[The physician-patient relation in the light of the attachment theory. Attachment counseling]. / La relazione medico-paziente alla luce della teoria dell'attaccamento. Il counseling di attaccamento.

INTRODUCTION: The doctor-patient relationship has always played a key role in the patient's treatment and recovery process. However, it is still difficult to interpret its dynamic healing aspects. Above all, the mechanisms that enable the patient to improve and to change are not still sufficiently clear. WORKING THEORY: The attachment theory assumes an emotional support of the doctor towards the patient. According to this, the patient completely "invests" the doctor of his emotions as in the ancestral model of family relationship. The possibility of obtaining success seems to be strictly linked to the doctors' capacity of accepting this "mandate" offered by the patient who autonomously takes this decision. CURRENT SITUATION: Physicians deal with the complexity of pathologies every day and this shows an increasing necessity of a "doctor-patient relationship", enabling the physician to identify the patients symptoms in a more extended way which involves pain and suffering as well. As for the pharmacological intervention, the patient's attitude and expectations of recovery have a definite effect on the simple assumption of medicine. CONCLUSION: Today's physicians' scientific education would be extremely insufficient, if it were not encouraged by the awareness that his/her duty goes beyond the simple medical prescription. It has to reach the patient's heart as well as arouse the understanding of events related to him/her. This is not just a cultural factor but also a precise way of interacting with the patient according to one's own Counselling models.

[Counseling for adolescents with eating disorders]. / Il counseling nei disturbi del comportamento alimentare degli adolescenti.

INTRODUCTION: The increase of disorders connected to eating behaviours arises serious problems in the social and health-care setting. These require long-term therapeutic interventions, which have to be strongly integrated on the pharmacological, psychotherapeutic, social and cultural aspects. At present the issues develops itself on three levels: a) increase of the number of subjects, especially adolescents, b) protraction of the illness, with frequent critical relapses, c) always less defined evolution of the pathology with a tendency to become chronic and develop other kinds of illnesses. OUTLINE OF THE SURVEY: The Clinical Psychology Service of the CBM University Hospital examined 300 records of adolescents with various forms of eating disorders. Some of these interventions were requested by various clinical departments while other cases were directly taken care of and offering pharmacological as well as therapeutic interventions. RESULTS: The analysis of adolescents' dynamics allows an interpretation of modern eating disorders as one of the issues characteristic of the always more difficult body-mind integration. For adolescents corporeality is a weight, some kind of foreign body they don't like, and it is not thought as the basic way to get in contact with others so to express one's own feelings and wishes. CONCLUSIONS: Eating disorders are very strong symptoms of personal and social malaise. For this reason they require an integrated intervention starting from the family environment, reaching the child in its uniqueness as well as the larger social context. Actually the latter sends messages to young people which are strongly destabilizing from an ethical point of view as well as for body aesthetics. A counseling service offered at first to parents becomes an effective way of preparing both sides to more complex and articulated types of treatment. These can be more expensive but can build up again a disturbed or not properly developed psychological balance in adolescents.

Intradermal skin test with diabetes specific antigens in patients with type 1 diabetes.

Cell mediated immune response in vitro to a number of antigens has been reported in patients with Type 1 diabetes. The aim of the present study was to develop an in vivo intradermal (delayed type hypersensitivity) skin test using antigens known to be recognized by lymphocytes of patients with Type 1 diabetes and to compare, where possible, the in vivo response to the in vitro T cell proliferation to the same antigens. The skin test was performed in the following group of patients: 55 with recent onset Type 1 diabetes; 16 patients with Type 1 diabetes of longer duration; 10 patients with autoimmune thyroid disease and 20 patients with Latent Autoimmune Diabetes in Adults (LADA). Type 1 diabetes specific antigens for the skin test included glutamic acid decarboxilase (GAD65), insulin and beta casein, whereas diabetes non specific antigens included tetanus toxoid, diphteria, proteus, tubercolin, streptococcus, and glycerol as control. A multitest device consisting of heads delivering intradermally 10 microl of solution containing the antigens was applied to the forearms; the specific antigens were injected in one forearm whereas the non specific antigens were injected in the other forearm. Reading of the reaction, which was considered positive in the presence of a nodule of 2 mm diameter was performed 48 h after the multitest application. The in vitro T cell response to diabetes specific antigens used in the multitest was studied using conventional proliferation assays in patients with recent onset Type 1 diabetes and in age matched normal subjects. Only recent onset Type 1 diabetes patients showed an in vivo positive response to GAD65, such response being detectable in 10 patients (18%). Two patients reacted also to beta casein and insulin, all other patient groups resulted negative but 2 patients with longer duration of Type 1 diabetes. There was no apparent link between the in vivo skin test and in vitro T cell proliferation to GAD65. We conclude that in vivo cell mediated immune reaction to GAD65, insulin and beta casein can be visualized in a minority of patients with recent onset Type 1 diabetes. Further studies are required to determine specificity and whether altering the dose can improve the sensitivity of the test.

Bovine beta-casein antibodies in breast- and bottle-fed infants: their relevance in Type 1 diabetes.

BACKGROUND: Bovine beta-casein is a cow's milk protein that targets both humoral and cellular immune responses in patients with Type 1 diabetes and, to a lesser degree, also in normal subjects. In this study we aimed to determine whether the avoidance of cow's milk consumption early in life could prevent the development of antibody response to bovine beta-casein despite the mother being exposed on a daily basis to cow's milk consumption. MATERIALS AND METHODS: We measured the antibody response to bovine beta-casein using an ELISA method in 28 healthy infants under 4 months of age, of whom 16 were exclusively breast-fed and 12 were bottle-fed with cow's milk. In addition, beta-casein antibodies were measured in 37 prepubertal children with Type 1 diabetes and in 31 healthy children who were exposed to cow's milk or dairy products to see whether differences in antibody titers exist in this young age group. Antibodies binding to beta-casein were also evaluated by immunoblotting analysis. RESULTS: Elevated levels of beta-casein antibodies were found in bottle-fed infants compared to breast-fed infants (p<0.0001). Antibody levels to bovine beta-casein were also significantly higher in children with Type 1 diabetes compared to age-matched controls (p=0.03). By western blot analysis we confirmed specific binding to bovine beta-casein in bottle-fed infants, in children with Type 1 diabetes and in controls exposed to cow's milk, but not in infants who were exclusively breast-fed. CONCLUSIONS: The results of this study indicate that breastfeeding within the first 4 months of life prevents the generation of antibody response to bovine beta-casein despite the mothers' consumption of cow's milk during the breastfeeding period. These findings may have relevance for disease prevention.

No effect of oral insulin on residual beta-cell function in recent-onset type I diabetes (the IMDIAB VII). IMDIAB Group.

AIMS/HYPOTHESIS: Induction of tolerance to insulin is achievable in animal models of Type I (insulin-dependent) Diabetes mellitus by oral treatment with this hormone, which can lead to prevention of the disease. In the Diabetes Prevention Trial of Type I diabetes (DPT-1), oral insulin is given with the aim of preventing disease insurgence. We investigated whether if given at diagnosis of Type I diabetes in humans, oral insulin can still act as a tolerogen and therefore preserve residual beta-cell function, which is known to be substantial at diagnosis. METHODS: A double-blind trial was carried out in patients (mean age +/- SD: 14 +/- 8 years) with recent-onset Type I diabetes to whom oral insulin (5 mg daily) or placebo was given for 12 months in addition to intensive subcutaneous insulin therapy. A total of 82 patients with clinical Type I diabetes ( < 4 weeks duration) were studied. Basal C peptide and glycated haemoglobin were measured and the insulin requirement monitored every 3 months up to 1 year. Insulin antibodies were also measured in 27 patients treated with oral insulin and in 18 patients receiving placebo at the beginning of the trial and after 3, 6 and 12 months of treatment. RESULTS: The trial was completed by 80 patients. Overall and without distinction between age at diagnosis, at 3, 6, 9 and 12 months baseline mean C-peptide secretion in patients treated with oral insulin did not differ from that of those patients treated with placebo. In patients younger than 15 years a tendency for lower C-peptide values at 9 and 12 months was observed in the oral insulin group. Insulin requirement at 1 year was similar between the two groups as well as the percentage of glycated haemoglobin. Finally, IgG insulin antibodies were similar in the two groups at each time point. CONCLUSION/INTERPRETATION: The results of this study indicate that the addition of 5 mg of oral insulin does not modify the course of the disease in the first year after diagnosis and probably does not statistically affect the humoral immune response against insulin.