Why do I have to suffer? Symptom management, views and experiences of persons with a CPTSD: a grounded theory approach.

BACKGROUND: For the 11th version of the International Classification of Diseases, a new stress related diagnosis has been proposed: complex post-traumatic stress disorder (CPTSD). It is described as a chronic condition with several severe and concurrent symptoms. In the literature, these symptoms are discussed as a common reason for seeking psychiatric treatment as they can influence and impair the quality of life not only for affected persons but also for their social and familial system. AIM: This research studies symptom management in everyday life by exploring and reconstructing the views, perceptions, experiences, facilitators and barriers of adults with CPTSD. METHODS: A theoretical sampling was used to recruit 18 to 65 years old patients diagnosed with CPTSD from an inpatient setting. The 17 semi-structured interviews were audio recorded and transcribed verbatim. The transcriptions were uploaded into MAXQDA, and a Grounded Theory method based on Corbin and Strauss was used to analyse the data. RESULTS: We provide a process model with 5 interacting phases: trauma experience, emotional ignorance, overcompensation, paroxysm, and perspectives. Each phase is specified with subcategories. CONCLUSIONS: The participants did not recognise their symptoms as such and were unaware of their diagnosis for many years. Nevertheless, they used various resources and were able to develop skills and techniques to deal with their symptoms and to function on a day-to-day basis. Overall, the process of symptom management was extremely exhausting for the participants and they felt left alone with it. The participants were eager to gain support from healthcare professionals and, when necessary, financial support from the government. Thus, these results indicate an essential need to develop support and tailored interventions for the symptom management of persons with a CPTSD. TRIAL REGISTRATION: Ethical approval was obtained from the Swiss Cantonal Ethic Commission (Nr 201,500,096). This research was also registered at the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial DRKS00012268 .

Symptom management in complex post-traumatic stress disorder (ICD-11), view and experience of patients and their relatives: a mixed methods approach (Research Proposal).

OBJECTIVE: Using the framework of IDC-11, complex post-traumatic stress disorder will be diagnosed using the core criteria of a post-traumatic stress disorder and the presence of at least one symptom from the following three domains: symptoms of emotional dysregulation, negative self-concept, and problems in interpersonal relationships. In the literature, these symptoms are discussed as a common reason for seeking treatment. The symptoms can influence and impair the quality of life. This article describes a mixed methods study with a sequential exploratory design. The aim is to describe specific patient characteristics, levels of symptom burden and perspectives of adult inpatients and to describe the experiences, views and needs of patients' relatives. The study will also investigate facilitators of and barriers to symptom management. The research will be conducted in four phases. The first phase will assess patients' symptom burdens. The second phase will use semi-structured interviews to explore attitudes to symptom management and perceptions of patients and their relatives. The third phase will statistically explore hypotheses generated after the qualitative interviews. The fourth phase will mix the quantitative and qualitative results and interpret critically. RESULTS: The present study will add new results to the growing literature on complex post-traumatic stress disorder. These results could serve as the basis for further research into the development of interventions to improve symptom management. Trial registration Ethical approval has been obtained from the Swiss cantonal ethic commission (Nr. 201500096). This research was also registered to the World Health Organization Clinical Trials Search Portal through the German Clinical Trial Register, Trial DRKS00012268 (21/04/2017).

Local immune response in bladder pain syndrome/interstitial cystitis ESSIC type 3C.

INTRODUCTION AND HYPOTHESIS: Bladder pain syndrome/interstitial cystitis (BPS/IC) is identified based on subjective symptoms which lead to heterogeneous patient populations. Previous studies using gene expression arrays for BPS/IC with Hunner's lesions [European Society for the Study of Interstitial Cystitis (ESSIC) type 3C], a subtype of the condition discernible by cystoscopy, have revealed characteristic immune responses and urothelial abnormalities. This current study aimed to further characterize this subtype using a gene expression panel. We hypothesized that B-cell activation with high levels of urinary antibody concentration would be found. METHODS: Cold-cup bladder biopsies, catheterized urine and blood were collected from 15 BPS/IC ESSIC type 3C patients, 11 non-inflammatory overactive bladder (OAB) patients and eight healthy controls. Gene expression in biopsies was quantified by real-time quantitative polymerase chain reaction (RT-qPCR), immunohistochemistry was performed on bladder tissue and urinary immunoglobulins G and A were quantified by enzyme-linked immunosorbent assay. Statistical analyses included the Kruskal-Wallis test for non-parametric data and post hoc tests identified differences between groups. RESULTS: High expression of T- and B-cell markers (CTLA4, CD20, CD79A, IGH@), low expression of urothelial markers (KRT20, UPK1B, UPK3A), focal lymphoid aggregates in the submucosa and high immunoglobulin concentration in urine were found exclusively in BPS/IC ESSIC type 3C patients. Results for OAB were in intermediate ranges between the other two groups and UPK1B even reached significantly lower expression when compared to healthy controls. CONCLUSIONS: BPS/IC ESSIC type 3C is characterized by a local adaptive immune response with elevated urinary antibody concentrations. Quantification of urinary immunoglobulin levels could be used for a non-invasive diagnosis of BPS/IC ESSIC type 3C.

Gene expression profile of bladder tissue of patients with ulcerative interstitial cystitis.

BACKGROUND: Interstitial cystitis (IC), a chronic bladder disease with an increasing incidence, is diagnosed using subjective symptoms in combination with cystoscopic and histological evidence. By cystoscopic examination, IC can be classified into an ulcerative and a non-ulcerative subtype. To better understand this debilitating disease on a molecular level, a comparative gene expression profile of bladder biopsies from patients with ulcerative IC and control patients has been performed. RESULTS: Gene expression profiles from bladder biopsies of five patients with ulcerative IC and six control patients were generated using Affymetrix GeneChip expression arrays (Affymetrix--GeneChip Human Genome U133 Plus 2.0). More than 31,000 of > 54,000 tested probe sets were present (detection p-value < 0.05). The difference between the two groups was significant for over 3,500 signals (t-test p-value < 0.01), and approximately 2,000 of the signals (corresponding to approximately 1,000 genes) showed an IC-to-healthy expression ratio greater than two. The IC pattern had similarities to patterns from immune system, lymphatic, and autoimmune diseases. The dominant biological processes were the immune and inflammatory responses. Many of the up-regulated genes were expressed in leukocytes, suggesting that leukocyte invasion into the bladder wall is a dominant feature of ulcerative IC. Histopathological data supported these findings. CONCLUSION: GeneChip expression arrays present a global picture of ulcerative IC and provide us with a series of marker genes characteristic for this subtype of the disease. Evaluation of biopsies from other bladder patients with similar symptoms (e.g. patients with non-ulcerative IC) will further indicate whether the data presented here will be valuable for the diagnosis of IC.

Robotic surgery in urology: fact or fantasy?

Advanced robotic surgery was first introduced into urology in 2000. The first studies showed the feasibility and safety of the daVinci (Intuitive Surgical Inc., Sunnyvale, CA) telemanipulator assistance in radical prostatectomy, pelvi-ureteric junction obstruction, and radical cystectomy and neobladder formation. The miniature endowristed tools offer a potential advantage over standard laparoscopy in the accuracy of preparation and suturing. Other features are a three-dimensional vision system and unimpaired hand-eye coordination. Complex laparoscopic tasks are learned faster by using the robot, which may also explain the shorter training required for radical prostatectomy than for manual laparoscopy. This new and expensive technology has spread rapidly over the last 4 years. By 2004, approximately 10% of radical prostatectomies in the USA will be robot-assisted. Data on the functional and oncological outcomes are accruing but not yet conclusive. There will be a further spread of robotic surgery, routine telesurgery, smaller and more affordable systems, the introduction of virtual reality, all developments which have the potential to urological surgeons to improve.

Induction of apoptosis in human prostate stromal cells by 4-hydroxytamoxifen: an alternative therapy for benign prostate hyperplasia.

Benign prostate hyperplasia (BPH) is a disease of the aging male. In BPH, the imbalance of cell proliferation and programmed cell death (apoptosis) leads to continuous stromal growth. Common medication interrupts stromal cell proliferation but has only little effect on inducing stromal cell apoptosis. In this study, we investigated tamoxifen (TAM) and 4-hydroxytamoxifen (OHT) for their ability to induce apoptosis in human prostate stromal cells (PrSC) in vitro. After the incubation of PrSC with different concentrations of TAM or OHT, the cytotoxic effect was measured using an MTT-assay. The induction of apoptosis after OHT treatment was investigated by FACS-analysis (annexin V FITC staining) and Western blot (PARP-1 cleavage, BCL-2 and BAX-alpha expression). The administration of TAM at concentrations of 0-20 microM had very little effect on cell viability as measured by MTT assay. In contrast, the use of 10-20 microM OHT led to a significant decrease in cell viability. The binding of annexin V FITC to apoptotic cells was demonstrated by FACS-analysis. The induction of apoptosis was further proven by Western blot of PARP-1 protein cleavage and the expression of the anti-apoptotic BCL-2 and the pro-apoptotic BAX-alpha proteins. In conclusion, our data clearly demonstrate, that the administration of OHT at concentrations from 10-20 microM induced apoptosis in human PrSC. The more effective induction of apoptosis with OHT compared with TAM could very well explain the results of clinical studies showing no clinical effect of TAM treatment on BPH. Furthermore, our results, if reproducible in vivo, could open new avenues for the treatment of BPH by local administration of OHT in apoptosis-inducing concentrations.

Neurological soft signs and neuropsychological performance in patients with first episode schizophrenia.

Neurological soft signs and neuropsychological (NP) impairments are prevalent in schizophrenic patients. However, the relationship of these deficits is rarely studied, and it remains controversial in what way soft signs influence NP performance. The Neurological Evaluation Scale (NES) and a comprehensive neuropsychological test battery were used to assess soft signs and cognitive functions in 61 first-episode schizophrenic patients. The NP test battery included tests such as the California Verbal Learning Test, the Continuous Performance Test, the Span of Apprehension Test, the Stroop Color-Word Test, the Trail-Making Test and the Wisconsin Card Sorting Test. The NP tests were also administered to 87 healthy controls. The first-episode schizophrenic patients were split along the median of their NES total score (SS- vs. SS+). The level of NP performance and the differences in relative performance (shape of the NP profile) on NP functions between the two groups were assessed. The two groups (SS- vs. SS+) did not differ in any demographic or clinical variable. However, they differed in the level of their NP performance (profile mean) but did not show differential deficits in NP performance (profile shape). Neurologic soft signs influence NP performance and are correlated to a generalized NP deficit rather than to any specific NP functions.

Da Vinci robot assisted Anderson-Hynes dismembered pyeloplasty: technique and 1 year follow-up.

In experienced hands, laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction (UPJO). Although laparoscopic surgery can clearly benefit patients, laparoscopic pyeloplasty using conventional instrumentation is complex. The purpose of this report is to evaluate the feasibility of robot assisted laparoscopic surgery. Eleven pyeloplasties for UPJO were performed via a laparoscopic transperitoneal approach exclusively with the da Vinci Surgical System. The mean procedure time was 197 min (range 110-310 min). All operations were completed laparoscopically with no intraoperative complications and negligible blood loss. All patients recovered rapidly after surgery with excellent functional results at the 1 year follow-up. Our initial experience suggests that robot assisted Anderson-Hynes pyeloplasty is a safe and effective alternative to conventional laparoscopic surgery. In our opinion, robot assisted surgery will allow urologists to perform complex procedures with greater precision, confidence, and better results, as well as enable them to adapt the whole spectrum of laparoscopic procedures to their field.

Robotic technology and the translation of open radical prostatectomy to laparoscopy: the early Frankfurt experience with robotic radical prostatectomy and one year follow-up.

OBJECTIVE: Laparoscopic radical prostatectomy is a complex procedure and has been standardized only during the last years. The remote controlled da Vinci Surgical System has opened up a new era in minimally invasive surgery. We here present our initial experience with the translation of open retropubic radical prostatectomy to laparoscopic technique using da Vinci and a one year follow-up. METHODS: After a period of technical development and training on cadavers, 40 consecutive patients eligible for radical prostatectomy were treated. After port placement, the urologist took control of the 3D 30 degrees laparoscope and the two instrument arms at the da Vinci remote console to perform bilateral pelvic lymph node dissection, radical prostatovesiculectomy and urethrovesical anastomosis. RESULTS: The procedure was completed laparoscopically in all but two patients. Mean procedure time was 8.3 hours and mean intra-operative blood loss 570 ml. Learning curves associated with the use of the da Vinci Surgical System show that there is a 22-minute decrease in time required to perform the radical prostatectomy and lymphadenectomy for each case (p<0.0001). Patients recovered rapidly after surgery with early oncological and functional results that were similar to those obtained with our standard radical prostatectomy technique. CONCLUSIONS: Remote controlled robotic surgical systems are useful to translate open retropubic radical prostatectomy to laparoscopy. This new technology has the potential to equip the urologist with the microsurgical precision needed to preserve the delicate structural integrity of the pelvic floor in order to improve functional results without compromising the oncological outcome.

Characterization of the endothelium-derived hyperpolarizing factor (EDHF) response in the human interlobar artery.

BACKGROUND: In addition to nitric oxide (NO) and prostacyclin (PGI2), the vascular endothelium can influence local vascular tone by a mechanism involving the hyperpolarization of vascular smooth muscle cells. This response is attributed to the release of an endothelium-derived hyperpolarizing factor (EDHF). The present study was performed to determine the characteristics of the EDHF that mediates the NO/PGI2-independent hyperpolarization and relaxation of human renal interlobar arteries. METHODS: Acetylcholine-induced, EDHF-mediated hyperpolarization and relaxation were assessed using sharp microelectrodes impaled into interlobar smooth muscle cells and in organ chamber experiments, respectively. All experiments were performed in the combined presence of NO synthase (NOS) and cyclooxygenase inhibitors and the thromboxane analog U46619. RESULTS: Interlobar arteries demonstrated pronounced NO/PGI2-independent relaxations and hyperpolarizations that were sensitive to the blockade of calcium-activated K+-channels (KCa+ channels) by the combination of charybdotoxin and apamin and to the inhibition of the Na-K-ATPase by ouabain. Exogenously applied KCl also exhibited relaxations and hyperpolarizations that were sensitive to ouabain but insensitive to the combined inclusion of charybdotoxin and apamin. Relaxations induced by KCl were also observed in endothelium-denuded interlobar arteries. CONCLUSION: These results indicate that in the human renal interlobar artery, EDHF-mediated responses display the pharmacologic characteristics of K+ ions released through endothelial KCa+ channels. Smooth muscle cell hyperpolarization and relaxation appear to be dependent on the activation of ouabain-sensitive subunits of the Na-K-ATPase.

Serum levels of basic fibroblast growth factor reflect disseminated disease in patients with testicular germ cell tumors.

The potential role of angiogenesis stimulators in the pathogenesis of different tumor entities has been confirmed in several studies. We measured the serum levels of basic fibroblast growth factor (bFGF), vascular endothelial growth factor (VEGF) and platelet derived growth factor (PDGF) in 51 patients with testicular germ cell tumors and in 39 healthy volunteers. Serum concentrations of bFGF, VEGF and PDGF-AB were determined by enzyme-linked immunosorbent assay. The median serum bFGF level for tumor patients was 3.46 pg/ml (range 0-61.6) compared to 0.7 pg/ml (0-11) in the control group (P<0.01). In patients with metastatic disease, the median serum bFGF level was 10.3 pg/ml (0-61.6) in contrast to 2.8 pg/ml (0-50) in patients with localized disease (P<0.01). The median serum VEGF and PDGF levels were 270 pg/ml (0-1,903) and 37,837 pg/ml (9,075-108,800), respectively, for tumor patients and 200 pg/ml (44-585) and 23,000 pg/ml (4,250-70,650) in the control group ( P<0.05). Our data suggest that angiogenesis, as reflected by serum concentrations of bFGF, VEGF and PDGF, plays a functional role in the growth and progression of testicular germ cell tumors.

Telerobotic minimally invasive procedures in urology--laparoscopic radical prostatectomy.

A telerobotic device, the daVinci Surgical System (Intuitive Surgical, Inc., Mountain View, CA) is one of the recently developed, remotely operated systems for laparoscopic surgical procedures. This telemanipulation system consists of two components: a control console operated by the surgeon, and the surgical arm cart that holds a three-dimensional (3-D) 30 degrees laparoscope and two detachable laparoscopic surgical tools. The instruments are equipped with a wrist--a unique feature that provides additional dexterity. Since its clinical introduction in Europe in early 1999, this system has opened up a new era in minimally invasive surgery enhancing endoscopic vision and anastomosis suturing. For the first time, cardiac surgeons were able to perform a totally endoscopic coronary bypass procedure on a beating heart.

Serum angiogenic activity: diagnostic relevance in renal cell carcinoma.

OBJECTIVE: Angiogenesis is essential for tumor growth and progression. However, reported data on angiogenic parameters in patients with renal cell carcinoma are contradictory. The objective of this study was to use serum to compare the systemic angiogenic activity in patients with renal cell carcinoma and to determine if pathologic stage and grade correlated to this angiogenesis parameter. METHODS: Serum of 28 patients with a newly diagnosed renal cell carcinoma, 28 healthy volunteers and 9 patients with bladder carcinoma were used for this study. All sera were tested in a 72-hour endothelial cell proliferation assay. In addition the serum concentrations of the angiogenesis stimulators basic fibroblast growth factor (bFGF) and vascular endothelial growth factor (VEGF) were determined using standard ELISA assays. RESULTS: The serum of renal cell carcinoma patients showed a median stimulation of human umbilical vein endothelial cells (HUVEC) of 89.79% (range 58.47-147.95%) and serum of healthy volunteers showed a median stimulation of 95.35% (range 74.64-141.77%) (p > 0.05). In contrast serum of patients with bladder carcinoma showed a median stimulation of 140.16% (range 64.82-200.16%) (p = 0.024). No correlations of the serum angiogenic activity and tumor stage or grade have been found in renal cell carcinoma patients. Furthermore, no correlations for serum bFGF and VEGF concentrations have been found. CONCLUSIONS: Serum angiogenic activity of patients with renal cell carcinoma did not differ significantly from healthy controls, while serum of patients with bladder carcinoma showed a significant increase in endothelial cell stimulation. Furthermore, bFGF and VEGF serum concentrations did not correlate to serum angiogenic activity in patients with renal cell carcinoma. Therefore, the determination of systemic angiogenic parameters, in case of renal cell carcinoma, might not lead to adequate data concerning prognosis or therapeutic effects.

Effects of prolonged pneumoperitoneum on hemodynamics and acid-base balance during totally endoscopic robot-assisted radical prostatectomies.

Laparoscopic techniques have become a standard approach for diagnostic and therapeutic procedures in many surgical disciplines. Recent progress in endoscopic surgery is based on the integration of computer-enhanced telemanipulation systems. Because robot-assisted radical prostatectomies take up to 10 hours, the present study was performed to evaluate the effects of prolonged intraperitoneal CO2 insufflation on hemodynamics and gas exchange in 15 patients with prostate cancer. When CO2 insufflation was initiated, peak inspiratory pressure increased and reached significant values after a 1.5-hour period of intraperitoneal CO2 insufflation. With the release of CO2, peak inspiratory pressure decreased close to baseline values. A significant increase in heart rate was observed after a 4-hour period of increased intraabdominal pressure. Mean arterial blood pressure and central venous pressure remained stable during CO2 insufflation. Minute ventilation was adjusted according to repeated blood gas analyses to maintain pH, base excess (BE), bicarbonate (HCO3?), and PaCO2 within physiologic ranges. The present data show, that prolonged CO2 insufflation during totally endoscopic robot-assisted radical prostatectomy results in only minor changes in hemodynamics and acid-base status. Because of the limited experience with long-term pneumoperitoneum, we consider invasive haemodynamic monitoring and repeat blood gas analysis essential for such operations.

Laparoscopic transperitoneal adrenalectomy using a remote-controlled robotic surgical system.

BACKGROUND AND PURPOSE: Laparoscopic adrenalectomy is considered the standard method for removal of benign adrenal tumors. Although laparoscopic surgery provides clear patient benefit, laparoscopic adrenalectomy using conventional instrumentation is complex. Our objective was to evaluate whether the da Vinci trade mark Surgical System, a comprehensive robotic endoscopic surgical device, could be used effectively to perform laparoscopic adrenalectomy. PATIENTS AND METHODS: Through a transperitoneal approach, three right and one left adrenal tumors were removed in four patients using this method. RESULTS: There were no complications, and the clinical results were excellent. CONCLUSION: We demonstrate the feasibility of performing laparoscopic adrenalectomy exclusively by using robotic telepresent technology from a remote workstation. The da Vinci System enables conventionally trained urologic surgeons to perform complex minimally invasive procedures with ease and precision. Therefore, we are convinced that the system helps the urologist to adapt the whole spectrum of laparoscopic procedure in this field.

Reduced plasma levels of coagulation factors in relation to prostate cancer.

BACKGROUND: Prostate cancer has historically been associated with coagulation abnormalities. This study was undertaken to investigate the prevalence of abnormalities of coagulation factors in patients with prostate cancer before and after radical prostatectomy (RP). Because coagulation factors have been shown to be involved in tumor angiogenesis, the vascular density of the prostate tumors was assessed. METHODS: Plasma of 40 consecutive patients with histologically proven prostate cancer was investigated pre-RP and post-RP. The antigen level for antithrombin, plasminogen activator inhibitor-1, and heparin cofactor-II, and the plasma activity of antithrombin and plasminogen were determined by using immunologic and chromogenic assays. The values of these assays were compared with a group of 28 male, age-matched patients without any evidence of cancer and 18 patients with orthopedic interventions preoperatively and postoperatively. The vascular density of the prostate tumors was assessed by staining paraffin sections with an antibody to CD34. RESULTS: The median plasma antigen levels and/or activities of the investigated factors were below normal in the prostate cancer patients before RP. Furthermore, coagulation factors were significantly lower than in the age-matched control group and patients before and after orthopedic surgery. In prostate cancer patients, the median values of all investigated factors went up to normal levels within 2 weeks after RP, whereas postsurgical levels in orthopedic patients remained stable. No correlations to tumor parameters have been observed. CONCLUSION: We assume that the reduction of these coagulation factors is a principle concept in prostate cancer that needs further investigation.