[Clinical effectiveness of home treatment as compared to inpatient treatment at the Alexianer Hospital Krefeld, Germany]

BACKGROUND

Although all relevant guidelines recommend "home treatment" (HT) as part of psychiatric care, this strategy is very rarely applied in the German mental health system. For the first time HT was introduced in Germany as "integrative psychiatric treatment" (IPT) at the Alexianer Hospital in Krefeld. In the present study IPT was compared for the first time with inpatient treatment considering patient characteristics, drop-out rates, effects on symptoms and rehopitalisation after treatment.

METHOD

106 patients who had been treated by IPT in 2001 (or subgroups) were compared to patients who were treated as inpatients in the same year (or subgroups).

RESULTS

Regarding sample characteristics IPT patients were significantly older and more often female than inpatients. Inpatients were more frequently diagnosed with organic, schizophrenia or personality disorders. The drop-out rate from IPT (inpatient stay during IPT treatment) was 17.9 % (n = 19). The pre-post effect sizes on symptoms in 14 randomly selected patients with schizophrenia were very large (d = 1.7 - 2.6). At two-year follow-up there were no differences between IPT and a matched inpatient sample with respect to days spent in inpatient treatment (25.4 vs.27.9 days).

CONCLUSION

In the German mental health system, at least in a subgroup of severely mentally ill patients, treatment effects of HT are comparable to the effects of inpatient treatment.

Genetic variation of Mimetes hirtus and Mimetes fimbriifolius (Proteaceae) - a comparative analysis of two closely related fynbos species

We investigated the influence of differing life history traits on the genetic structure of the related species Mimetes fimbriifolius and Mimetes hirtus (Proteaceae), which occur in the South African fynbos. Both species are bird-pollinated and ant-dispersed, but differ in rarity, longevity, ecological strategy and the fragmentation of their distribution area. We used AFLPs to study genetic variation within and between 21 populations of these two species across their distribution range. AFLP analysis revealed significantly higher genetic variation within populations of M. fimbriifolius than within M. hirtus. While M. fimbriifolius clearly lacked any significant genetic differentiation between populations, a distinct geographic pattern was observed for M. hirtus. Differentiation was, however, stronger at the regional (Phi(PT) = 0.57) than at the local scale (Phi(PT) = 0.08). Our results clearly indicate that even closely related species that share the same mode of pollination and seed dispersal can differ in their genetic structure, depending on the magnitude of fragmentation, longevity of individuals and ecological strategy.

Complex postglacial history of the temperate bark beetle Tomicus piniperda L. (Coleoptera, Scolytinae)

Tomicus piniperda is an economically important pine bark beetle infesting European Pinus spp. stands. We sequenced and analyzed 797 bp of the mitochondrial genome from individuals obtained from 34 populations sampled throughout the European range. We obtained 36 haplotypes, from which a haplotype network was constructed. In the Iberian Peninsula, high-genetic variability was detected with numerous endemic haplotypes. In contrast, the other European populations were less diverse with a single haplotype predominating from the Pyrenees to Scandinavia. Nevertheless, even within Europe, a few populations showed significant amounts of diversity. Four groups were obtained by Spatial Analysis of Molecular Variance, illustrating the regional characteristics of the species. T. piniperda had multiple fragmented refugia in the Iberian Peninsula. These currently isolated populations only partly contributed to postglacial re-colonizations of Northern Europe during interglacials. Nevertheless, few long-range migration events up to Northern Europe were detected, mostly originating from the Pyrenees. In the rest of Europe, the phylogeographical patterns were unclear, because of repeated cycles of contraction and expansion. The genetic analysis showed one glacial refugium in North-Central Europe, whereas other refugia most likely occurred in the Southern Alps, Apennine and the Balkans. The phylogeographical pattern depicted here reflects partly the postglacial history of the beetles' main host tree P. sylvestris.

Prolonged prophylaxis with dalteparin to prevent late thromboembolic complications in patients undergoing major abdominal surgery: a multicenter randomized open-label study

BACKGROUND

Patients undergoing major abdominal surgery carry a high risk of venous thromboembolism (VTE), but the optimal duration of postoperative thromboprophylaxis is unknown.

OBJECTIVES

To evaluate the efficacy and safety of thromboprophylaxis with the low molecular weight heparin (dalteparin), administered for 28 days after major abdominal surgery compared to 7 days' treatment.

PATIENTS/METHODS

A multicenter, prospective, assessor-blinded, open-label, randomized trial was performed in order to evaluate prolonged thromboprophylaxis after major abdominal surgery. In total, 590 patients were recruited, of whom 427 were randomized and received at least 1 day of study medication, and 343 reached an evaluable endpoint. The primary efficacy endpoint was objectively verified VTE occurring between 7 and 28 days after surgery. All patients underwent bilateral venography at day 28.

RESULTS

The cumulative incidence of VTE was reduced from 16.3% with short-term thromboprophylaxis (29/178 patients) to 7.3% after prolonged thromboprophylaxis (12/165) (relative risk reduction 55%; 95% confidence interval 15-76; P=0.012). The number that needed to be treated to prevent one case of VTE was 12 (95% confidence interval 7-44). Bleeding events were not increased with prolonged compared with short-term thromboprophylaxis.

CONCLUSIONS

Four-week administration of dalteparin, 5000 IU once daily, after major abdominal surgery significantly reduces the rate of VTE, without increasing the risk of bleeding, compared with 1 week of thromboprophylaxis.

Cholecystectomy improves long-term success after endoscopic treatment of CBD stones

BACKGROUND/AIMS

The aim was to study prospectively primary endoscopic treatment of CBD stones and further the long-term need for renewed gallstone disease interventions, defined as short- and long-term outcome.

METHODOLOGY

Seven years prospective follow-up of 101 consecutive patients with CBD stones who underwent endoscopic treatment with the intent of primarily achieving duct clearance.

RESULTS

Many patients underwent several endoscopy sessions before stone clearance was completed in 83%. Eleven patients were treated surgically, 2 patients received a permanent stent, and the remaining 3 became stone free with other means. Complications occurred in 47 patients. During follow-up, 31 patients were readmitted for gallstone disease and 15 of these had recurrent CBD stones. Ten percent (8/78) of patients with the gallbladder in situ had acute cholecystitis during follow-up and late cholecystectomy was carried out in 22%. Risk factors for new gallstone disease were an in situ gallbladder containing stones and previous episodes of CBD stones.

CONCLUSIONS

A goal of complete CBD stone clearance with ERC and ES proved to be relatively resource consuming. Subsequent cholecystectomy after duct clearance for CBD should be advised when the gallbladder lodges gallstones, especially in younger patients. Recurrent CBD stones were not influenced by cholecystectomy.

Phylogeographic structure and past history of the circum-Mediterranean species Tomicus destruens Woll. (Coleoptera: Scolytinae)

Phylogeographic studies are often focused on temperate European species with relict footholds in the Mediterranean region. Past climatic oscillations usually induced range contractions and expansions from refugial areas located in southern Europe, and spatial distribution of genetic diversity show that northward expansions were usually pioneer-like. Actually, few studies have focused on circum-Mediterranean species, which probably were not influenced in the same way by climatic oscillations. We present the phylogeography of the bark beetle Tomicus destruens, which is restricted to the whole Mediterranean basin and the Atlantic coasts of North Africa and Portugal. We systematically sequenced 617 bp of the mitochondrial genes COI and COII for 42 populations (N = 219). Analysis revealed 53 haplotypes geographically structured in two clades, namely eastern and western clades, that diverged during the Pleistocene. A contact zone was identified along the Adriatic coast of Italy. Interestingly, we found contrasting levels of genetic structure within each clade. The eastern group was characterized by a significant phylogeographic pattern and low levels of gene flow, whereas the western group barely showed a spatial structure in haplotype distribution. Moreover, the main pine hosts were different between groups, with the Aleppo-brutia complex in the east and the maritime pine in the west. Potential roles of host species, climatic parameters and geographical barriers are discussed and the phylogeographic patterns are compared to classical models of postglacial recolonization in Europe.

The occurrence of asymptomatic and symptomatic simple hepatic cysts. A prospective, hospital-based study

AIM

To examine the prevalence of asymptomatic and symptomatic liver cysts in a university hospital patient population using modern US equipment.

METHODS

Abdominal US scans of 1541 cases referred during the period 21 January to 11 November 2000 were examined for hepatic cysts.

RESULTS

Of 1541 cases, 174 (11.3%) were found to have hepatic cysts, i.e. 109 female (12.5%) and 65 (9.7%) male patients (9.7%). In 413 individuals younger than 40 years, no cysts were found. Above the age of 40 years, prevalence increased with age.

CONCLUSION

By using modern US equipment, we found a higher prevalence of hepatic cysts than that reported in previous studies. Patient selection and the prevalence of liver cysts in the population from which the patients were referred may have influenced our results.

Biochemical and cytologic analysis of cystic contents in benign non-parasitic symptomatic hepatic cysts before and after ethanol sclerotherapy

PURPOSE

To examine the fluid of liver cysts by cytologic and biochemical analysis before and after ethanol sclerotherapy in order to explore the etiology of cystic fluid reproduction after sclerotherapy.

MATERIAL AND METHODS

The contents of 11 cysts in 11 patients were examined on the day of sclerotherapy, and 2-8 (mean 4.5) days later, and analysed for cytologic and biochemical parameters.

RESULTS

Cytologic signs of acute or subacute inflammatory reaction were absent before and present in all cysts after sclerotherapy. Biochemical parameters reflecting the acute inflammatory reaction (CRP, orosomucoid and haptoglobine), changes in capillary permeability (protein, albumin), and the cystic epithelial function (bilirubin, alkaline phosphatase) were significantly elevated after sclerotherapy.

CONCLUSION

The post-sclerotherapy fluid production is probably due to an inflammatory reaction. This may explain the success of performing sclerotherapy in one single session.

Community based program to improve firearm storage practices in rural Alaska

OBJECTIVE

To develop and evaluate a pilot program to reduce unauthorized access to firearms by youth by distributing gun safes and trigger locks to households.

DESIGN

Pilot intervention with pre/post-evaluation design.

SETTING

Two Alaska Native villages in the Bristol Bay Health Corporation region of southwest Alaska.

SUBJECTS

Forty randomly selected households with two or more guns in the home.

INTERVENTION

Initially, a focus group of community members who owned guns was convened to receive input regarding the acceptability of the distribution procedure for the gun storage devices. One gun safe and one trigger lock were distributed to each of the selected households during December 2000. Village public safety officers assisted with the distribution of the safes and provided gun storage education to participants.

MAIN OUTCOME MEASURES

Baseline data were collected regarding household gun storage conditions at the time of device distribution. Three months after distribution, unannounced onsite home visits were conducted to identify if residents were using the gun safes and/or trigger locks.

RESULTS

All selected households had at least two guns and 28 (70%) of the 40 households owned more than two guns. At baseline, 85% of homes were found to have unlocked guns in the home and were most often found in the breezeway, bedroom, storage room, or throughout the residence. During the follow up visits, 32 (86%) of the 37 gun safes were found locked with guns inside. In contrast, only 11 (30%) of the 37 trigger locks were found to be in use.

CONCLUSIONS

This community based program demonstrated that Alaska Native gun owners accepted and used gun safes when they were installed in their homes, leading to substantial improvements in gun storage practices. Trigger locks were much less likely to be used.