Pancreatitis leading to thrombotic thrombocytopenic purpura in systemic lupus erythematosus: a case report and review of literature

Pancreatitis is a well-established but unusual complication of thrombotic thrombocytopenic purpura (TTP). It is also an unusual complication of systemic lupus erythematosus (SLE). However, TTP occurring as a consequence of acute pancreatitis in a patient with SLE has never been reported. We report a 24-year-old African American woman with active systemic lupus (SLE) who developed thrombotic thrombocytopenic purpura (TTP) following an episode of acute pancreatitis. The TTP was manifested by low-grade fever, microangiopathic hemolytic anemia, renal insufficiency, altered mental status, seizures and thrombocytopenia. The patient was initially treated with pulse corticosteroids with inadequate response and subsequently with daily plasmaphresis, leading to full remission. This case represents first report of pancreatitis leading to TTP in a patient with systemic lupus erythematosus.

Endoscopic snare polypectomy for bleeding postinflammatory polyps

We describe a patient with ulcerative colitis and protracted rectal bleeding who had required several blood transfusions and who was unresponsive to medical therapy, whose symptoms resolved after endoscopic resection of multiple giant postinflammatory polyps. This case report highlights the fact that postinflammatory polyps can occasionally cause significant symptoms, such as rectal bleeding, and that in these circumstances careful endoscopic polypectomy can be performed safely and result in a significant improvement in symptoms over a prolonged period of follow-up.

The Impaired Control Scale: confirmation of factor structure and psychometric properties for social drinkers and drinkers in alcohol treatment

AIMS

To examine (1). the structure of the Impaired Control Scale using confirmatory factor analytical techniques and (2). the internal consistency and validity of the ICS subscales.

DESIGN

Cross-sectional data were collected on alcohol-related variables using standard self-completion scales.

PARTICIPANTS

Three hundred and fifty-seven social drinkers (not in alcohol treatment) and 137 treatment drinkers (in alcohol treatment) who acknowledged experiencing impaired control over alcohol intake in the last 6 months. Impaired control was defined as drinking more than intended or more than one thinks one should.

MEASUREMENTS

Self-completion questionnaire consisting of demographic questions, Severity of Alcohol Dependence Data questionnaire (SADD), Impaired Control Scale (ICS) and three questions assessing alcohol consumption from the Alcohol Use Disorders Identification Test (AUDIT).

FINDINGS

This first confirmatory factor analytical study of the ICS found that all three parts of the ICS were unidimensional for both social and treatment drinkers. These results confirmed previous exploratory principal components analysis findings. The excellent validity and internal consistency of all three parts of the ICS found here also confirmed results of previous research into the scale.

CONCLUSIONS

The confirmation of the structure and psychometric properties of the ICS suggest that the scale is a reliable and valid instrument, with a predictable and stable factor structure, for use with both clinical and non-clinical samples.

Xanthomonas Leaf Spot and Stem Canker on Blueberry in Nurseries in Florida

In June and July 1998, in nurseries in south Florida, lesions were observed on the foliage and stems of three southern high-bush cultivars of blueberry hybrids (Vaccinium coryumbosum). Plants were approximately 1.5 to 2 years of age (0.6 to 1 m high). Disease incidence ranged from 95 to 50%, depending on cultivar. Lesions on leaves were roughly round, 5 to 20 mm in diameter, reddish brown surrounded by a yellow halo, and frequently coalesced to form large blighted areas. Stem cankers were soft, dark brown-to-black, and often resulted in the death of the entire branch. Microscopic examination of free-hand sections through lesion margins revealed bacterial streaming. Isolation of bacteria on nutrient agar consistently recovered mucoid, yellow bacteria typical of a xanthomonad. A pure culture of the bacteria was gram negative, oxidase negative, nonfluorescent, and proteolytic and produced a hypersensitive reaction on tobacco. Strains had fatty acid profiles with 88.5% similarity to Xanthomonas campestris pv. maniotis and 84.6% similarity to X. campestris pv. fici. Koch's postulates were fulfilled by spray-inoculation of 18-month-old blueberry cv. Sharpblue with a bacterial suspension (1 × 10⁸ CFU/ml) in sterile water. Control plants were sprayed with sterile distilled water. Plants were covered with plastic for 24 h and kept in a growth chamber at 25°C with a 12-h photoperiod. Symptoms were reproduced on inoculated plants, and bacteria were reisolated from lesions. Control plants were asymptomatic. The disease was controlled by applications of copper compounds, increased plant spacing, rouging of infected plants, reduction of leaf wetness, and elimination of overhead irrigation.

Rape and physical violence: comparison of assault characteristics in older and younger adults in the National Women's Study

This study compared characteristics of recently occurring assaults against younger adults (age 18-34 years) with those of distant-past assaults against older adults (age 55-89 years) when they were younger. Responses of a subset of participants in the National Women's Study were the source of data for this study. With the exception of perceived life threat during assault (more prevalent in younger women), assault characteristics did not vary greatly by age in terms of proportions reporting that they had seen the perpetrator before; the event was one in a series; they or the perpetrator were under the influence of a substance; they actually experienced injury; and they reported the assault to authorities. Consistent with previous research, younger women reported greater prevalences of assault than older women.

Inflammation and lymphocyte activation during mycobacterial infection in the interferon-gamma-deficient mouse

Interferon-gamma is a pivotal cytokine in the protective response to tuberculosis. In its absence rampant bacterial growth results in tissue destruction and death. While macrophage activation is key, this pleiotropic cytokine has other secondary but significant roles. To investigate these roles, both intravenous and aerosol infection of the IFN-gamma gene disrupted (GKO) mouse was performed. For the first time we describe the very similar growth of bacteria, during the initial phase of infection, between control and GKO mice. During this initial phase, however, very different histopathologic consequences between control and GKO mice were observed. Key observations included an early increased accumulation of granulocytes and a much more rapid and pronounced interstitial pneumonia in the GKO mice. As infection developed, GKO mice mounted an antigen-specific response; however, lymphocyte activation was much more rapid in these mice. Of interest is the fact that this increased rapidity occurred prior to significant differences in bacterial number. Taken together these data support a role for IFN-gamma in limiting both initial cellular recruitment and acquired lymphocytic responses to mycobacterial infection. This role may be key in surviving the kind of chronic stimulatory disease caused by Mycobacterium tuberculosis.

Cross-cultural evaluation of two drinking assessment instruments: alcohol timeline followback and inventory of drinking situations

This article describes the psychometric characteristics of two major assessment instruments used in a World Health Organization (WHO) clinical trial: (a) Alcohol Timeline Followback (TLFB, which assesses daily drinking patterns), and (b) Inventory of Drinking Situations (IDS, which assesses antecedents to "heavy" drinking). Clients (N = 308) were outpatient alcohol abusers from four countries (Australia, Canada, Mexico, and Sweden). Generally, the Alcohol TLFB and IDS were shown to be reliable and valid with outpatient alcohol abusers in four countries, and in three languages. These results suggest that the Alcohol TLFB and the IDS can be used in clinical and research settings with Swedish-, Spanish-, and English-speaking alcohol abusers.

Impact of childhood rape and aggravated assault on adult mental health

Associations among childhood assault (rape, aggravated assault, or both) and indices of adult mental health (posttraumatic stress disorder, major depressive episode) were examined in a national probability sample of 4,008 (weighted) women. Relationships among assault characteristics and these adult mental health indices were also investigated. Findings suggested particularly deleterious effects for childhood aggravated assault and rapes that caused additional physical injury.

The influence of intrapartum antibiotics on the clinical spectrum of early-onset group B streptococcal infection in term infants

OBJECTIVE

The use of intrapartum antibiotics to prevent early-onset group B streptococcal (EOGBS) infection has left pediatricians in a quandary about the appropriate evaluation and treatment of infants at risk for this infection. The aim of this study was to determine whether intrapartum antibiotic prophylaxis changed the constellation and timing of onset of clinical signs of group B streptococcal (GBS) infection in term infants.

METHODOLOGY

We conducted a retrospective chart review of infants who had EOGBS infection and were born in Southern California Kaiser Permanente Hospitals from 1988 through 1996. Objective criteria were used to ascertain maternal risk of infection, intrapartum antibiotic prophylaxis, and onset of clinical signs of infection.

RESULTS

Three hundred nineteen infants with EOGBS sepsis, bacteremia, or clinically suspected infection were identified from a population of 277 912 live births. Of the 172 term infants with culture-positive infection who had clinical signs of infection, 95% exhibited them in the first 24 hours of life. All of the infants exposed to intrapartum antibiotics became ill within the first 24 hours of life.

CONCLUSIONS

Exposure to antibiotics during labor did not change the clinical spectrum of disease or the onset of clinical signs of infection within 24 hours of birth for term infants with EOGBS infection. A 48-hour stay is not required to monitor asymptomatic term infants exposed to intrapartum antibiotics for onset of GBS infection.

Assault, PTSD, family substance use, and depression as risk factors for cigarette use in youth: findings from the National Survey of Adolescents

A national household probability sample of 4,023 adolescents aged 12 to 17 years was surveyed by telephone via structured clinical interview to determine the impact of familial substance use, sexual and physical assault, witnessed violence, depression and posttraumatic stress disorder (PTSD) on risk of smoking. Results indicated that familial substance use increased risk of smoking only for boys and sexual assault or depression increased risk of smoking only for girls. Age, Caucasian ethnicity, and experiencing physical assault or witnessing violence elevated risk of current cigarette use for both genders. By contrast, PTSD per se was not associated with increased risk of smoking, after the effects of other variables were controlled.

The effect of celecoxib, a cyclooxygenase-2 inhibitor, in familial adenomatous polyposis

BACKGROUND

Patients with familial adenomatous polyposis have a nearly 100 percent risk of colorectal cancer. In this disease, the chemopreventive effects of nonsteroidal antiinflammatory drugs may be related to their inhibition of cyclooxygenase-2.

METHODS

We studied the effect of celecoxib, a selective cyclooxygenase-2 inhibitor, on colorectal polyps in patients with familial adenomatous polyposis. In a double-blind, placebo-controlled study, we randomly assigned 77 patients to treatment with celecoxib (100 or 400 mg twice daily) or placebo for six months. Patients underwent endoscopy at the beginning and end of the study. We determined the number and size of polyps from photographs and videotapes; the response to treatment was expressed as the mean percent change from base line.

RESULTS

At base line, the mean (+/-SD) number of polyps in focal areas where polyps were counted was 15.5+/-13.4 in the 15 patients assigned to placebo, 11.5+/-8.5 in the 32 patients assigned to 100 mg of celecoxib twice a day, and 12.3+/-8.2 in the 30 patients assigned to 400 mg of celecoxib twice a day (P=0.66 for the comparison among groups). After six months, the patients receiving 400 mg of celecoxib twice a day had a 28.0 percent reduction in the mean number of colorectal polyps (P=0.003 for the comparison with placebo) and a 30.7 percent reduction in the polyp burden (the sum of polyp diameters) (P=0.001), as compared with reductions of 4.5 and 4.9 percent, respectively, in the placebo group. The improvement in the extent of colorectal polyposis in the group receiving 400 mg twice a day was confirmed by a panel of endoscopists who reviewed the videotapes. The reductions in the group receiving 100 mg of celecoxib twice a day were 11.9 percent (P=0.33 for the comparison with placebo) and 14.6 percent (P=0.09), respectively. The incidence of adverse events was similar among the groups.

CONCLUSIONS

In patients with familial adenomatous polyposis, six months of twice-daily treatment with 400 mg of celecoxib, a cyclooxygenase-2 inhibitor, leads to a significant reduction in the number of colorectal polyps.

Risk factors for adolescent substance abuse and dependence: data from a national sample

A national household probability sample of 4,023 adolescents aged 12 to 17 years was interviewed by telephone about substance use, victimization experiences, familial substance use, and posttraumatic reactions to identify risk factors for Diagnostic and Statistical Manual of Mental Disorders--(4th ed.; American Psychiatric Association, 1994) defined substance abuse/dependence. Age and ethnicity data were available for 3,907 participants. Major findings were (a) adolescents who had been physically assaulted, who had been sexually assaulted, who had witnessed violence, or who had family members with alcohol or drug use problems had increased risk for current substance abuse/dependence; (b) posttraumatic stress disorder independently increased risk of marijuana and hard drug abuse/dependence; and (c) when effects of other variables were controlled, African Americans, but not Hispanics or Native Americans, were at approximately 1/3 the risk of substance abuse/dependence as Caucasians.

Risk factors for adolescent substance abuse and dependence: data from a national sample

A national household probability sample of 4,023 adolescents aged 12 to 17 years was interviewed by telephone about substance use, victimization experiences, familial substance use, and posttraumatic reactions to identify risk factors for Diagnostic and Statistical Manual of Mental Disorders--(4th ed.; American Psychiatric Association, 1994) defined substance abuse/dependence. Age and ethnicity data were available for 3,907 participants. Major findings were (a) adolescents who had been physically assaulted, who had been sexually assaulted, who had witnessed violence, or who had family members with alcohol or drug use problems had increased risk for current substance abuse/dependence; (b) posttraumatic stress disorder independently increased risk of marijuana and hard drug abuse/dependence; and (c) when effects of other variables were controlled, African Americans, but not Hispanics or Native Americans, were at approximately 1/3 the risk of substance abuse/dependence as Caucasians.

The process of relapse in severely dependent male problem drinkers

AIMS

The aim of the study was to investigate factors hypothesized to influence the relapse process, with a focus on the role of self-efficacy, alcohol dependence and cognitive functioning.

DESIGN

The study was conducted in the context of a controlled trial of a relapse prevention programme. Subjects were assessed prior to treatment, at immediate conclusion of treatment and at 6- and 12-month follow-up.

SETTING

The study was conducted in an Alcohol Treatment Unit (ATU) in Scotland.

PARTICIPANTS

Subjects were 60 male problem drinkers who were patients at the ATU. They were heavy drinkers, with corresponding high levels of alcohol dependence and alcohol-related harm.

MEASUREMENTS

The independent variables were post-treatment self-efficacy, alcohol dependence, cognitive functioning, level of depression and alcohol consumption prior to admission to treatment. The dependent variables were post-treatment drinking behaviour and functioning and time to lapse and relapse.

FINDINGS

Although the methodology does not allow identification of causality, support was found for the hypothesis that post-treatment self-efficacy was an intervening variable between treatment and outcome. Higher post-treatment self-efficacy predicted better outcome at 6-month follow-up and was associated with a reduced risk of lapse and relapse over the 12-month follow-up. Poorer cognitive functioning was significantly associated with being categorized as a problem drinker at 6-month follow-up and with higher risk of a lapse over the 12-month follow-up. Level of alcohol dependence did not predict outcome.

CONCLUSIONS

It was concluded that post-treatment self-efficacy rating is a predictor of treatment outcome and time to lapse and relapse and that cognitive functioning is a predictor of treatment outcome and time to lapse.

Risk factors for rape, physical assault, and posttraumatic stress disorder in women: examination of differential multivariate relationships

The National Women's Study, a 2-year, three-wave longitudinal investigation, employed a national probability sample of 3,006 adult women to: (a) identify separate risk factors for rape and physical assault, and (b) identify separate risk factors associated with post-rape posttraumatic stress disorder (PTSD) and post-physical assault PTSD. This investigation differed from previous studies in that it prospectively examined risk factors at the multivariate, as opposed to univariate level. Overall, past victimization, young age, and a diagnosis of active PTSD increased women's risk of being raped. By contrast, past victimization, minority ethnic status, active depression, and drug use were associated with increased risk of being physically assaulted. Risk factors for PTSD following rape included a history of depression, alcohol abuse, or experienced injury during the rape. However, risk factors for PTSD following physical assault included only a history of depression and lower education.

Accurate PEG tube placement with magnetic positional imaging

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) is a common procedure and accounts for an increasing proportion of an endoscopist's workload. Serious complications can occur from inaccurate abdominal wall puncture. Electronic three-dimensional imaging has been used to aid colonoscopy. We adapted the principles of this technique to PEG insertion in a procedure called magnetic positional imaging.

METHODS

Magnetic positional imaging was used to determine the abdominal wall puncture site and angle of insertion that would provide the shortest distance from abdominal wall to the stomach. The pull-through technique was used to perform PEG.

RESULTS

PEG insertion with magnetic positional imaging was performed on four patients without complications. The average distance between the internal and external sensors was 5 mm.

CONCLUSION

A new technique, magnetic positional imaging, facilitates the pull-through technique for PEG. Additional studies are needed to clarify the potential benefit in endoscopic practice.

The insulin-like growth factor 1 receptor induces transformation and tumorigenicity of ovarian mesothelial cells and down-regulates their Fas-receptor expression

Cell proliferation and papillogenesis are growth factor-sensitive events in the ovarian mesothelium, the tissue source of ovarian epithelial cancer. To further investigate the regulation of cell proliferation in this tissue, rabbit ovarian mesothelial cells (OMC) were transfected in vitro with a CVN expression vector carrying the human gene for insulin-like growth factor 1 receptor (IGF-1R). The growth characteristics of IGF-1R transfectants (OMIR) and their response to IGF-1 were then compared with those of OMC in serumless HL-1 cultures. OMIR cells formed epithelial-like colonies and, even when nonconfluent, produced tridimensional structures reminiscent of papillae seen in ovarian serous epithelial tumors. After 3 and 7 days of exposure to IGF-1, OMIR cells grew approximately 20-fold (P < 0.05), and papillogenesis was 15- to 25-fold over similar events in OMC, respectively. Exposure to treatment with antisense oligonucleotides against IGF-1R mRNA inhibited OMIR growth rate by 70%. Western immunoblotting and flow cytometry revealed higher expression of IGF-1R in OMIR cells than in OMC. The reverse was true when Fas-receptor expression was evaluated. OMIR cells were clonogenic in 15% serum-rich soft agar assay (OMIR:OMC colony-forming ratio 150-200:1), and tumorigenic in nude mice in which high-grade carcinomas with occasional lung metastases were observed. These data suggest that IGF-1R plays a role in ovarian epithelial carcinogenesis. The overexpression of this receptor induces transformation and morphogenesis of OMCs via an autocrine mechanism. IGF-1R may down-regulate the Fas expression rendering transformed ovarian mesothelial cells resistant to apoptosis.

Adult Crohn disease: can ileoscopy replace small bowel radiology?

BACKGROUND

This study aimed to document the radiological features and distribution of small bowel Crohn disease (CD) in adults by using a barium follow-through (BaFT) technique and to determine whether disease would be missed or its distribution underestimated if only colonoscopy with ileoscopy were performed.

METHODS

The BaFT examinations of 121 adults with proven CD were reviewed retrospectively with respect to the stage and distribution of disease. Colonoscopy with attempted ileoscopy was performed in 37 of these subjects, and the results were compared with radiological findings.

RESULTS

A normal villous pattern was visualized in 89 studies (74%). BaFT showed small bowel CD in 71 (59%) of 121 patients studied. The terminal ileum (TI) was the most common site of disease, affecting 62 (87%) of patients with small bowel CD. Forty-six patients (65%) had more proximal small bowel disease, including nine (13%) with a normal TI. BaFT showed early mucosal changes of CD in 52 subjects (73%), which was the sole manifestation in 15 (21%). Ileoscopy was possible in the majority of patients colonoscoped but was not achieved in 14 (38%), nine of whom had CD on BaFT. Of the 23 patients in whom ileoscopy was performed, findings agreed with BaFT assessment of the TI in 22.

CONCLUSION

BaFT adequately demonstrates the stage and extent of small bowel CD. The majority of patients with small bowel CD have disease proximal to the TI, which cannot be diagnosed by ileoscopy.

A trial of relapse prevention with severely dependent male problem drinkers

Over the last two decades, relapse prevention has emerged as a major focus of the treatment of drug problems. Few studies have demonstrated any impact on generally high relapse rates. In this paper the outcome of a controlled trial of a relapse prevention programme with male problem drinkers (n = 60) attending an Alcohol Treatment Unit is reported. Subjects who met the inclusion criteria were allocated to a relapse prevention (n = 20) procedure or a discussion (n = 20) or no-additional treatment (n = 20) control procedure. Subjects were followed-up at 6 and 12 months by the first author. The relapse prevention programme was associated with significantly greater increases in pre- and post-treatment self-efficacy compared to the discussion control group and significantly greater probability of total abstinence than all controls over the first 6-month follow up. In addition, the relapse prevention programme was associated with significantly longer survival time to an initial lapse and relapse than the controls. At 12-month follow-up, treatment effects had been eroded. It was concluded that the relapse prevention programme was an effective treatment in the short term and that longer-term impact may require greater focus on maintenance factors, such as the individual's environment.

Relapse revisited: a critique of current concepts and clinical practice in the management of alcohol problems

How a problem is understood dictates how it is responded to. In this paper the problem of relapse and alcohol dependence is reconsidered. The existing major relapse paradigm is evaluated against the last two decades of research. It is concluded that the available research strongly questions the notion that relapse is an addiction-specific event. Instead, relapse is probably better understood as a complex, generic, human behaviour, undertaken at times by all of us. Given this, it is possible that mainstream psychological theories, such as decision making and attribution theory, are important in coming to any understanding of the phenomenon of relapse. It is also contended that the investigation of relapse is potentially an error of focus. Such study invites the investigation of those who do not succeed in changing behaviour, as against the study of those who do. For those concerned with the treatment of alcohol dependence, studying the successes may be a more informative process than studying the putative failures. Given the burgeoning of research over the past two decades the impact on treatment practice is reviewed. It is concluded that relapse prevention and management is very much on the alcohol-intervention agenda. However, the research evidence to date is consistent with the general psychotherapy literature in that doing something appears better than no intervention, but that an optimum, effective, intervention has yet to be devised.