Cognitive milieu therapy and physical activity: experiences of mastery and learning among patients with dual diagnosis.

During the last decade, there has been a growing interest in implementing cognitive milieu therapy (CMT) in psychiatric institutions. However, there is a lack of systematic evaluations from patients' point of view. The aim of this study was to explore and describe patient perceptions of essential experiences of mastery, learning alternative ways of thinking, and acquiring new skills through CMT and physical activity in an inpatient setting. Qualitative interviews were carried out with 20 patients with dual diagnosis. A hermeneutic - phenomenological approach was used in the data collection and analysis. The results showed that the learning climate in the unit was important. This included a proactive attitude from the staff, focusing on cooperation on equal terms between patients and staff, and a professional methodological approach through CMT. The optimal balance between staff-induced activities and patient initiatives was not easy to obtain. Patients appreciated both the education provided by the staff and learning from other patients. The cognitive method was sometimes experienced as too theoretical and difficult to understand. Physical activity, however, was experienced as 'concrete' and providing practical knowledge. It motivated patients to establish new habits and provided opportunities for the development of mastery together with other patients.

Patients' experience of learning and gaining personal knowledge during a stay at a mental hospital.

The focus is on voluntarily hospitalized patients' subjective experiences of learning and gaining personal knowledge during a stay at a mental hospital. The aim was to explore and describe patients' learning as personal knowledge acquisition related to the therapeutic process during hospitalization. The study was exploratory and descriptive, with a hermeneutic--phenomenological approach in data collection and analysis. Qualitative interviews were carried out with 15 patients during and after their stay. A re-analysis was conducted. The results underline the importance of the environmental effects on patients' motivation for learning and self-esteem in an acknowledging milieu. Moving towards relearning presupposes that the patient's motivation is aroused. Patients must participate in the treatment and the validity of the knowledge must be tested in the individual patient's life. The patients confirmed and helped each other to increase insight through recognizing each other's problems and reactions. Time in itself seemed to increase self-reflection. Receiving impulses and getting concrete tools through therapy stimulated meaning and hope for future living. The professionals must use a holistic approach including a learning climate in pleasant surroundings and a conjoint contribution from fellow patients and staff. Further research should focus on how to combine therapy with learning--preferably by means of a co-operative inquiry design.

[Rehabilitation of women with breast cancer]. / Rehabilitering av kvinner med brystkreft.

BACKGROUND: Previous studies on effects of rehabilitation programmes for women with breast cancer are rare, but promising. This study aimed to examine the physical and psychological conditions for these patients before and after a rehabilitation programme at Red Cross Haugland Rehabilitation Centre in Norway. MATERIAL AND METHODS: Included in the study were a total of 50 women, aged 31-66 (mean 49) years, who had undergone surgical treatment, chemotherapy and radiation therapy for cancer mammae stage 1 and 2 (limited to the breast only or spread to the axillary lymph nodes, respectively). They received a three-week rehabilitation programme, followed by a three-month period at home and a one-week follow-up at the rehabilitation centre. Examinations of physical and psychological status were performed before and after the three-week stay and at follow-up. RESULTS: Maximum oxygen uptake increased from 67% to 77% of predicted value, the mental status and subjective rating of life quality improved, the physical activity level increased, and 36 out of 46 subjects returned to their jobs during the three-month follow-up. The women themselves reported subjective positive effects of participating in the programme. INTERPRETATION: Although the present study was non-controlled, the positive results were so promising that further controlled studies should be encouraged, as well as rehabilitation programmes for women with breast cancer.

[Quality of life, loneliness and social contacts among persons with long-term mental illness]. / Livskvalitet, ensomhet og sosial kontakt hos mennesker med langvarige psykiske lidelser.

Chronic long-term patients who were residents in psychiatric nursing homes at a given point in time were traced six years later. Over this period, there had been deep cuts in the number of psychiatric beds in the county in question; we wanted to assess how the patients now perceived their quality of life. All 107 patients were traced; of the 75 who were still alive, 74 took part in the study and were visited at their place of residence. 42 patients, mean age 56.9 years, were able to respond to personal questions regarding social contact, loneliness and quality of life. Health care providers were the most important persons in the patients' networks. Most patients reported a satisfactory quality of life; those who lived outside institutions (N = 21) tended to be more satisfied than those in residential care, they were more socially active and had better contact with their families. The variables loneliness, satisfaction with neighbourhood and leisure activities explained 63% of the variance in quality of life.

Quality of life, loneliness, and social contact among long-term psychiatric patients.

OBJECTIVE: Long-term patients who resided in county-operated psychiatric nursing homes in a county in Norway as of November 15, 1989, were visited by researchers in 1996 to assess how they perceived their living situations and how they had adjusted to a large reduction in county psychiatric beds during the six-year period. METHODS: Of 107 patients identified in 1989, a total of 75 were still alive in 1995. Seventy-four took part in the study and were visited at their place of residence. Thirty patients were living in general nursing homes, 23 patients remained in the psychiatric nursing homes, and 21 patients lived outside of institutions, in a personal residence. The quality of the patients' contact with others was rated by health care providers who were familiar with the patients. Forty-two patients, with a mean age of 56.9 years, responded to personal questions about their life situation, loneliness, and quality of life. RESULTS: Health care providers constituted the patients' most important network. Patients outside of institutions were the most socially active and had the most satisfying contact with their families. Patients reported a satisfactory quality of life, and those who lived outside institutions tended to be most satisfied. The variables of loneliness, satisfaction with neighborhood, and leisure time activities explained 63 percent of the variance in patients' subjective well-being. CONCLUSIONS: Most long-term patients who had moved out of psychiatric institutions were satisfied with their living situation and reported a relatively high quality of life.

The fate of chronic in-patients after closure of psychiatric nursing homes in Norway: a personal follow-up 6 years later.

We evaluated all 107 chronic in-patients in a catchment area before and 6 years after a planned reduction in the number of psychiatric institution beds was implemented. At follow-up, 32 of the patients had died. One had probably committed suicide, while the others were elderly people who had died of natural causes. In the remaining patients the level of functioning was low, and below that which could be deduced from their level of symptoms, which was also low. The majority of the patients still lived in institutions, mostly in general nursing homes. Among those who had moved out, there were non-significant trends towards a reduction in symptoms and an increase in functioning. In general, the patients were satisfied with their new accommodation. Most of them needed extensive help and support to establish an acceptable standard of living in the community.

Restoration of the differentiated functions of serially passaged chondrocytes using staurosporine.

Among the various directions explored in order to have a large number of differentiated articular chondrocytes easily available, the restoration of the differentiated properties after cell multiplication in monolayer has been proposed. It has been clearly shown that the synthesis of cartilage proteoglycans and type II collagen synthesis is coincident with the presence of a faint microfibrillar architecture but is absent in chondrocytes showing well-defined actin cables. Staurosporin, mainly described as a protein kinase C inhibitor, has also been shown to rapidly induce the disruption of the actin microfilaments. The purpose of this paper was to investigate whether properties of differentiated chondrocytes were reinitiated upon staurosporin treatment of serially passaged chondrocytes. Results showed, after staurosporine treatment of cells at Passage two for 5 d, complete suppression of type I and type III collagen synthesis and induction of type II collagen synthesis and of Alcian blue stainable matrix. Additionally, we showed that staurosporin restored metabolic responses that chondrocytes in primary culture exhibit upon interleukin-1 beta treatment (decrease of Alcian blue- positive cells, induction of expression of the 92 kDa gelatinase, nitric oxide production). We conclude that staurosporin is a potent redifferentiating agent of articular chondrocytes that have been subcultured up to Passage two for multiplication. Taking into account that the cellularity of cartilage is very low, staurosporine-treated chondrocytes could be useful as an alternative cellular model to evaluate pharmacotoxicological effects of drugs.

The use of Fluoresceincadaverine for detecting amine acceptor protein substrates accessible to active transglutaminase in living cells.

The use of Fluoresceincadaverine as a primary amine donor for detecting the endogenous substrates for active transglutaminase in living cells was studied. Fluoresceincadaverine was found to be suitable for labelling cells in culture as it did not induce cytotoxicity when used at 0.5 mM in culture media and diffused throughout the cell. After appropriate fixation using methanol, Fluoresceincadaverine-labelled cells were observed by direct fluorescence microscopy, allowing visualization of the substrates for active transglutaminase. Simultaneous detection of transglutaminase and of Fluoresceincadaverine incorporated into proteins strongly suggested that cytosolic transglutaminase was inactive in these living cells. However, transglutaminase co-distributed with Fluoresceincadaverine-labelled structures, which resembled a lattice. Fluoresceincadaverine-labelled proteins detected by Western blotting using an anti-Fluorescein antibody showed that, in living cells, the major transglutaminase substrate migrated at an apparent molecular weight of 220 kDa, as does fibronectin. Fibronectin was found to co-distribute with Fluoresceincadaverine-labelled lattice. This confirmed that these lattice structures were extracellular and, therefore, that transglutaminase is in an active form in this compartment. This opportunity to perform morphological and biochemical analyses in the search for transglutaminase substrates in living cells should help in determining the specific function of transglutaminases in a particular cell type as well as in universal cellular events, such as apoptosis or cell growth.

[The project Better Cancer Care in Buskerud]. / Prosjektet Bedre kreftomsorg i Buskerud.

A project called Better cancer care in Buskerud was started in 1991 in the county of Buskerud, in Norway. The main objective was to improve the out-patient services for cancer patients at the central hospital. In this article we describe the activities at the out-patient clinic during the period 1991-1993. The clinic was staffed by two oncologists and two cancer nurses. A total of 8060 consultations were held with patients during the period. Breast cancer patients comprised the largest group (30%), followed by patients with gastrointestinal cancer (24%) or malignant lymphoma (13%). The hospital's Department of Surgery was particularly relieved to hand over the administration of chemotherapy. The number of patients who received radiotherapy at the nearest cancer centre did not increase, however, during the period. We conclude that the project in Buskerud was a success, and that most of the objectives were achieved.

[Competence and work identity--an evaluation of Norwegian continuing education in psychiatric nursing]. / Kompetanse og yrkesidentitet--en evaluering av norske videreutdanninger i psykiatrisk sykepleie.

Mental health services are in transition. The question is to what extent professional training programmes within the health and social sectors have taken into consideration claims and expectations on professionals following this organizational transition. The purpose of this descriptive study was, by means of a semi-structured questionnaire, to evaluate Norwegian postgraduate programmes of psychiatric nursing with respect to what extent they had met the psychiatric nurses' need for competence in their clinical work. Only few evaluations of this type are reported from Scandinavia, and, consequently, it is important to conduct such studies to elucidate strengths and weaknesses in existing programmes. In all 154 psychiatric nurses participated (response rate 48%). The study revealed that psychiatric nurses perceived their training as significant to their practice--and that their professional identity and competence had been strengthened. This was connected to the possibility of studying their own professional field in depth--and to clarify their field of responsibility. Thus, the respondents regarded an alteration of the postgraduate programme in an interdisciplinary direction as unfortunate. Such an alteration might contribute to a weakening of their specific competence and professional perspective. The respondents held that productive interdisciplinary co-operation presupposes a multi-disciplinary approach. The postgraduate programmes seem definitely to qualify psychiatric nurses for working in psychiatric institutions, but their training is also relevant for working in the community health services.

Type II transglutaminase expression in rabbit articular chondrocytes in culture: relation with cell differentiation, cell growth, cell adhesion and cell apoptosis.

Depending on the cell type studied, the involvement of type II transglutaminase (TGase) has been proposed in almost any event of the cell life such as differentiation, apoptosis, growth, aging, cell morphology and adhesion, metastatic capacity or extracellular matrix stabilization. In order to define the field(s) where this enzyme may be implicated in chondrocytes, type II TGase expression was studied in chondrocytes at different passages which differentiated state was modulated by retinoic acid, dihydrocytochalasin B or staurosporin. Results showed that (i) type II TGase expression is not incompatible with type II collagen expression, a main marker of chondrocyte differentiation (ii) type II TGase expression is higher when cells are in the exponential phase of growth than when growth arrested (iii) a high type II TGase expression does not imply that cells are apoptotic although cell apoptosis correlates with increased type II TGase expression (iv) non-adherent cells do not express type II TGase whereas adherent cells do whatever their differentiation state as assessed by type II collagen synthesis. These results suggest that, in articular chondrocytes, type II TGase is specifically implicated in the cell adhesion capacity.

Transglutaminase activity in rabbit articular chondrocytes in culture.

In vivo, articular chondrocytes produce an important amount of extracellular matrix (cartilage) whose quality is impaired upon inflammation or aging leading to arthritis or arthrosis. Transglutaminases (EC 2.3.2.13) are a family of enzymes which have been shown to be involved in extracellular matrix stabilization, cell differentiation and possibly in initiation and propagation of inflammatory diseases. It is therefore of interest to study transglutaminase activity in chondrocytes. Transglutaminase activity was studied in rabbit articular chondrocytes in primary culture, where cells are in a well-differentiated state as assessed by collagen-type synthesis, as well as in subculture and in retinoic acid-treated cells, where cells are in a dedifferentiated state. Results showed that two different TGases activities are expressed in chondrocytes. One, down-regulated upon retinoic acid treatment of cells, preferentially membrane bound and strongly activated upon trypsin treatment of cell lysates, is expressed at a high level in primary culture. The other one is up-regulated upon retinoic acid treatment, preferentially cytosolic and inactivated upon trypsin treatment of cell lysates. The rate of expression of the TGase down-regulated by RA seems to correlate with the differentiation state of the chondrocyte. This suggests that this TGase activity may have a physiological role in cartilage and merits further study.

How safe is surveillance in patients with histologically low-risk non-seminomatous testicular cancer in a geographically extended country with limited computerised tomographic resources?

In patients with clinical stage I non-seminomatous testicular cancer only limited information is available about the administrative problems with the surveillance programme, in particular if this policy is to be implemented in a geographically extended country with limited computerised tomography (CT) resources. One hundred and two patients with non-seminomatous testicular cancer clinical stage I and low-risk histology (MRC criteria, UK) were followed by the surveillance policy for at least 1 year after orchiectomy (median 47 months, range 21-81 months). Twenty-two patients (22%) relapsed after a median time of 5 months (range 2-18 months), 14 of them in the retroperitoneal space. Serum alpha-fetoprotein and/or human chorionic gonadotrophin were elevated in eight of the 22 relapsing patients. The progression-free and cancer-corrected survival rates were 78% and 99% respectively. Patient non-compliance did not represent a major problem, whereas the regular and adequate performance of necessary CT examinations yielded some administrative difficulties. One and 3 years after orchiectomy about 50% of the relapse-free patients had no psychological problems and were satisfied with the surveillance programme, whereas 46% reported minor and 4% major psychological distress. Despite non-negligible administrative difficulties in geographically extended countries, surveillance is feasible and safe in compliant patients with low-risk non-seminomatous testicular cancer stage I. The responsible cancer centre and the local hospitals should establish a high degree of cooperation and enable adequate follow-up examinations in these patients.

Infection after splenectomy for Hodgkin's disease.

The incidence of non-fatal infections after staging laparotomy in 95 adult patients with Hodgkin's disease was compared with that of 94 non-splenectomized patients. In addition, mortality of infections in 248 splenectomized patients was compared with mortality in 275 non-splenectomized patients. The observation time was 10 years from start of therapy. No difference was found between splenectomized and non-splenectomized adult Hodgkin's patients as to frequency and death from infection. However, the incidence of more serious infections was significantly higher in advanced disease (stage III and IV) as compared with localized disease (stage I and II). Deaths from rapid fatal infection occurred only in patients with advanced disease, unrespective of splenectomy.

The treatment of advanced metastatic seminoma: experience in 55 cases.

Thirty-six of 39 previously untreated evaluable patients with advanced metastatic seminoma (stage greater than or equal to IIb) obtained a complete response (CR) and three a partial response (PR) after cisplatin-based combination chemotherapy with or without surgery/radiotherapy (group 1). After a median observation time of 36 months, 33 patients are alive with no evidence of disease (NED). Fifteen additional patients received cisplatin-based chemotherapy due to relapsing seminoma after initial radiotherapy (group 2). Thirteen patients obtained a CR, and two a PR. Patients from group 1 lived significantly longer after the start of chemotherapy than those from group 2. The rate and severity of the treatment-related complications were comparable in both groups. The most frequent nonfatal side effects of cisplatin-based combination chemotherapy were Raynaud-like phenomena, polyneuropathy, and myelosuppression. Four patients developed fatal complications (septicemia, bone marrow aplasia). In three of 12 patients with evaluable postchemotherapy histology, vital malignant seminoma was found. Cisplatin-based combination chemotherapy in advanced seminoma patients is highly effective, but includes a significant risk of severe complications. Less toxic treatment regimens should be explored, at least for patients who have less advanced tumors (stage IIb/limited stage IIc).

Platelet aggregation induced by 1-desamino-8-D-arginine vasopressin (DDAVP) in Type IIB von Willebrand's disease.

Type IIB von Willebrand's disease is a distinct form of this disorder, in which there are abnormal factor VIII/von Willebrand factor multimers in plasma (but normal multimers in platelets) and heightened interaction between the von Willebrand factor and platelets in the presence of ristocetin. We have found that infusion of desmopressin acetate (1-desamino-8-D-arginine vasopressin [DDAVP]), an agent used in the treatment of von Willebrand's disease, causes platelet aggregation and thrombocytopenia in patients with Type IIB disease. In vitro, platelets in normal plasma and those obtained from patients with Type IIB disease before DDAVP infusion aggregated upon the addition of platelet-poor plasma from Type IIB patients treated with DDAVP. Platelet aggregation was associated with adsorption of multimers of factor VIII/von Willebrand factor onto the platelets and was inhibited by EDTA. We conclude that in Type IIB von Willebrand's disease, DDAVP releases an abnormal factor with platelet-aggregating properties. DDAVP should not be used to treat patients with Type IIB disease, since the presence of platelet aggregates in the circulation may be harmful.