Recommendations for enhancing psychosocial support of NICU parents through staff education and support.

Providing psychosocial support to parents whose infants are hospitalized in the neonatal intensive care unit (NICU) can improve parents' functioning as well as their relationships with their babies. Yet, few NICUs offer staff education that teaches optimal methods of communication with parents in distress. Limited staff education in how to best provide psychosocial support to families is one factor that may render those who work in the NICU at risk for burnout, compassion fatigue and secondary traumatic stress syndrome. Staff who develop burnout may have further reduced ability to provide effective support to parents and babies. Recommendations for providing NICU staff with education and support are discussed. The goal is to deliver care that exemplifies the belief that providing psychosocial care and support to the family is equal in importance to providing medical care and developmental support to the baby.

Emotional distress in mothers of preterm hospitalized infants: a feasibility trial of nurse-delivered treatment.

OBJECTIVE: Mothers of preterm infants in a hospital neonatal intensive care unit (NICU) are at risk for clinically significant depression and anxiety, but for these women their own treatment is likely a secondary priority. This study evaluated the feasibility, acceptability and effectiveness of an evidence-based, nurse-delivered, on-site depression treatment: listening visits (LVs). STUDY DESIGN: Therapeutic LVs were delivered on site to 23 distressed mothers of NICU infants. The intervention was conducted by a neonatal nurse practitioner and the outcome was examined in an open-trial, pre-post evaluation. RESULT: A part-time nurse practitioner delivered six LVs to each participant within a 1-month time frame. LVs were associated with significantly improved mood and well-being in mothers. The majority of eligible women took advantage of LVs and felt satisfied with their care. CONCLUSION: This open trial provides 'proof-of-concept', with results that warrant further evaluation in a multisite randomized controlled trial.

Referral patterns and motivation for anti-reflux surgery of patients suffering from gastroesophageal reflux disease.

Due to a better understanding of the pathophysiology of gastroesophageal reflux disease (GERD), as well as the improvements in surgical technique, the number of anti-reflux procedures has increased world-wide during the last decade. This trend has been facilitated by the advent of minimally invasive surgery. Although a great number of publications deal with the indications or selection of patients for surgery, only a few discuss the motivation of patients for choosing surgery rather than long-term medical treatment. In order to evaluate the different elements of motivation of patients suffering from primary gastroesophageal reflux disease, the data of 115 patients who had undergone anti-reflux surgery between January 1990 and June 1997 at the Department of Surgery, Technical University, Munich, were evaluated. As laparoscopic anti-reflux surgery has only been regularly performed since 1994 in our Department, the study period was divided and the two periods (1990-1993 and 1994-1997) were analyzed separately. The data were evaluated according to the referral pattern and the motivation of patients with GERD who chose surgery. In the period from 1990 to 1993, 38.5% of the patients were referred to surgery by general practitioners, 38.5% by internists, 10% by practicing surgeons and 8% by gastroenterologists. In 5% of the cases the patients themselves initiated surgery. The corresponding results for the period from 1994 to 1997 were 29%, 38%, 12%, 8% and 13%, respectively. The most common reason for a patient to choose surgery was moderate or only short-term response to appropriate conservative treatment, which accounted for 98% and 92% of the patients, respectively, during the study periods. This was followed by avoidance of life-long medical therapy and its potential risks in 77% and 85% of the patients. Fear of cancer was reported in 10% and 25%, respectively. In the second period, the option of a minimally invasive procedure was reported as an important factor in 45% of the patients. Although the number of anti-reflux procedures performed per year is increasing and there is also an increasing tendency regarding the application of minimally invasive procedures, the factors leading to referral failed to show significant differences in the two periods. The motivation of patients, however, clearly changed in favour of surgical therapy, mainly because of the availability of a minimally invasive approach.

Composition and concentration of bile acid reflux into the esophagus of patients with gastroesophageal reflux disease.

BACKGROUND: Reflux of duodenal contents into the esophagus of patients with gastroesophageal reflux disease has been suggested by pH and bilirubin monitoring but is rarely directly measured. A portable device has been developed and was used to collect and quantitate material refluxed into the esophagus under ambulatory conditions during a prolonged time period. The objective of this study was to use this device to quantitate the composition and concentration of bile acids refluxed into the esophagus of patients with gastroesophageal reflux disease. METHODS: Esophageal aspiration was performed on 43 normal subjects and 37 patients with reflux disease during a 17-hour period. Aspiration was performed through a modified 16F Salem sump tube, positioned 5 cm above the lower esophageal sphincter and connected to a portable, battery powered pump that aspirated continuously at 100 mm Hg pressure. Validation studies showed that minimal amounts of saliva and swallowed liquids were aspirated and that gastric pressure was not altered. Postprandial, upright, and supine collections were performed. Total bile acids were assayed by a standard enzymatic assay; specific conjugated bile acids were analyzed by high-performance liquid chromatography. RESULTS: There was no difference in the total aspiration volume between normal volunteers and patients with gastroesophageal reflux disease, although patients tended to have a higher volume in the supine and postprandial periods. Bile acids could be detected in 58% of normal subjects and 86% of patients (p < 0.003). The mean concentration of bile salt exposure (micromole per liter) was higher in patients during the postprandial and supine periods. The mean bile acid reflux rate (micromole per hour) during all three aspiration periods was significantly higher in patients. On a molar basis the composition of the bile acids was 60% glycocholic acid, 16% glycodeoxycholic acid, and 15% glycochenodeoxycholic acid. Taurocholic, taurodeoxycholic, taurochenodeoxycholic, and glycolithocholic acid constituted the remaining 10%. CONCLUSIONS: Patients with reflux disease have an increased concentration of bile acids in their esophageal aspirates. Most of the exposure occurs during the postprandial and supine periods. A variety of bile acids were detected, most of which were in their glycine conjugated form.

Histologic, immunohistochemical and morphometric study of the mucosa of the total gastric antrum in patients with carcinoma of the stomach.

Examination of gastrin-immunoreactive G-cells, somatostatin-immunoreactive D-cells, enterochromaffin cells and 5-hydroxytryptamine-immunoreactive (5-HT-immunoreactive) cells of the completely mapped histologic antrum (70 to 100 tissue blocks) was done in 20 normal stomachs of persons between 17 and 94 years of age (from forensic autopsy). Results were compared with those of nine patients between 48 and 76 years of age with total gastrectomy for carcinoma of the proximal part of the stomach. Cell counts and morphometric examinations were performed. Results were summarized for the proximal (I), middle (II) and distal (III) one-third of the antrum and for the major (A) and minor (B) curvature side. In normal stomachs, the G-cell count was 2.52 percent of the total gland cell count in AI; 4.25 percent in AII and 4.77 percent in AIII. In BI, the numbers were 2.5 percent, in BII, 3.73 percent and 4.06 percent in BIII. The D-cell count was 0.47 percent in AI, 0.62 percent in AII and 0.58 percent in AIII. The numbers were 0.44 percent in BI, 0.51 percent in BII and 0.51 percent in BIII. In the antrum of the stomach with carcinoma, the G-cells revealed a non-significant 20 to 70 percent lower cell count, while the D-cell count was reduced insignificantly by as much as 35 percent in all areas. The 5-HT-immunoreactive cell count in normal stomachs is 0.25 percent in AI of the total gland cells, 0.32 percent in AII and 0.39 percent in AIII. In B, it shows numerically no difference to that of A. Contrary to the cell count in normal stomachs, the carcinoma antrum revealed a 200 to 400 percent increase in 5-HT-immunoreactive cell count, highly significant in every area of the antrum. Because 5-HT is known as a growth stimulant, especially for tumors, an increase in 5-HT-immunoreactive cells may be a factor that contributes to the initial histologic changes observed during the early phase of gastric tumor.

[Can gastroesophageal reflux be prevented by inducing a scar tissue ring around the cardia?]. / Megakadályozza-e a gastrooesophagealis refluxot a cardia körül kialakított heges gyürü?

Severe gastroesophageal reflux was accomplished in 18 dogs by circular cardiomyectomy. After this intervention a Vicryl scarf was placed around the cardia in 12 dogs. The Vicryl scarf was absorbed within 6 months and in its place remained a scarred tissue. In the follow up gastroesophageal reflux could not be detected by manometry, pH-metry, radiology and endoscopy. In the control group all 6 dogs died within 3 weeks due to complications of gastroesophageal reflux. On the basis of these data the Vicryl scarf implantation is an effective, simple, new antireflux operation which can be initiated into the human surgical practice.

Vernier scaling in shortened optical correlators.

Vernier transform scaling is achieved in a shortened optical correlator by placing the input spatial light modulator (SLM) between the telephoto transform lens pair. Translating the SLM changes the Fourier transform scale but not the position of the transform plane.

[The transformation of gamma-tocopherol to alpha-tocopherol in the animal organism; a generational study in rats]. / Uber die Transformation von gamma-Tocopherol zu alpha-Tocopherol im tierischen Organismus; ein Generationsversuch an Ratten.

The biosynthesis of alpha-tocopherol, the most effective vitamer among the vitamin E-group, is found only in higher plants and microorganisms. Due to the lack of the shikimate pathway, animals are not able to synthesize alpha-tocopherol. Also not found is a whole enteral synthesis; only the conversion of dimethyletocol to trimethyletocol seems to be possible. Using four generations of rats, we sought to determine: Is a transformation of gamma-tocopherol to alpha-tocopherol in the animal body possible? Are there any differences in the transformation rates in organs, tissues, or in the entire body along the generations? Does gut flora play any role in the conversion of gamma-tocopherol? Is it possible to increase the efficiency of the transformation by supplying additional CH3-groups? Wistar rats were fed a semisynthetic basal diet, supplemented with 78.8 mg DL-gamma-tocopherol/kg in the first three generations (F1-F3). In the fourth generation (F4), some of the animals were fed a vitamin E-free diet and gamma-tocopherol (approx. 1.5 mg on alternate days) was injected s.c. Two other groups of animals received the basal diet containing additional methionine (0.25%) or choline (0.45%), as well as gamma-tocopherol (as in F1-F3). alpha- and gamma-tocopherol were analyzed by HPTLC in the whole body and in serum, liver, heart, lung, gut, gonads, and feces. The ratio of alpha-/gamma-tocopherol (micrograms/micrograms) as transformation rate and vitamin E-biopotency (microgram alpha-tocopherol equivalents/g) were calculated. Growth and fertility were normal until the fourth generation; no abnormal developments could be recognized. alpha-tocopherol was found in the whole-body as well as in all tissues and organs. In the whole-body, vitamin E-biopotency decreased 25-70% in F2 and F3. On the other hand, the increase of the transformation rate of gamma- to alpha-tocopherol amounted to 23% (F2) and 168% (F3). Highest conversion rates were found in F2 and F3 for feces, followed by gonads and lungs; the lowest rates were found for serum and liver. Due to the s.c. injection of gamma-tocopherol, feces showed a four-times lower transformation rate in F4 than in F3. There was an increase in heart, gut, lung and serum for both transformation rate and vitamin E-biopotency. These parameters could be improved also by the additional supplements of methionine and choline. Both methyl-group-donators revealed nearly the same positive effect. The results show that the animal organism can adapt to gamma-tocopherol supply over generations.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical considerations for antireflux therapy.

Surgery has a major role to play in the treatment of reflux disease. Several factors should be considered prior to utilising the surgical approach. Severity of the reflux disease and response to conservative treatment are generally acceptable criteria for deciding whether a patient should undergo a surgical procedure. Once the decision is made to utilise a surgical approach, a specialised centre with an abundance of experienced, skilled surgeons and a specialised diagnostic laboratory should be selected. It is the responsibility of the referring physician and surgeon to diagnose accurately the presence of reflux disease. Endoscopy, pH-metry, and manometry are useful in precisely diagnosing the presence of reflux disease. Fundoplication is the favoured surgical procedure. The most common complications associated with this procedure are gas bloat and hypercontinence, which are acceptable tradeoffs for reflux disease. The patient must be educated about the surgical procedure and its consequences prior to the operation and informed of the alternatives. Accurate diagnosis, coupled with selection of an experienced surgeon and patient education can have a dramatic impact on reflux disease in the individual patient.

Effect of somatostatin on skin lesions and concentrations of plasma amino acids in a patient with glucagonoma-syndrome.

A case of glucagonoma syndrome in a 58-year-old male patient who had the typical skin lesions associated with severe hypoaminoacidemia is described. The decrease in amino acids has been proposed to be causally related to the dermatosis. Furthermore, it has been shown previously that somatostatin rapidly improves skin lesions in glucagonoma patients. Therefore, plasma amino acid levels were determined before and during an infusion of somatostatin prior to surgical removal of the tumor in the tail of the pancreas. During somatostatin infusion in combination with total parenteral nutrition, 10 out of 22 amino acids were in the normal range. Thus it seems unlikely that normalization of amino acid levels is responsible for the rapid improvement in skin lesions in glucagonoma patients. On the other hand it cannot be excluded that partial normalization of amino acids contributed to the observed healing process. Nevertheless, somatostatin administered prior to surgery is a useful therapeutic regimen in these patients.

Psychophysiological reactivity of migraine sufferers in conditions of stress and relaxation.

The assumption of a specific migraine-related psychophysiological response stereotype under conditions of stress, recovery and relaxation was examined in 37 migraineurs (non-headache state) and 44 normal controls. Two stressors were presented, industrial noise and a 'social discomfort' situation, each was followed by a recovery period. Relaxation was induced by verbal instructions accompanied by soft music. The following physiological measures were assessed: pulse volume amplitude (fronto-temporal and digital), skin temperature (fronto-temporal and digital) and skin resistance responses. Results showed no group differences in responses to the stressors. Physiological recovery from stress was delayed in migraineurs in the electrodermal parameter. During relaxation, migraineurs showed less digital vasodilation than the controls. Overall, physiological and subjective responses differed between the two stressors. The hypothesis of a specific vasomotor stress response stereotype in migraineurs could not be corroborated. The observed differences in relaxation and recovery were hypothesized. But the overall results are not easily explained on the grounds of a coherent model (e.g. elevated sympathetic arousal level).

Different response of gastric inhibitory polypeptide to glucose and fat from duodenum and jejunum.

Gastric inhibitory polypeptide (GIP), insulin, and blood glucose after ingestion of glucose or fat were examined in patients after gastrectomy with esophagojejunostomy or esophagoduodenostomy. After a glucose load patients without duodenal passage had significantly higher glucose and significantly smaller insulin levels than patients with duodenal passage. The fasting levels of serum immunoreactive GIP were moderately elevated and reached significantly higher levels after oral glucose ingestion in both gastrectomized groups as compared with normal subjects. In patients with preserved duodenal passage serum IR-GIP levels peaked earlier and were significantly higher than in patients without duodenal passage. In contrast to the finding after oral glucose ingestion, the IR-GIP response to an oral fat load was nearly twofold greater in patients without duodenal passage than in patients with duodenal continence. Thus, glucose-induced GIP release is mainly of duodenal and fat-induced GIP release mainly of jejunal origin. This suggests the existence of two types of GIP cells.

[Pancreatic pseudocysts. Actual diagnostic and therapeutic approaches. Surgical treatment (author's transl)]. / Pankreaspseudozysten. Aktuelle Möglichkeiten der Diagnostik und Therapie. Wann und wie soll man operieren?

The development of modern diagnostic technics (ultrasound and CT) has facilitated diagnosis of pancreatic pseudocysts. The subsequent demonstration of spontaneous resolution (in 25-50%) has however produced new controversies on the optimal therapeutic strategy. In spite of the progress in the area of diagnosis important questions regarding the evaluation of the percutaneous fine needle puncture, the indication for surgical treatment in relationship to the size of the pseudocysts and the optimal timing of surgical measures are still be open to discussion. To clarify these problems a prospective controlled study should be begun. According to most reports operative intervention is indicated if after a period of 6 weeks no spontaneous resolution has been observed. The optimal surgical treatment is thought to be internal drainage, for instance a cystojejunostomy.

[Proximal gastric vagotomy - an interim balance]. / Proximal-gastrische Vagotomie - Eine Zwischenbilanz.

As a result of recent trials and meetings, the results of proximal gastric Vagotomy (PGV) can now be judged with more certainty: the rate of recurrence is higher than after partial gastrectomy or recurrence is higher than after partial gastrectomy or combined procedures, but mortality is low and sequelae are rare. Errors of indication with regard to pyloric and prepyloric ulcers and inadequate denervation because of inaccurate surgical technique are the main causes of recurrence. Recurrent ulcers after PGV usually have good prognosis.

[Cardial function after a proximal gastric vagotomy]. / Función del cardias después de una vagotomía gástrica proximal.

We realize this study with the purpose of verifying if the cardias is affected or not by the proximal gastric vagotomy. Thirty six (36) patients suffering from chronic recurrent duodenal ulcer without complications were examined in sucession immediately before the operation and also three and twelve months after operation. The PGV was carried out without drainage. Only two cases needed pyloroplasty (Finney Type) due to stenosis of the pylorus. The completeness of the vagotomy was comprobated through the insulin test which was made three months postoperatively. This was obtained in 89% of the cases. We took 12 volunteers that they were not suffering from known disease of esophagus or stomach. The tests made to observe the function of the cardias after the proximal gastric vagotomy (PGV) were: Manometry, pH metry and Endoscopy/Histology. The obtained results are established. The conclusions of this work are drawn.