Surgical technique for placement of the automated low flow ascites pump (Alfapump).

Approximately 10% of patients with ascites associated with cirrhosis fail to respond to dietary rules and diuretic treatment and therefore present with refractory ascites. In order to avoid iterative large-volume paracentesis in patients with contraindication to TIPS, the automated low flow ascites pump system (Alfapump) was developed to pump ascites from the peritoneal cavity into the urinary bladder, where it is eliminated spontaneously by normal micturition. This manuscript reports the surgical technique for placement of the Alfapump.

Autofluorescence endoscopy in surveillance of Barrett's esophagus: a multicenter randomized trial on diagnostic efficacy.

BACKGROUND AND STUDY AIMS: The reference surveillance method in patients with Barrett's esophagus is careful endoscopic observation, with targeted as well as random four-quadrant biopsies. Autofluorescence endoscopy (AFE) may make it easier to locate neoplasia. The aim of this study was to elucidate the diagnostic accuracy of surveillance with AFE-guided plus four-quadrant biopsies in comparison with the conventional approach. PATIENTS AND METHODS: A total of 187 of 200 consecutive Barrett's esophagus patients who were initially enrolled (73 % male, mean age 67 years, mean Barrett's segment length 4.6 cm), who underwent endoscopy for Barrett's esophagus in four study centers, were randomly assigned to undergo either AFE-targeted biopsy followed by four-quadrant biopsies or conventional endoscopic surveillance, also including four-quadrant biopsies (study phase 1). After exclusion of patients with early cancer or high-grade dysplasia, who underwent endoscopic or surgical treatment, as well as those who declined to participate in phase 2 of the study, 130 patients remained. These patients were examined again with the alternative method after a mean of 10 weeks, using the same methods described. The main study parameter was the detection of early cancer/adenocarcinoma or high-grade dysplasia (HGD), comparing both approaches in study phase 1; the secondary study aim in phase 2 was to assess the additional value of the AFE-guided approach after conventional surveillance, and vice versa. Test accuracy measures were derived from study phase 1. RESULTS: In study phase 1, the AFE and conventional approaches yielded adenocarcinoma/HGD rates of 12 % and 5.3 %, respectively, on a per-patient basis. With AFE, four previously unrecognized adenocarcinoma/HGD lesions were identified (4.3 % of the patients); with the conventional approach, one new lesion (1.1 %) was identified. Of the 19 adenocarcinoma/HGD lesions detected during AFE endoscopy in study phase 1, eight were visualized, while 11 were only detected using untargeted four-quadrant biopsies (sensitivity 42 %). Of the 766 biopsies classified at histology as being nonneoplastic, 58 appeared suspicious (specificity 92 %, positive predictive value 12 %, negative predictive value 98.5 %). In study phase 2, AFE detected two further lesions in addition to the initial alternative approach in 3.2 % of cases, in comparison with one lesion with conventional endoscopy (1.7 %). CONCLUSIONS: In this referral Barrett's esophagus population with a higher prevalence of neoplastic lesions, the AFE-guided approach improved the diagnostic yield for neoplasia in comparison with the conventional approach using four-quadrant biopsies. However, AFE alone was not suitable for replacing the standard four-quadrant biopsy protocol.

[Peptic diseases]. / Maladies peptiques.

The therapeutical acquisitions of the year 2004 are: 1. The sequential treatment of the Helicobacter pylori infection reaches an eradication rate of 95%. 2. The use of COX-2 inhibitors reduced significantly the gastrointestinal side effects of anti-inflammatory treatments. Since cardiac averse effects of certain COX-2 inhibitors had been reported, the treatments with COX-2 inhibitors came widely into question. In the case of patients with risk of NSAID induced gastrointestinal toxicity, the alternative is to return to a treatment with non specific NSAID associated to an prophylactic PPI treatment.

Neuropsychological correlates of the PANSS Cognitive Factor.

OBJECTIVE: Factor analytic studies of the Positive and Negative Syndrome Scale (PANSS) have consistently isolated a factor that is frequently labeled as 'cognitive'. The present study sought to further explore the factor by examining the relationships between 4 versions of the cognitive factor and a set of neuropsychological tests. METHOD: Thirty-seven inpatients diagnosed with schizophrenia or schizoaffective disorder were assessed with the PANSS and neuropsychological measures. RESULTS: Verbal intelligence and verbal memory were found to be most closely associated with cognitive factor scores. A global rating of illness severity showed greater relationships to cognitive variables than any cognitive factor. CONCLUSIONS: The PANSS cognitive factor may reflect verbal ability and memory, but is not sufficiently comprehensive to be considered as a replacement for direct assessment of cognitive functioning.

[Non-healing gastric ulcer]. / Nicht-heilendes Magen-Ulkus.

HISTORY AND ADMISSION FINDINGS: A 47-year-old Angolan complained of upper abdominal pain, fever, weight loss and night sweats. Abdominal ultrasound performed by his general practitioner showed enlarged lymph nodes at the liver hilum. Physical examination was negative except for slight tenderness over the right upper abdomen. INVESTIGATIONS: A tuberculin skin test was clearly positive. Upper gastrointestinal endoscopy revealed multiple gastric ulcers and the Helicobacter pylori test was positive. The lymph nodes at the liver hilum were needle-aspirated, this showed granulomatous inflammation similar to the biopsies of the ulcers. Eradication of Helicobacter pylori and therapy with proton pump inhibitors were initiated. DIAGNOSIS, TREATMENT AND COURSE: Epigastric pain and the ulcers persisted unchanged. The culture of the lymph node aspirate grew multiresistent Mycobacterium tuberculosis. With adequate tuberculostatic therapy the patient improved rapidly and the further course was without any complications. CONCLUSION: Tuberculosis should be included in the differential diagnosis in non-healing ulcers of the gastrointestinal tract, especially in immigrants from endemic areas.

Outcome measurement in pharmacological trials: validity of the Routine Assessment of Patient Progress (RAPP).

The assessment of outcomes after treatment with antipsychotic medication is fundamental to clinical care and research. The Routine Assessment of Patient Progress (RAPP) is a reliable multidimensional scale that employs nurses' ratings of symptoms and functioning in psychiatric inpatients. The present study sought to extend validity evidence for the RAPP by examining its ability to reflect changes associated with treatment by antipsychotic medications. The use of a different sample in this study also provided the opportunity to replicate earlier validity data collected on the original set of patients. Ninety-seven separate trials were conducted, involving 65 consecutive admissions to a unit that specializes in the assessment and treatment of patients with long standing severe psychiatric disorders. The RAPP, along with the Positive and Negative Syndrome Scale and global measures of severity, were administered at baseline and at the end of each trial. Both factor scores and clinically-derived subscales were analysed for sensitivity to change. Patients were globally rated as improved, unchanged or worsened at the end of the medication trial. Results indicated that the RAPP factor, clinical scale and total scores compared favourably to other outcome measures in patients rated as improved or worse. In patients rated as unchanged, RAPP scores displayed significantly less change than did the PANSS scores. These findings support the validity of the RAPP as an outcome measure in treatment trials.

Violence in treatment resistant psychotic inpatients.

This study sought to: a) ascertain the effect on rates of violence by varying its operational definition and b) compare characteristics of violent and nonviolent patients. Aggressive behavior was recorded daily for every patient (N = 78) during a 2-year period. Standardized rating scales were used to rate psychopathology and functioning. Almost two thirds of patients were aggressive to others, and 26% violently assaulted another person. Official incident reports underestimated rates of violence to others, self- harm, and property damage. Multivariate predictive models that greatly improved accuracy over base rates showed that violent patients tended to be female, schizophrenic (nonparanoid type), and abusive of alcohol before admission. Violence is more common in treatment resistant psychotic inpatients than suggested by incident reports. Standardized definitions of violence are urged in order to accurately study its prevalence and correlates. Models combining both historical/demographic and clinical data may enhance prediction of violence.

Low birthweight in schizophrenia: prematurity or poor fetal growth?

In the general population, low birthweight (LBW) is associated with neurological and psychological problems during childhood and adolescence. LBW may result from premature birth or poor fetal growth, and the independent effects of these two events on childhood development are not fully understood. The rate of low weight births is increased in schizophrenia and is associated with social withdrawal during childhood and an early onset of illness. However, it is unclear whether this LBW reflects poor fetal growth or premature birth, or whether these two risk factors have distinct implications for childhood functioning and age at onset of schizophrenia. Subjects included 270 patients with schizophrenia for whom a detailed history of obstetric events could be obtained. The rate of low weight births was high and was associated with poorer premorbid functioning and an earlier age at illness onset. The rate of both premature births and poor fetal growth was high relative to the normal population. Prematurity, but not poor fetal growth, was associated with premorbid social withdrawal and an early age at illness onset. Poor fetal growth, but not prematurity, was associated with low educational achievement. These results suggest that poor fetal growth and prematurity are associated with distinct patterns of childhood maladjustment in individuals who develop schizophrenia.

Multidimensional assessment of psychosis: a factor-analytic validation study of the Routine Assessment of Patient Progress.

The areas of function affected by major mental disorders are more diverse than the list of core symptoms assessed by many psychiatric rating scales, and the cross-sectional picture obtained in mental status interviews often fails to capture important data. Information on patient function can be obtained from measures that are based on extended observation and complement symptom-focused assessments. The Routine Assessment of Patient Progress (RAPP) is a 21-item rating scale that assesses both functional and psychiatric symptoms. It is usually completed by nursing staff who have observed patients over a 1-week period. Previous research has shown it to be reliable, valid, simple to complete, and of substantial value for patient care and diagnosis. The present study sought to examine the psychometric structure of the RAPP to define what domains of symptoms and behavior it measures. RAPP scores obtained from 165 psychotic inpatients were submitted to a factor analysis. A five-factor solution was derived in which 18 of 21 RAPP items were assigned to factors. The factors were labeled aggression, positive symptoms, negative symptoms, somatization/anxiety, and organic/ disorganization. The RAPP factors were moderately correlated with conceptually similar factor scores derived from the Positive and Negative Syndrome Scale (PANSS). RAPP aggression scores were validated with an independent clinical measure of aggression. Patients who were independently rated as improved over their hospital stay showed significant improvement on all RAPP factors, and unimproved patients showed stability or deterioration on RAPP measures. The data indicate that RAPP factors assess domains of psychopathology that are moderately correlated with both global ratings and symptom-focused scales. The RAPP's sensitivity to change suggests it is a valid measure of treatment outcome that could be used in controlled trials, as well as standard care outcome evaluation.

Donepezil in schizophrenia--is it helpful? An experimental design case study.

OBJECTIVE: To assess the clinical and cognitive effects of adding donepezil, a reversible acetylcholinesterase inhibitor, to the risperidone treatment of a high functioning stable out-patient with schizophrenia. METHOD: Case study using an experimental ABAB design. Assessments were completed objectively by standardized neuropsychological tests and clinical rating scales and subjectively with visual analogue scales. RESULTS: Strong improvements attributable to donepezil were found for verbal fluency and the patient's subjective response. No adverse changes were noted in psychiatric symptoms or side effects. CONCLUSION: Cholinergic enhancement as an adjunctive treatment in schizophrenia should be explored in larger controlled trials.

Ultra-trace analytical monitoring of silicon wafer surfaces by capillary electrophoresis.

Several methods are presented for the routine ultra-trace analytical monitoring of inorganic and organic anions and cations on the surface and in the native oxide of silicon wafers--the wafer-surface water-extraction method, the vapor-phase-decomposition method, and the re-dissolving method. Electrokinetic injection, sample stacking, and electrolyte composition were, therefore, optimized and made robust. For electrokinetic injection with transient isotachophoretic preconcentration a linear range of 0.05 to 0.5 micromol L(-1) was obtained; for sample stacking the linear range was 0.5 to 10 micromol L(-1), even in the presence of up to 750 micromol L(-1) hydrofluoric acid. Inorganic anions and monovalent carboxylic acids are predominately dissolved in the aqueous layer on the wafer surface whereas dicarboxylic acids are chemically bonded to the silanol groups and form esters.

A centralized system for monitoring clozapine use in British Columbia.

The Clozapine Resource Centre in British Columbia is a centralized information source for all physicians wishing to prescribe clozapine and also performs back-up hematological and compliance monitoring. Laboratories fax weekly hematology results to physicians and to the center. The center enters results in a national database and compiles twice-weekly noncompliance reports; physicians are notified of abnormal results, and caregivers of noncompliance. The centralized system obviates the practice in some jurisdictions of hiring case coordinators to oversee these procedures and may reduce physician reluctance to prescribe clozapine. It improves coordination among monitoring and treatment parties and ensures better continuity of care.

The abdominal lift: is there any advantage for the critically ill patient?

The use of carbon dioxide to create a cavity for the operation of laparoscopic cholecystectomy leads to serious complications of the cardiovascular system; consequently, patients with ischaemic heart disease can be put at greater risk. For example, on reaching an intra-abdominal pressure of 15mmHg, a fall of about 35% of the static compliance was observed. Upon using the Laparolift, these influences on the respiratory system were not detected, and the rise in systemic vascular resistance usually seen with the CO2-pneumoperitoneum did not occur. From the anaesthetist's viewpoint the Laparolift was helpful in the treatment of patients with serious limitations of cardiac function.

Routine assessment of patient progress: a multiformat, change-sensitive nurses' instrument for assessing psychotic inpatients.

A new instrument, the Routine Assessment of Patient Progress (RAPP), is a standardized scale with a unique format that allows trained nurses to incorporate both interview and observational data into a comprehensive assessment of psychiatric inpatients. The scale was developed to accurately document treatment effects, assist in treatment planning, and provide ancillary judgments of psychopathology that may affect diagnosis. The RAPP demonstrates satisfactory interrater reliability and internal consistency. The RAPP total score and its two subscales correlated highly, where expected, with an observation-based nursing scale, global measures, and an interview-based psychopathology scale. RAPP scores demonstrated sensitivity to change over time in patient functioning. It reliably discriminated among patients discharged to settings with varying degrees of independent living. The use of the RAPP over several years on a psychiatric inpatient unit has shown it to be a practical clinical tool that eases nurses' charting demands, helps create care plans, and facilitates interdisciplinary communication.

A clinical study of clozapine treatment and predictors of response in a Canadian sample.

OBJECTIVE: To study the clinical response to clozapine in patients with refractory schizophrenia. METHOD: Open trial of clozapine in 61 consecutively-treated patients. RESULTS: Following clozapine, the level of function of patients was improved relative to admission (p = 0.0001) and to the highest level in the previous year (p = 0.0001). Severity of illness was decreased (p = 0.0001). Overall, 31% of the patients were classified as responders to clozapine and the responders were all identified by 32 weeks of treatment. Poor functioning in the previous year was associated with less favourable response. At a mean interval of 26 months following discharge, 72% of the patients were continuing clozapine treatment. CONCLUSIONS: This open trial of patients who were treated consecutively indicates a comparable degree of response to clozapine as observed in controlled clinical trials, and that level of functioning in the previous year was the best predictor of response.

Diagnostic reassessment and treatment response in schizophrenia.

BACKGROUND: The reasons for poor treatment response in some patients with schizophrenia remain unclear. It is possible that misdiagnosis of nonschizophrenic disorders as schizophrenia could result in suboptimal pharmacotherapy in some patients. METHOD: To assess this possibility, 110 severely ill, chronic patients with a referral diagnosis of schizophrenia were comprehensively assessed and rediagnosed according to DSM-III-R criteria. Global Assessment of Function (GAF) and Clinical Global Impressions (CGI) ratings were made at admission and at discharge from the ward, after the implementation of individualized treatment plans. RESULTS: The diagnosis of schizophrenia was confirmed in 80 patients (73%) and revised to another type of psychotic illness in 30 patients (27%). The GAF and CGI ratings were similar at admission in patients with confirmed and revised diagnoses. All patients improved by the time of discharge (p = .0001); however, patients with a revised diagnosis improved more than those with confirmed schizophrenia (p = .02). Patients with a revised diagnosis were less likely to require continued hospitalization on chronic care wards (p = .004). At admission, medication regimens were similar in the two groups of patients. At discharge, patients with a revised diagnosis were less likely to have received neuroleptics (p = .007) and more likely to have received antimanic drugs (p = .0002) or electroconvulsive therapy (p = .0004). CONCLUSION: These findings from a clinical sample suggest that diagnostic reassessment is an important first step in the management of apparently refractory schizophrenia.

Diagnostic confusion in treatment-refractory psychotic patients.

BACKGROUND: Two surveys of diagnostic practices in the United States suggest that many clinicians base their diagnoses on presenting symptoms and pay little attention to course and exclusionary criteria. Failure to correctly diagnose patients may result in inappropriate therapy and poor treatment response. The purpose of the present study was to investigate diagnostic practices. METHODS: We made detailed assessments of 50 consecutively admitted treatment-refractory psychotic patients and carefully applied DSM-III-R criteria. RESULTS: Referral diagnoses were changed in 23 of the 50 patients. Diagnoses of schizophrenia and schizoaffective disorder were made far less frequently and mood disorders (bipolar disorder and major depression) were diagnosed far more frequently by our group than by referring psychiatrists. Patients whose diagnosis was changed were more likely to be given mood-stabilizing medication and tended to show more improvement than patients whose diagnosis was not changed. CONCLUSIONS: These findings raise the possibility that patients may not respond to treatment because incorrect diagnoses result in inappropriate treatment.

Coping, social support, and depressive symptoms in Parkinson's disease.

Social support, depressive symptoms, and three methods of coping were assessed in 45 patients with Parkinson's disease (PD) and 24 comparably disabled controls. The PD subjects employed significantly fewer cognitive and behavioral coping strategies compared with the controls. Fewer depressive symptoms were related to increased cognitive coping in PD subjects. Behavioral coping strategies were associated with lesser depression among controls. Avoidance coping methods showed a marginally significant positive association with depressive symptoms in PD subjects. Social support was related to the significant coping predictors in each group, but was not related to depressive symptoms. Although correlational, these results might suggest that active (cognitive and behavioral) coping strategies are superior to avoidance strategies in attenuating the affective distress expected from chronic deteriorative illnesses.

Depressive symptoms in Parkinson's disease: a comparison with disabled control subjects.

A high incidence of depressive symptoms has been observed in patients with Parkinson's disease (PD). PD involves a loss of central monoamines, and a decrease of monoamines has been implicated in depression; therefore, it is possible that depressive symptoms in PD result from the loss of endogenous neurotransmitters. However, it is equally possible that depressive symptoms represent a reaction to the chronic disabling course of PD. By comparing depressive symptoms in PD patients to those in matched patients with other chronic disabling diseases not involving a loss of central monoamines, it may be possible to decide between these alternatives. Thus, depressive symptoms were assessed in 45 patients with PD and 24 disabled controls that did not differ from the PD subjects on a measure of functional disability. Results showed that PD subjects obtained significantly higher total scores on the Beck Depression Inventory (BDI) than controls. PD subjects scored significantly higher than controls on BDI items grouped to reflect cognitive-affective and somatic depressive symptoms. The BDI scores of PD subjects were not reliably related to age, sex, duration of PD, or clinical ratings of PD symptom severity or functional disability. Self-rated disability and the number of recent medical problems were the greatest predictors of depressive symptoms. These findings supported the hypothesis that depressive symptoms in PD may not represent solely a reaction to disability.