Sexually abused girls: patterns of psychopathology and exploration of risk factors.

This paper studies the patterns of psychopathology in sexually abused girls. It also explores some environmental risk factors for psychopathology including abuse characteristics and environmental experiences. The data are derived from the baseline assessment of 81 sexually abused girls referred to the London Child Sexual Abuse Psychotherapy Outcome Study (collaborative Tavistock and Maudsley project). Data about abuse were collected from the parent or foster parent using a standardised, semi-structured interview format. The girls' psychopathology was assessed using the Kiddie-SADS schedule. Widespread and serious psychopathology in sexually abused girls attending a psychotherapy clinic previously reported in a small-scale study was confirmed; so, too, was the extent of comorbidity and impairment of psychosocial functioning. Further, a significant association was found between children looked after away from home and high rates of Separation Anxiety Disorder. No such significant associations were found for Major Depressive Disorder nor impairment of functioning. Multivariate prediction analysis revealed that significant predictors of Major Depressive Disorder consisted of seriousness of abuse, the abuser not being a parent figure, and the abuse not being recent; the only significant predictor of Separation Anxiety Disorder was that the abuser was not a parent figure; finally, impairment of general functioning was strongly predicted by the greater seriousness of abuse and also by the abuser/s not being a parent figure. Theoretical explanations advanced for the reported associations have a sense of face validity: that girls abused by strangers will be at risk of developing Separation Anxiety Disorders; that serious sexual abuse is followed by the development of a Major Depressive Disorder and a high level of impairment of social functioning.

Psychotherapy for sexually abused girls: psychopathological outcome findings and patterns of change.

BACKGROUND: Controversy exists about the efficacy of psychotherapy for the mental health problems of sexually abused children. AIMS: To compare the relative efficacy of focused individual or group therapy in symptomatic sexually abused girls, and to monitor psychiatric symptoms for persistence or change. METHOD: A multi-centre psychotherapy outcome study recruited 71 sexually abused girls aged 6-14 years who were randomly assigned to focused individual psychotherapy (up to 30 sessions) or psychoeducational group therapy (up to 18 sessions). Changes over the course of the study were monitored. RESULTS: Both treatment groups showed a substantial reduction in psychopathological symptoms and an improvement in functioning, but with no evident difference between individual and group therapy. However, individual therapy led to a greater improvement in manifestations of post-traumatic stress disorder (PTSD). CONCLUSIONS: The beneficial effects on PTSD support the use of individual therapy. However, the small sample size and lack of a control group limit conclusions about changes attributable to treatment.

Behavioural psychopathology of child sexual abuse in schoolgirls referred to a tertiary centre: a North London study.

The sexually abused girls in this study were a sub-sample of a group of girls referred to a Regional Centre for Psychotherapy for the whole of London, North Thames. An inclusion criterion was that they were psychologically symptomatic and so it is likely that they were more problematic cases causing concern in their locality. The control clinical group consisted of referrals to local Child and Family consultation services, were an opt-in matched sample and not a total clinic referral sample. In addition, the reasons for referral covered both child disorder and family problems. It is, therefore, important to bear in mind the differences between these two groups. Certain clear cut findings have emerged from this study. No disorders specific to child sexual abuse in girls were identified but the extent and severity of the disturbance in the sexually abused sample was most striking. In these girls an event (CSA), together with referral because of emotional symptoms, was associated with enhanced severity of disorder and comorbidity particularly with reference to a cluster of disorders comprising post-traumatic stress disorder, depressive disorder, anxiety disorders (general and separation), social phobias and reactive attachment disorder. In the community clinic sample the identified disorders were mainly those of separation anxiety disorders and adjustment. Wide comorbidity was common in the sexual abuse sample and also severity of impairment was notable when compared to the clinic sample. However, because of the selected nature of the abuse group the findings are not generalisable beyond the population from which they emerged. The view is advanced that there are strong grounds for exploring the utility of psychodynamic psychotherapy in similar samples of sexually abused girls. These findings are discussed in the light of the current literature.

Biopsy specimen appearances of ischaemic gastritis in splanchnic arterial insufficiency.

A 74 year old man presented with a one month history of epigastric discomfort, anorexia, weight loss, and postprandial vomiting. The diagnosis of ischaemia was made on endoscopic biopsies from the stomach and duodenum. He was too ill for major vascular surgery and died eight days after admission. Postmortem examination confirmed the diagnosis of splanchnic arterial insufficiency caused by atheroma and thrombosis. Ischaemic gastritis is rare but could easily be missed in unrepresentative biopsy specimens. Prompt diagnosis with revascularisation surgery is the only hope for long term survival.

Increased expression of CD44v6 and CD44v3 in ulcerative colitis but not colonic Crohn's disease.

Immune mechanisms, possibly involving cell-surface molecules such as CD44, have been invoked to explain the pathogenesis of inflammatory bowel disease. We used monoclonal antibodies against epitopes encoded within the variable region of CD44 to investigate CD44 isoform expression in colon, small intestine, and liver in patients with various intestinal disorders and in controls. Biopsy samples from patients with ulcerative colitis showed significantly increased epithelial expression of CD44 isoforms containing the v6 and v3 epitopes, detected with antibodies 2F10 and 3G5, respectively. CD44v6 was detected on colonic crypt epithelial cells in 23 of 25 ulcerative colitis samples compared with 3 of 18 colonic Crohn's disease samples (p = 3.0 x 10(-6); odds ratio 57.5 [95% CI 6.83-702]) and 3 of 52 controls (22 normal colon, 10 infective colitis, 2 radiation colitis, and 18 colonic Crohn's disease; p < 1 x 10(-8); odds ratio 199 [25.5-2294]). No significant expression of CD44v6, CD44v3, or CD44v8/9 was found in samples of normal proximal colon from 4 patients with distal ulcerative colitis, whereas samples from the affected area showed staining for CD44v6 and CD44v3. No expression of CD44 variants was found in 15 samples of normal small intestine, 11 small-bowel pouchitis, 8 coeliac disease, 3 small-bowel Crohn's disease, 6 normal liver, 6 primary biliary cirrhosis, or 9 primary sclerosing cholangitis. The high intensity of CD44v6 and v3 epitope expression on crypt epithelial cells in ulcerative colitis suggests that CD44 isoforms may have an important role in ulcerative colitis. Their detection could have diagnostic potential in differentiating ulcerative colitis from other forms of colonic inflammation including Crohn's disease.

Testicular seminoma in a patient with pineal germinoma.

A case is reported of a 30 year old man with a testicular seminoma. He had presented 16 years previously with a pineal germinoma, followed two years later by intracranial metastases. This is an unusual occurrence of double pathology in the germ cell line.

Dextropropoxyphene induced hepatotoxicity: a report of nine cases.

Nine patients are described with jaundice, upper abdominal pain and malaise attributable to dextropropoxyphene hepatotoxicity. In each case the history was suggestive of large bile duct obstruction. All patients underwent ultrasound examination and percutaneous liver biopsy. Three patients also underwent endoscopic retrograde cholangio pancreatography. The histological features of the biopsies concur with previously reported cases of dextropropoxyphene hepatotoxicity. The histological changes seen on biopsy were remarkably constant, consisting of centrilobular cholestasis, portal tract inflammation and bile duct abnormalities, in all cases mimicking large bile duct obstruction. Fifteen previous patients with probable dextropropoxyphene hepatotoxicity have been described. The occurrence of 9 further cases at one centre, 6 presenting within 12 months, suggests that it is much more common than previously assumed and may be misdiagnosed as large bile duct obstruction.

Hypoadrenal crisis caused by disseminated histoplasmosis.

We report a case of disseminated histoplasmosis presenting with acute renal impairment due to adrenal insufficiency. The finding of bilateral adrenal gland enlargement on abdominal ultrasound examination led to a diagnostic CT-guided adrenal biopsy. Prolonged therapy with amphotericin and itraconazole resulted in a clinical cure, although the patient still requires adrenal replacement therapy.

Reinfection or recrudescence after apparently successful eradication of Helicobacter pylori infection: implications for treatment of patients with duodenal ulcer disease.

Helicobacter pyloris is considered to be aetiologically implicated in gastritis and peptic ulceration, since if H. pyloris infection can be eradicated the risk of subsequent ulcer relapse is markedly reduced. The rate of 'reinfection' following treatment ranges from 0% to 45%, but its origin remains controversial (reappearance of uneradicated original infection or a fresh infection). To distinguish temporary suppression of H. pylori from fresh infection we conducted a retrospective analysis of the criteria used to establish eradication of the original infection in 304 patients. We used the [14C]urea breath test, in which an integrated area under the curve (AUC) value of < 40 in 2 h is considered to indicate eradication of H. pylori in patients tested 1 month after treatment. The results suggest that relapsed infection with H. pylori usually represents recrudescence of the original infection rather than a fresh infection; there was a higher relapse rate in patients with a breath test AUC > 20 < 40, compared with those with an AUC < 20. All 'reinfections' occurred within 24 months of the original treatment. 'Reinfection' was uncommon in patients receiving powerful therapeutic regimens (e.g. triple therapy) compared with those receiving monotherapy or relatively ineffective dual therapy combinations. In patients whose urea breath test remains negative 12 months after treatment the subsequent reinfection rate is only 0.44%/year. This supports the strategy of eradicating H. pylori infection from suitable peptic ulcer patients.

Experience with 'triple' anti-Helicobacter pylori eradication therapy: side effects and the importance of testing the pre-treatment bacterial isolate for metronidazole resistance.

At the 1990 World Congresses of Gastroenterology, the Working Party on Helicobacter pylori (H. pylori) recommended that, in suitable patients, the bacterium should be eradicated using a therapeutic regimen comprising a bismuth salt, tetracycline and metronidazole for two weeks. We have treated 40 patients infected with H. pylori with 'triple' therapy consisting of 120 mg tripotassium dicitrato bismuthate q.d.s., 500 mg tetracycline q.d.s. and 400 mg metronidazole t.d.s. for two weeks. The success rate, in terms of bacterial eradication, was 19/21 (90.5%) in patients with metronidazole-sensitive organisms, compared with only 6/19 (31.6%) in patients whose H. pylori were resistant to metronidazole (P less than 0.01). Side effects, particularly diarrhoea and vomiting/nausea, were common: 23/40 patients reported such symptoms during the 14-day course of therapy. Fifteen of these 23 patients completed the entire 14-day course, although suffering from significant side effects, while the remaining eight patients had to discontinue the treatment because side effects became intolerable. If a form of triple therapy is going to be widely used to eradicate H. pylori infection, the regimen will have to be simpler, shorter, produce fewer side effects and be more effective in patients with metronidazole-resistant bacteria.

Does a previous course of tripotassium dicitrato bismuthate affect the subsequent chances of successful Helicobacter pylori eradication?

We have performed a retrospective study of 103 patients with either peptic ulcer or non-ulcer dyspepsia, infected with metronidazole-sensitive strains of Helicobacter pylori (H. pylori), who were treated with a combination of tripotassium dicitrato bismuthate and metronidazole for a period of at least two weeks. Dual therapy with tripotassium dicitrato bismuthate plus metronidazole showed similarly high eradication rates (greater than or equal to 80%) of H. pylori from patients irrespective of age, gender or clinical diagnosis. Most importantly, dual therapy achieved a similar eradication rate of H. pylori infection in 41 patients who had previously been treated with tripotassium dicitrato bismuthate alone or in combination with an antibiotic other than metronidazole. It therefore appears that H. pylori does not become resistant to treatment with tripotassium dicitrato bismuthate.

Helicobacter pylori: treatment with combinations of pivampicillin and tripotassium dicitrato bismuthate.

Fifty Helicobacter pylori- (H. pylori) positive patients entered an open study and were assigned to one of four treatment regimens comprising: pivampicillin (500 mg b.d.) for 2 weeks +/- tripotassium dicitrato bismuthate (tablet or liquid form) for one month. The 14C-urea breath test was used to evaluate clearance (negative at the end of treatment) and eradication (negative at 1 month post-treatment) of H. pylori. Clearance rates were 20% (2/10) after pivampicillin alone, 86% (12/14) after tripotassium dicitrato bismuthate tablets (240 mg b.d.) plus pivampicillin, 67% (6/9) after tripotassium dicitrato bismuthate tablets (120 mg q.d.s.) plus pivampicillin, and 100% (13/13) after tripotassium dicitrato bismuthate liquid (120 mg in 5 ml q.d.s) plus pivampicillin. The eradication rates were 0% (0/10), 13% (2/15), 0% (0/11) and 54% (7/13), respectively. Combination of the results from the 2 tripotassium dicitrato bismuthate tablet/pivampicillin groups gave an eradication rate of 7.7% (2/26) which was significantly lower than the 53.9% (7/13) obtained with tripotassium dicitrato bismuthate liquid/pivampicillin (P less than 0.02). In conclusion, a liquid tripotassium dicitrato bismuthate pivampicillin combination may be of special use in the treatment of H. pylori-positive patients when triple therapy is contraindicated (e.g. patient sensitivity/allergy to metronidazole) or when the H. pylori isolate is resistant to metronidazole.

Autoimmune oophoritis associated with polycystic ovaries.

Autoimmune oophoritis is a rare cause of premature ovarian failure. Previous histological descriptions are sparse, with even fewer reports of cystic ovaries associated with this condition. Two cases of autoimmune oophoritis presenting as cystic ovaries with menstrual abnormalities are described, with immunocytochemical analysis of the inflammatory cell infiltrate. Serum autoantibodies to ovary and adrenal were present in both cases. Although rare, recognition of the condition by histopathologists is important because of the strong association with other 'organ-specific' autoimmune diseases, especially idiopathic Addison's disease. A review of the 17 reported cases indicates five where cystic changes were present in the ovary.

Omeprazole and Helicobacter pylori: temporary suppression rather than true eradication.

Twenty-four Helicobacter pylori (H. pylori)-positive patients were treated for 28 days with either 20 mg omeprazole o.m. (n = 12) or 40 mg omeprazole o.m. (n = 12). Clearance (absence of H. pylori at the end of or shortly after treatment) and eradication (absence of H. pylori 1 month after cessation of treatment) were assessed using the 14C-urea breath test. Observed clearance and eradication were: 20 mg omeprazole 3/12 and 0/12; 40 mg omeprazole 6/12 and 1/12 respectively. The effect on H. pylori is probably due to the change in gastric pH from acid to neutral, however it is insufficient to recommend the inclusion of omeprazole in regimens aimed at eradicating H. pylori.

Helicobacter pylori infection treated with a tripotassium dicitrato bismuthate and metronidazole combination.

Seventy-two patients with H. pylori infection in their antral mucosa took part in the study. Forty-three received metronidazole 400 mg t.d.s. for two weeks, plus De-Nol tabs 2 b.d. for four weeks, and the remaining 29 patients received metronidazole 400 mg t.d.s. for two weeks plus De-Nol liquid 5 ml q.d.s. for four weeks. Seven of 57 H. pylori isolates were found to have pre-treatment metronidazole resistance. Success, in terms of eradication of H. pylori, was assessed using a one-month post-treatment 14C urea breath test. Successful eradication of H. pylori was achieved in 72% and 79%, respectively, of the metronidazole/De-Nol tablet and metronidazole/De-Nol liquid groups. These figures increased to 87% and 84%, respectively, if the patients whose organisms were known to be metronidazole-sensitive were considered in isolation. H. pylori was successfully eradicated in only one of seven patients with a metronidazole-resistant organism.

Liver abnormality in ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) is a potentially fatal condition associated with the therapeutic induction of ovulation in infertility. Liver function abnormality has been previously reported in four patients, one of whom had ultrastructural abnormalities on liver biopsy. This paper describes a patient presenting with severe OHSS 16 days after ovulation had been induced. Liver function abnormality was apparent 11 days later, with a sustained rise in alkaline phosphatase and aspartate aminotransferase (AST) which lasted up to 2 months. A liver biopsy performed during the second month of her protracted hospital admission showed marked zonal fatty change (acinar zone 1) and associated inflammation, with mitochondrial crystalline inclusions and rough endoplasmic reticulum dilatation on electron microscopy. This report discusses the clinical features and possible aetiological factors.