scored on the basis of mortality or cardiac arrest. Results indicated that the type B behavior pattern, higher levels of depression and lower pulse rate reactivity to challenge were significant risk factors for death or cardiac arrest, after adjusting statistically for a set of known clinical predictors of disease severity. The implication of these results for future research relating behavioral factors to cardiac endpoints is discussed.

Relation of psychosocial and stress reactivity variables to ventricular arrhythmias in the Cardiac Arrhythmia Pilot Study (CAPS).

Both animal and human data implicate psychosocial distress and cardiovascular reactivity in response to challenge in the etiology of sudden cardiac death. In this study, the relation of these biobehaviorial factors to frequency of ventricular premature complexes, a predictor of sudden death was investigated. The study population was made up of patients enrolled in the National Heart, Lung, and Blood Institute's Cardiac Arrhythmia Pilot Study (CAPS). Ventricular premature complexes (VPCs) were assessed by multiple, 24-hour ambulatory electrocardiographic recordings. Patients completed trait psychosocial measures assessed at baseline and state psychosocial measures assessed periodically during a 1-year follow-up period. Psychosocial measures included self-reports of depression, anxiety, anger and type A behavior pattern. A competitive challenge using a video game was used as a stressor to elicit cardiovascular reactivity and was administered at baseline and during follow-up sessions. Cardiovascular reactivity was defined as peak level during stressor exposure minus the mean of resting levels for systolic and diastolic blood pressure and pulse rate. Results indicated that biobehavioral factors were not associated with diurnal VPC rates. Furthermore, biobehavioral factors did not predict response to antiarrhythmic therapy. Based upon the results of this study, it is speculated that the established relation between behavioral factors and sudden death may not be mediated by VPC rates.

Relationship of one form of human histamine-releasing factor to connective tissue activating peptide-III.

We have previously reported purification of three forms of histamine-releasing factors (HRFs) from mixtures of streptokinase-streptodornase stimulated human mononuclear cells and platelets with apparent molecular masses of 10-12, 15-17, and 40-41 kD (1989. J. Clin. Invest. 83:1204-1210). We have also prepared mouse MAbs against the 10-12-kD HRF (1989. J. Allergy Clin. Immunol. 83:281). Affinity-purified 10-12-kD HRF appears as a broad band upon polyacrylamide gel electrophoresis in the presence of SDS. We determined the NH2-terminal amino acid sequence of the top and bottom halves of this broad band. Sequence analysis revealed striking homology between this HRF and connective tissue activating peptide-III (CTAP-III), a platelet-derived 8-10-kD protein known to cause mitogenesis and extracellular matrix formation in fibroblast cultures. 19 of 21 NH2-terminal residues in the top half of the HRF band were identical to the NH2-terminal sequence of CTAP-III. 20 of 21 NH2-terminal residues in the bottom half were identical to the NH2-terminal sequence of neutrophil-activating peptide-2, which is derived from CTAP-III by proteolytic cleavage between residues 15 and 16. Purified CTAP-III also released histamine from basophils. Rabbit antiserum raised against either native or recombinant CTAP-III recognized affinity-purified HRF in immunodot blot assays, and MAb against HRF recognized CTAP-III in both dot blot and microtiter plate based immunoassays. These data demonstrate the first structural, functional, and immunologic relationship between one form of human HRF and a previously described cell product.

Psychiatric outcome of heart transplantation.

The authors evaluated 73 cardiac transplant recipients 1 month to 6 years after transplantation to determine the prevalence of psychiatric disorders and psychosocial problems after cardiac transplantation. Affective illnesses had occurred in 51%, chiefly as a steroid-related syndrome, with mood lability, irritability, and grandiosity (22%). Major depressive episodes occurred in 11%. Postoperative delirium occurred in 4%. Anxiety symptoms were frequent (26%) but generally transient. Other frequent problems included cognitive, family, marital, and sexual dysfunction and inability to gain employment. Further effort is needed to reduce psychiatric morbidity and improve outcome for heart transplant recipients.