Neurocognitive deficits in borderline personality disorder: implications for treatment.

The cognitive dimension of Borderline Personality Disorder has received relatively little attention in the clinical literature and is poorly understood. This article illustrates how a range of cognitive problems including attention deficit disorder and learning disabilities may contribute to the cognitive disturbances identified in the disorder including dissociation, paranoia, all or nothing thinking, overvalued ideas, and denial and splitting. A review of relevant research supporting the presence of cognitive deficits is summarized along with a developmental pathway for the expression of the cognitive dimension. Clinical examples are provided. Recommendations for inclusion of assessment and treatment strategies that address cognitive deficits within a psychodynamically based psychotherapy are discussed.

Chronic illness histories of adults entering treatment for co-occurring substance abuse and other mental health disorders.

Little is known about the medical status of individuals entering treatment for co-occurring substance abuse and other mental disorders (COD). We analyzed the medical histories of 169 adults entering outpatient treatment for CODs, estimating lifetime prevalence of chronic illness and current smoking, comparing these rates to the general population, and examining psychiatric and substance-related correlates of chronic illness. Results revealed significantly higher prevalence of hypertension, asthma, arthritis, and smoking compared to the general US population, and showed an association between chronic illness and psychiatric symptom distress and substance use severity. Findings support integration of chronic illness management into COD treatment.

Association between Faecalibacterium prausnitzii and dietary fibre in colonic fermentation in healthy human subjects.

The intestinal microbiota are a complex ecosystem influencing the immunoregulation of the human host, providing protection from colonising pathogens and producing SCFA as the main energy source of colonocytes. Our objective was to investigate the effect of dietary fibre exclusion and supplementation on the intestinal microbiota and SCFA concentrations. Faecal samples were obtained from healthy volunteers before and after two 14 d periods of consuming formulated diets devoid or supplemented with fibre (14 g/l). The faecal microbiota were analysed using fluorescent in situ hybridisation and SCFA were measured using GLC. There were large and statistically significant reductions in the numbers of the Faecalibacterium prausnitzii (P < or = 0.01) and Roseburia spp. (P < or = 0.01) groups during both the fibre-free and fibre-supplemented diets. Significant and strong positive correlations between the proportion of F. prausnitzii and the proportion of butyrate during both baseline normal diets were found (pre-fibre free r 0.881, P = 0.001; pre-fibre supplemented r 0.844, P = 0.002). A significant correlation was also found between the proportional reduction in F. prausnitzii and the proportional reduction in faecal butyrate during both the fibre-free (r 0.806; P = 0.005) and the fibre-supplemented diet (r 0.749; P = 0.013). These findings may contribute to the understanding of the association between fibre, microbiota and fermentation in health, during enteral nutrition and in disease states such as Crohn's disease.

Fecal microbiota in patients receiving enteral feeding are highly variable and may be altered in those who develop diarrhea.

BACKGROUND: The pathogenesis of diarrhea in patients receiving enteral feeding includes colonic water secretion, antibiotic prescription, and enteropathogenic colonization, each of which involves an interaction with the gastrointestinal microbiota. OBJECTIVE: The objective was to investigate temporal changes in the concentrations of fecal microbiota and short-chain fatty acids (SCFAs) in patients starting 14-d of enteral feeding and to compare these changes between patients who do and do not develop diarrhea. DESIGN: Twenty patients starting exclusive nasogastric enteral feeding were monitored for 14 d. Fecal samples were collected at the start, middle, and end of this period and were analyzed for major bacterial groups by using culture independent fluorescence in situ hybridization and for SCFAs by using gas-liquid chromatography. RESULTS: Although no significant changes in fecal microbiota or SCFAs were observed during enteral feeding, stark alterations occurred within individual patients. Ten patients (50%) developed diarrhea, and these patients had significantly higher concentrations of clostridia (P = 0.026) and lower concentrations (P = 0.069) and proportions (P = 0.029) of bifidobacteria. Patients with and without diarrhea had differences in the proportion of bifidobacteria (median: 0.4% and 3.7%; interquartile range: 0.8 compared with 4.3; P = 0.035) and clostridia (median: 10.4% and 3.7%; interquartile range: 14.7 compared with 7.0; P = 0.063), respectively, even at the start of enteral feeding. Patients who developed diarrhea had higher concentrations of total fecal SCFAs (P = 0.044), acetate (P = 0.029), and butyrate (P = 0.055). CONCLUSION: Intestinal dysbiosis occurs in patients who develop diarrhea during enteral feeding and may be involved in its pathogenesis.

Covert assessment of concurrent and construct validity of a chart to characterize fecal output and diarrhea in patients receiving enteral nutrition.

BACKGROUND: An accurate and convenient method for characterizing fecal output and a consistent threshold for classifying diarrhea in patients receiving enteral nutrition are required. The aim of this study is to covertly assess the construct and concurrent validity of a chart for characterizing fecal output and classifying diarrhea in patients receiving enteral nutrition. METHODS: The chart was used to monitor fecal output in patients receiving enteral nutrition for a total of 280 patient days. Nurses characterized 291 fecal samples, of which 84 underwent measurement of fecal water using lyophilization and 60 underwent Clostridium difficile enterotoxin analysis using enzyme-linked immunosorbent assay. Construct and concurrent validity was assessed covertly to measure the true performance of the chart in a real-life clinical and research context. RESULTS: Use of the chart demonstrated higher fecal frequency (P

The effect of consuming instant black tea on postprandial plasma glucose and insulin concentrations in healthy humans.

OBJECTIVE: To determine the effects of black tea on postprandial plasma glucose and insulin concentrations in healthy humans in response to an oral glucose load. METHODS: A four-way randomised, crossover trial was designed in which 16 healthy fasted subjects would consume 75g of glucose in either 250ml of water (control), 250ml of water plus 0.052g of caffeine (positive control) or 250 ml of water plus 1.0g or 3.0g of instant black tea. Blood samples were collected at fasting and at 30min intervals for 150min from commencement of drink ingestion. Glucose and insulin concentrations were measured using standard methodology. The tea was chemically characterised using colorimetric and HPLC methods. RESULTS: Chemical analysis showed that the tea was rich in polyphenolic compounds (total, 350mg/g). Results from only 3 treatment arms are reported because the 3.0g tea drink caused gastrointestinal symptoms. Plasma glucose concentrations <60min in response to the drinks were similar, but were significantly reduced at 120min (P<0.01), following ingestion of the 1.0g tea drink, relative to the control and caffeine drinks. Tea consumption resulted in elevated insulin concentrations compared with the control and caffeine drinks at 90min (P<0.01) and compared with caffeine drink alone at 150min (P<0.01). CONCLUSIONS: The 1.0g tea drink reduced the late phase plasma glucose response in healthy humans with a corresponding increase in insulin. This may indicate that the attenuation in postprandial glycemia was achieved as a result of an elevated insulin response following stimulation of pancreatic beta-cells. This effect may be attributable to the presence of phenolic compounds in the tea.

A randomized controlled trial of weight reduction as a treatment for breast cancer-related lymphedema.

BACKGROUND: Obesity is considered a risk factor for the development of breast cancer-related lymphedema of the arm and as a poor prognostic factor in response to lymphedema treatment. The objective of this study was to examine weight reduction as a treatment for breast cancer-related lymphedema. METHODS: Twenty-one women with breast cancer-related lymphedema were randomized either to receive dietary advice for weight reduction or to receive a booklet on general healthy eating. They were monitored for 12 weeks. RESULTS: The primary outcome measure was arm volume at 12 weeks. The results indicated a significant reduction in swollen arm volume at the end of the 12-week period (P = .003) in the intervention weight-reduction group. There was a significant reduction in body weight (P = .02) and body mass index (P = .016) in the weight-reduction group at the end of the 12-week study period. CONCLUSIONS: Weight loss achieved by dietary advice to reduce energy intake can reduce breast cancer-related lymphedema significantly.

Randomized controlled trial comparing a low-fat diet with a weight-reduction diet in breast cancer-related lymphedema.

BACKGROUND: Obesity is considered a risk factor for lymphedema of the arm resulting from breast cancer treatment (BCRL) as well as a poor prognostic factor in response to lymphedema treatment. The aim of the study was to compare the effect of 2 dietary interventions on excess arm volume in BCRL. METHODS: A total of 64 women with BCRL were randomized to 1 of 3 groups for 24 weeks: 1) weight reduction through reduced energy intake; 2) low-fat diet with no change in energy intake (isoenergetic); 3) control group with no dietary change from habitual intake. RESULTS: The primary outcome measure was arm volume at 24 weeks. Results showed significant reductions in body weight (P = .006), body mass index (P = .008), and skinfold thickness measured at 4 sites (P = .044) in the weight-reduction and low-fat groups compared with controls. A slightly greater, but not significant (P = .605), fall in excess arm volume occurred in the dietary groups but a significant correlation between weight loss (irrespective of group) and a reduction in excess arm volume (r: 0.423; P = .002) was demonstrated. CONCLUSIONS: Weight loss, whether through reduced energy intake or low-fat diet, appears to be helpful in the treatment of breast cancer-related lymphedema.

Formula delivery in patients receiving enteral tube feeding on general hospital wards: the impact of nasogastric extubation and diarrhea.

OBJECTIVE: In contrast to the intensive care unit, little is known of the percentage of formula delivered to patients receiving enteral tube feeding (ETF) on general wards or of the complications that affect its delivery. This study prospectively investigated the incidence of nasogastric extubation and diarrhea in patients starting ETF on general wards and examined their effect on formula delivery. METHODS: In a prospective observational study, the volume of formula delivered to patients receiving ETF on general wards was compared with the volume prescribed. The incidence of nasogastric extubation and diarrhea was measured and its effect on formula delivery calculated. RESULTS: Twenty-eight patients were monitored for a total of 319 patient days. The mean +/- SD volume of formula prescribed was 1460 +/- 213 mL/d, whereas the mean volume delivered was only 1280 +/- 418 mL/d (P < 0.001), representing a mean percentage delivery of 88 +/- 25% of prescribed formula. Nasogastric extubation occurred in 17 of 28 patients (60%), affecting 53 of the 319 patient days (17%). The percentage of formula delivered on days when the nasogastric tube remained in situ was 96 +/- 12% and on days when nasogastric extubation occurred it was only 45 +/- 31% (P < 0.001). Diarrhea affected 39 of 319 patient days (12%) but there was no difference in formula delivery on days when diarrhea did or did not occur (78% versus 89%, P = 0.295). There was a significant, albeit small, negative correlation between the daily stool score and formula delivery (correlation coefficient -0.216, P < 0.001). CONCLUSIONS: Formula delivery is marginally suboptimal in patients receiving ETF on general wards. Nasogastric extubation is common and results in an inherent cessation of ETF until the nasogastric tube is replaced and is therefore a major factor impeding formula delivery. Diarrhea is also common but does not result in significant reductions in formula delivery.

Appetite during consumption of enteral formula as a sole source of nutrition: the effect of supplementing pea-fibre and fructo-oligosaccharides.

Liquid enteral formulas are commonly used as a sole source of nutritional support of patients in hospital and community settings. Their effect on appetite has important consequences for dietary management of such patients and is likely to be affected by the formula composition. The aim of the present study was to compare appetite within healthy subjects consuming both a standard formula and one supplemented with pea-fibre (10 g/l) and fructo-oligosaccharide (FOS; 5 g/l) as a sole source of nutrition. Eleven healthy subjects consumed a standard formula or a pea-fibre/FOS formula as a sole source of nutrition for 14 d in a double-blind, cross-over trial. Appetite was recorded using standard 100 mm lines anchored at each end by a phrase denoting the most extreme appetite sensation. Consumption of the pea-fibre/FOS formula resulted in higher mean fullness (46 v. 37 mm, P=0.035), minimum fullness (13 v. 9 mm, P=0.024) and minimum satiety (12 v. 8 mm, P=0.012) compared to the standard formula. As there were no differences in macronutrient intake between formulas, these differences are likely to be due to supplementation with pea-fibre and FOS. The effect on appetite of the composition of an enteral formula, both with respect to nutrient content and functional components such as pea-fibre and FOS, may be an important aspect to consider in the dietary management of patients consuming enteral formula as a sole source of nutrition.

Fructooligosaccharides and fiber partially prevent the alterations in fecal microbiota and short-chain fatty acid concentrations caused by standard enteral formula in healthy humans.

The intestinal microbiota are important during enteral tube feeding because they exert colonization resistance and produce SCFAs. However, the effect of the enteral formula composition on major bacterial groups of the microbiota has not been clearly defined. The aim of this study was to investigate the effect of enteral formulas with and without prebiotic fructooligosaccharides (FOS) and fiber on the fecal microbiota and SCFAs. Healthy subjects (n = 10; 4 men, 6 women) consumed both a standard enteral formula and one containing FOS (5.1 g/L) and fiber (8.9 g/L) as a sole source of nutrition for 14 d in a randomized, double-blind, crossover trial with a 6-wk washout phase. Fecal samples were collected at the start and end of each formula phase, and were analyzed for major bacterial groups and SCFA concentrations using fluorescent in situ hybridization and GLC, respectively. Although there were reductions in total fecal bacteria due to both formula treatments, concentrations were higher after the FOS/fiber formula period compared with the standard formula period (11.2 +/- 0.2 vs. 11.0 +/- 0.2 log(10) cells/g, P = 0.005). The FOS/fiber formula increased bifidobacteria (P = 0.004) and reduced clostridia (P = 0.006). Compared with the standard formula, the FOS/fiber formula resulted in higher concentrations of total SCFA (332.4 +/- 133.8 vs. 220.1 +/- 124.5 micromol/g, P = 0.022), acetate (219.6 +/- 96.3 vs. 136.8 +/- 74.5 micromol/g, P = 0.034) and propionate (58.4 +/- 37.4 vs. 35.6 +/- 25.5 micromol/g, P = 0.02). This study demonstrates that standard enteral formula leads to adverse alterations to the fecal microbiota and SCFA concentrations in healthy subjects, and these alterations are partially prevented by fortification of the formula with FOS and fiber.

Enteral feeding: the effect on faecal output, the faecal microflora and SCFA concentrations.

Enteral tube feeding is common in both the hospital and community environment; however, patients can suffer alterations in faecal output that can have serious clinical sequelae. Problems associated with accurate characterisation of faecal output and definition of diarrhoea impede the comparison of research studies and prevent standardised assessment of therapeutic interventions in clinical practice. The colonic microflora may protect the patient against diarrhoea by preventing enteropathogenic infection and by producing SCFA that stimulate colonic water absorption. However, studies in healthy volunteers suggest that the composition of the enteral formula may have a negative impact on the microflora and SCFA concentrations. The addition of fructo-oligosaccharides to the enteral formula may partially prevent negative alterations to the microflora, although conclusive data from studies in patients are not yet available. Modification of the microflora with probiotics and prebiotics may hold potential in prophylaxis against diarrhoea during enteral tube feeding.