Self-management education for rehabilitation inpatients suffering from inflammatory bowel disease: a cluster-randomized controlled trial.

Although inflammatory bowel disease (IBD) affects patients' psychological well-being, previous educational programs have failed to demonstrate effects on psychosocial outcomes and quality of life. Therefore, we developed a group-based psychoeducational program that combined provision of both medical information and psychological self-management skills, delivered in an interactive manner, and evaluated it in a large, cluster-randomized trial. We assigned 540 rehabilitation inpatients suffering from IBD (mean age 43 years, 66% female) to either the new intervention or a control group comprising the same overall intensity and the same medical information, but only general psychosocial information. The primary outcome was patient-reported IBD-related concerns. Secondary outcomes included disease knowledge, coping, self-management skills, fear of progression, anxiety, depression and quality of life. Assessments took place at baseline, end of rehabilitation and after 3 and 12 months.The psychoeducational self-management program did not prove superior to the control group regarding primary and secondary outcomes. However, positive changes over time occurred in both groups regarding most outcomes. The superior effectiveness of the newly developed psychoeducational program could not be demonstrated. Since the intervention and control groups may have been too similar, this trial may have been too conservative to produce between-group effects.

[57-year-old female patient in early retirement with underweight and chronic-relapsing diarrhoea]. / 57-jährige, untergewichtige Patientin in Frührente mit intermittierenden Diarrhöen und krampfartigen Bauchbeschwerden.

Underweight as a consequence of chronic diarrhoea may lead to fatigue, tiredness and impaired physical performance, especially when the underlying cause has not been evaluated. In spite of algorithms as a help in the differential diagnosis, an individual approach with critical consideration of diet history, laboratory data and imaging procedures is necessary. Additional difficulties may arise when the history of food intolerance is inconsistent and technical findings including endoscopy are inconclusive. We report on a 57-year-old female patient with underweight, chronic intermittent diarrhoea and cramp-like abdominal pain for more than 10 years following pelvic irradiation due to Hodgkin's disease of the ovary. A systematic diagnostic approach was not undertaken until very recently due to the deterioration of her clinical conditions pointing to jejunal malabsorption. In spite of the absence of a specific history of milk/milk product intolerance a lactose H (2)-breath test was performed showing lactase deficiency with lactose intolerance. The rapid improvement of all her symptoms after a lactose-poor diet had been started supported this diagnosis. Possible reasons for the long time period which had elapsed until the diagnosis was established and the discrepancy of the H (2)-breath test results with the absence of a clear-cut history for milk/milk product intolerance are discussed in terms of the importance of a structured history-taking with regard to nutrition and diet habits. In addition, potential explanations for radiation-induced functional damage in the absence of morphological abnormalities are provided. Based on the experience of this case and considerations regarding the consequences of radiation-induced jejunal damage, we recommend that a lactose-H (2) breath test be routinely included in the diagnostic work-up of patients with unclear chronic diarrhoea even if there is no defined history of milk/milk product intolerance.

Survival in alcoholic liver cirrhosis: prognostic value of portal pressure, size of esophageal varices and biochemical data. Comparison with Child classification.

A survival analysis was carried out based on the data of 190 male patients with alcoholic liver cirrhosis (Child A: 82.2%; Child B: 17.8%). Patients (mean age: 49.6 +/- 7.1 years) were examined during the period 1983-1990. Censoring in May 1993 was based on the recordings of the "Rentenversicherungsanstalten". There were no "drop-outs". During follow-up (mean: 4.2 years) 64 (33.7%) of the patients died. 13 potential prognostic variables were examined individually by drawing Kaplan-Meier curves and performing log-rank tests. Portal pressure, determined during hepatic vein catheterization as hepatic vein pressure gradient HVPG (P), size of esophageal varices, serum bilirubin, serum albumin, prothrombin time (Quick), thromboplastin time (PTT), cholinesterase (ChE) and Child scores were correlated to survival (p < 0.05), whereas age, gamma GT, IgA, drinking habits and additional diagnoses were not. A multivariate Cox regression analysis stepwise eliminated all but three variables: ChE, albumin and variceal size were included in the prognostic index PI of the final model. The usefulness of the model was tested by a cross validation method. No significant difference was found between estimated and observed survivorship functions. To compare the PI of the Cox model with Child's scores, ROC curves of sensitivity and specificity of predicting death within one, three and five years were constructed. Better prognostic efficiency was indicated for PI. Because ChE, albumin and the size of varices are determined as a routine in our clinic, we consider the construction of PI an advisable alternative to Child's classification.