A focus group study of predictors of relapse in electronic gaming machine problem gambling, part 1: factors that 'push' towards relapse.

This study aimed to develop an empirically based description of relapse in Electronic Gaming Machine problem gambling. In this paper the authors describe part one of a two part, linked relapse process: the 'push' towards relapse. In this two-part process, factors interact sequentially and simultaneously within the problem gambler to produce a series of mental and behavioural events that ends with relapse when the 'push' overcomes 'pull' (part one); or as described in part two, continued abstinence when 'pull' overcomes 'push'. In the second paper, the authors describe how interacting factors 'pull' the problem gambler away from relapse. This study used four focus groups comprising thirty participants who were gamblers, gamblers' significant others, therapists and counsellors. The groups were recorded, recordings were then transcribed and analysed using thematic, textual analysis. With the large number of variables considered to be related to relapse in problem gamblers, five key factors emerged that 'push' the gambler towards relapse. These were urge, erroneous cognitions about the outcomes of gambling, negative affect, dysfunctional relationships and environmental gambling triggers. Two theories emerged: (1) each relapse episode comprised a sequence of mental and behavioural events, which evolves over time and was modified by factors that 'push' this sequence towards relapse and (2) a number of gamblers develop an altered state of consciousness during relapse described as the 'zone' which prolongs the relapse.

A focus group study of predictors of relapse in electronic gaming machine problem gambling, part 2: factors that 'pull' the gambler away from relapse.

This study aimed to develop an empirically based description of relapse in Electronic Gaming Machine (EGM) problem gambling (PG) by describing the processes and factors that 'pull' the problem gambler away from relapse contrasted with the 'push' towards relapse. These conceptualisations describe two opposing, interacting emotional processes occurring within the problem gambler during any relapse episode. Each relapse episode comprises a complex set of psychological and social behaviours where many factors interact sequentially and simultaneously within the problem gambler to produce a series of mental and behaviour events that end (1) with relapse where 'push' overcomes 'pull' or (2) continued abstinence where 'pull' overcomes 'push'. Four focus groups comprising thirty participants who were EGM problem gamblers, gamblers' significant others, therapists and counsellors described their experiences and understanding of relapse. The groups were recorded, recordings were then transcribed and analysed using thematic textual analysis. It was established that vigilance, motivation to commit to change, positive social support, cognitive strategies such as remembering past gambling harms or distraction techniques to avoid thinking about gambling to enable gamblers to manage the urge to gamble and urge extinction were key factors that protected against relapse. Three complementary theories emerged from the analysis. Firstly, a process of reappraisal of personal gambling behaviour pulls the gambler away from relapse. This results in a commitment to change that develops over time and affects but is independent of each episode of relapse. Secondly, relapse may be halted by interacting factors that 'pull' the problem gambler away from the sequence of mental and behavioural events, which follow the triggering of the urge and cognitions to gamble. Thirdly, urge extinction and apparent 'cure' is possible for EGM gambling. This study provides a qualitative, empirical model for understanding protective factors against gambling relapse.

Combined endoscopic and surgical management of Dieulafoy vascular malformation.

BACKGROUND: Dieulafoy's disease (exulceratio simplex) is an uncommon cause of gastric hemorrhage as a result of an abnormally large, submucosal, eroded gastric artery, often located in the upper part of the stomach. It represents a clinical challenge because of the intermittent nature of massive bleeding accounting for a constantly fatal course in conservatively (nonsurgically or nonendoscopically) treated patients. Published therapeutic options include techniques of endoscopic hemostasis or operative procedures. STUDY DESIGN: Herein we report two patients in whom a combined endoscopic and operative approach was performed to obtain a definitive prevention of rebleeding and an undoubted anatomopathologic diagnosis. RESULTS: Our innovative combined endoscopic and operative approach has offered three significant advantages: endoscopic preoperative diagnosis and control of the bleeding; valid aid in the intraoperative localization of hemorrhagic lesions, which is erratic intraoperatively, requires gastrotomy, and prolongs the duration of operation; and endoscopy-guided limited wedge resection as opposed to standard techniques involving gastrotomy for simple ligation or oversewing of the involved vessel, local excision, or wide wedge resections that used to be recommended until the recent past. CONCLUSIONS: We confirm that seemingly obscure origins of massive recurring hemorrhage of the upper part of the gastrointestinal tract should increase the suspicion of Dieulafoy's disease, prompting careful examination of the gastric fundic area and greater curvature. Endoscopic hemostasis is the first choice; whenever operative treatment is indicated (because of the endoscopic or clinical situation), it should be as conservative as possible because of intraoperative endoscopic localization of the bleeding source.

Fasting insulin and uric acid levels but not indices of iron metabolism are independent predictors of non-alcoholic fatty liver disease. A case-control study.

BACKGROUND: Non-alcoholic fatty liver disease is a common reason for hepatological consultation and may herald severe hepatic and extra-hepatic disease. The aetiopathogenesis of this condition is an area of increasing interest. AIM: To evaluate anthropometric and biochemical factors associated to non-alcoholic fatty liver disease in a case-control study. Methods. Demographic and biochemical data of 60 consecutive patients with bright liver absent-to-low alcohol consumption, no evidence of viral, genetic and autoimmune diseases, were compared to those of 60 age- and gender-matched historical controls without fatty liver by univariate and multiple logistic regression analysis. RESULTS: Patients were more often hypertriglyceridaemic, obese and diabetic than controls (p<.01). Mean values of alanine transaminase, gammaglutamyltranspeptidase, triglycerides, uric acid, fasting and log insulin, transferrin percent saturation and ferritin were significantly higher in the patients, while transferrin and quantitative insulin sensitivity check index, a quantitative insulin sensitivity index, were lower. No iron storage was found in those who underwent liver biopsy At univariate analysis the relative risk for non-alcoholic fatty liver disease significantly increased (p<0. 05) with increasing body mass index, fasting insulin, alanine transaminase, uric acid, triglycerides and gammaglutamyltranspeptidase; it decreased with increasing transferrin and quantitative insulin sensitivity check index. Multiple logistic regression analysis disclosed only fasting insulin and uric acid to be independent predictors of non-alcoholic fatty liver disease (p<0.05). CONCLUSIONS: Fasting insulin and serum uric acid levels indicating insulin resistance, but not indices of iron overload, are independent predictors of non-alcoholic fatty liver disease.

[Need of updating hepatological nosology]. / Sulla necessità di un aggiornamento della nosologia epatologica.

The nosological classification of chronic liver disease (CLD) seems to be unsatisfactory when clinical problems are faced such as the liver cirrhosis-diabetes mellitus and the autoimmune diseases-primary biliary cirrhosis (PBC) associations; the concept of PBC as a systemic disease; the multiorgan involvement of chronic active hepatitis. Accordingly, the Authors hypothesize that the present histopathological-based nosology of CLD will be modified as a result of a better understanding of the varied metabolic and immunologic derangements induced by CLD.

Peptic ulcer in migrants. Seven case-reports from Italy.

Migrant workers in Central Europe are reported to suffer from an increased prevalence of both duodenal and gastric ulcer as compared to native population. No information is available, however, as far as Italy is concerned. The Authors have thought of interest to report on 7 cases of peptic ulcer disease occurring in migrant workers in Italy. Patients were young adult males from African or Mediterranean developing Countries. In 5 cases the symptoms of their peptic ulcers began after their arrival in Italy. The etiopathogenesis of peptic ulcer was likely to include an interaction among emotional stress, low income, shift and manual work, cigarette smoking and nonsteroidal antiinflammatory drugs self-administration. This last factor has not been reported in literature. The hypothesis that migrant workers in Italy are a peptic ulcer-prone population needs further confirmation for its clinical and social implications.

Fatty liver in heterozygous hypobetalipoproteinemia caused by a novel truncated form of apolipoprotein B.

Fatty liver has been anecdotally associated with heterozygous hypobetalipoproteinemia. The aim of this study was to characterize the molecular defect in a subject with heterozygous hypobetalipoproteinemia (low-density lipoprotein cholesterol, 52 mg/dL; apolipoprotein [apo] B, 15 mg/dL) and otherwise unexplained fatty liver. Plasma lipoproteins were separated by ultracentrifugation, and apo B was analyzed by electrophoresis and immunoblotting. A fragment of genomic DNA corresponding to the 5' end of exon 26 of the apo B gene was amplified by polymerase chain reaction and sequenced. The plasma lipoproteins of the proband contained, besides normal apo B-100, a 200-kilodalton truncated apo B whose size suggested the presence of a mutation in exon 26 of the apo B gene. The nucleotide sequence of a fragment of the 5' end of exon 26 revealed that the proband was a heterozygote for a 14-nucleotide deletion, producing a frameshift resulting in a premature stop codon at residue 1768. This truncated apo B was named apo B-38.95. The proband's father was a carrier of the same mutation. Fatty liver in this subject with familial heterozygous hypobetalipoproteinemia most likely results from the inability of apo B-38.95 to export lipids from hepatocytes into the blood stream. Heterozygous hypobetalipoproteinemia should be considered in a hypolipidemic subject with an otherwise unexplained fatty liver.

Hemoductal pancreatitis secondary to gastroduodenal artery-ruptured pseudoaneurysm: a rare cause of hematemesis.

A 65-yr-old alcoholic man with a history of calcific pancreatitis presented with massive hematemesis complicated by lipothymia. Physical examination disclosed stigmata of chronic liver disease. The laboratory picture was predominantly of cholestatic type with impaired liver protein synthetic activity. Emergency esophagogastroduodenoscopy was unable to provide definitive diagnosis, but reendoscopy with a side-viewing duodenoscope revealed active bleeding through the ampulla of Vater. An ultrasound examination showed a large, complex pancreatic lesion that computed tomography showed to be a pancreatic pseudocyst with an inside pseudoaneurysm. A visceral angiography revealed an anomalous arising of the common hepatic artery from the superior mesenteric artery and a pseudoaneurysm of the gastroduodenal artery at its origin. A second massive hemorrhage required an emergency operation, and surgical liver biopsy revealed focal steatosis. In conclusion, bleeding of a pancreatic pseudoaneurysm may be massive but intermittent, and side-viewing duodenoscopy, even prolonged, is essential in the diagnosis.

Right colon adenocarcinoma presenting as Bacteroides fragilis liver abscesses.

Pyogenic abscesses of the liver occur in association with a variety of diseases. Sometimes they are caused by anaerobic infections of liver metastases. Uncommonly, however, multiple hepatic abscesses caused by anaerobic bacteria are the presenting signs of unsuspected colonic cancer in the absence of liver metastases. We report a 60-year-old man who presented with febrile cholestatic liver disease initially thought to be metastases. Repeated ultrasound-directed liver biopsies yielded a diagnosis of multiple abscesses. Bacteroides fragilis was grown from the liver specimen and the patient responded well to metronidazole treatment. Two months later, however, overt symptoms of large bowel disease led to the diagnosis of colonic adenocarcinoma. After a 6-month postoperative follow-up, the patient is free of liver metastases. Anaerobic liver abscesses should always alert the clinician to possible silent colonic cancer.

Are routine duodenal and antral biopsies useful in the management of "functional" dyspepsia? A diagnostic and therapeutic study.

Fifty-three patients with previously uninvestigated chronic dyspepsia symptoms in the absence of gastrointestinal or extra-gastrointestinal disease (functional dyspepsia) underwent antral and duodenal mucosal biopsies to detect the role of such samplings in the presence of normal endoscopic findings. Patients were enrolled in a randomized, placebo-controlled, double-blind trial, receiving either eradicating treatment (colloidal bismuth subcitrate plus metronidazole) or placebo if they had Helicobacter pylori-associated gastritis (20 patients), or cisapride or placebo if they had normal antral mucosa (28 cases). Unsuspected celiac sprue was found in one patient. Eradicating treatment ameliorated histological gastritis (p = 0.01). However, owing to great placebo efficacy, symptom remission rates following a 1-month wash-out period in both treatment groups were no higher than that in controls. Independent of the initial randomization, an extremely low symptom recurrence rate was observed during a drug-free follow-up study equivalent to the mean duration of symptoms before enrollment. We conclude that in functional dyspepsia, bulbar and antral biopsies are not useful in clinical management, equivalent symptom relief can be achieved in patients randomly assigned to both drugs and placebos, and such improvement can be long lasting in the absence of any maintenance treatment. We believe the prevalence of unsuspected villous atrophy and the therapeutic role of investigation-based reassurance deserve further assessment.