A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder

A randomized trial was performed in which imaginal exposure (IE) and cognitive therapy (CT) were compared in the treatment of chronic posttraumatic stress disorder (PTSD). Patients who continued to meet PTSD caseness at the end of a 4-week symptom-monitoring baseline period (n = 72) were randomly allocated to either IE or CT. There was a significant improvement in all measures over treatment and at follow-up, although there were no significant differences between the 2 treatments at any assessment. A significantly greater number of patients who showed worsening over treatment received IE, although this effect was not found at follow-up. Patients who worsened showed a greater tendency to miss treatment sessions, rated therapy as less credible, and were rated as less motivated by the therapist. It was concluded that either exposure or a challenge to cognition can result in symptom reduction, although neither resulted in complete improvement.

Dermatofibrosarcoma protuberans and the Bednar tumor: treatment in the pediatric population

Dermatofibrosarcoma protuberans (DFSP) is a low-intermediate-grade cutaneous sarcoma that has a marked propensity for local recurrence after excision. The Bednar variant of this tumor is even less common and is distinguished histologically by the dispersal of melanin containing cells in an otherwise typical DFSP. Both are considered to be tumors of the third and forth decades of life, but both DFSP and the Bednar variant have been described in children. Until this report of a congenital Bednar tumor, only the DFSP has also been described in the neonate. The histopathology and surgical management of DFSP and Bednar tumors are outlined with emphasis on reported experience in the pediatric population. The surgical management of these lesions in children is based on numerous series in adults and the limited pediatric experience. The recommended treatment is wide excision with 3-cm margins of visibly uninvolved tissue and inclusion of superficial fascia.

Hsp47 binds to the KDEL receptor and cell surface expression is modulated by cytoplasmic and endosomal pH

Hsp47 is a novel glycoprotein that binds specifically to procollagen and is retained in the ER by its COOH-terminus RDEL peptide sequence (Satoh, M. et al. Jol. Cell Biol. 1996; 133: 469-83). In this paper, we report that erd2P, the KDEL receptor, is distributed, coprecipitates with, and binds to Hsp47. Also, under stress conditions and lowering of pHi, the cytoplasmic epitope of erd2P is not recognized by erd2P antibodies unless the cells are pretreated with NEM. Coincident with the masking of the cytoplasmic epitope of erd2P, following lowering of pHi, Hsp47 is not retained but eludes its retention receptor to be expressed on the cell surface. Alkalization of the endosomal compartments by treatment with NH4Cl or chloroquine also results in the loss of Hsp47 to the cell surface, presumably by inhibiting the retrieval of trans-Golgi network proteins from the cell surface. The expression of Hsp47 on the cell surface under conditions of stress and alteration of pHi and pHe posture Hsp47 as a serpin family protein that may modulate cell migration during development and invasion and metastasis in cancer.

Neonatal disorders of the external genitalia and vagina

Abnormalities of the external genitalia and vagina range from simple lesions to very complex anomalies of the genitourinary and gastrointestinal systems. The author describes the most common disorders of the external genitalia and vagina in the neonate, and current management strategies.

Intrusive cognitions, coping strategies and emotional responses in depression, post-traumatic stress disorder and a non-clinical population

Patients with major depression but not PTSD, patients with PTSD with or without comorbid depression, and a sample of non-clinical controls, were interviewed about their most prominent intrusive cognition, coping strategies and emotional responses. Evaluative thoughts were more likely to be reported by the depressed sample and the control sample. They were also common in the PTSD group, but other types of intrusions were also common, particularly personal memory. All three groups reported a wide variety of different types of intrusive cognition, both singly and in combination. These included elaborative cognitions, future-oriented thoughts or images that represented an elaboration of a specific personal memory. Cognitions were more frequent, unacceptable, and intrusive in the PTSD group in the month preceding interview, but the two clinical groups did not differ in the use of or effectiveness of coping strategies, or in emotional responses.

Pediatric oncology. Surgical and radiologic correlations

Many aspects of surgical decision making related to the surgical evaluation and management of children with cancer depend on information gained from radiographic imaging and radiologic consultation. A brief review of the questions that surgeons ask the radiologist may aid the radiologist in focusing the consultation.

Neonatally wounded skin induces NGF-independent sensory neurite outgrowth in vitro

An in vitro model was established to investigate factors underlying the sensory hyperinnervation of neonatal rat skin wounds that has been observed in vivo (Reynolds and Fitzgerald, J. Comp. Neurol. 358 (1995) 487-489). Explants of normal and wounded rat dorsal foot skin were co-cultured with explants of embryonic chick or newborn rat dorsal root ganglia for 24 h and the number of sensory neurites counted. Explants of skin surrounding a wound made at birth were taken 3 (P3) or 10 (P10) days later and compared with normal skin of the same age. In addition, explants were taken from adult skin wounded 3 and 10 days earlier. At P3, normal skin induced weak neurite outgrowth (mean 13.1 +/- 2.1 neurites per ganglion explant) but skin that had been wounded 3 days earlier, at birth, induced three times more neurite outgrowth (37.8 +/- 3.3). Ten days after wounding at birth, neurite outgrowth was still substantial (40.9 +/- 3.3) although at that age (P10), even normal skin stimulates substantial growth (37.4 +/- 2.9). Normal adult skin also stimulated neurite outgrowth (28.7 +/- 0.45) but this was not increased by wounding 3 or 10 days earlier, and this was enhanced 3 days but not 10 days after wounding. Anti-NGF (nerve growth factor) added to the culture medium blocked the constitutive neurite stimulating activity from normal P10 and adult skin but was ineffective in blocking the neurite stimulating activity produced by neonatal wounding. It is concluded that skin wounding at birth results in release of one or more sensory neurotrophic factors that stimulate rat and chick dorsal root ganglia neurite outgrowth for at least 10 days, but which do not include NGF.

Echocardiographic prediction of neonatal ECMO outcome

Cardiopulmonary physiology was assessed by Doppler echocardiography in neonates undergoing pre-ECMO evaluation for meconium aspiration syndrome, congenital diaphragmatic hernia, persistent fetal circulation, and sepsis, from March 1987 through July 1992 (n = 136). Percent survival by diagnosis was: meconium aspiration syndrome, 86%; persistent fetal circulation, 68%; congenital diaphragmatic hernia, 63%; sepsis, 33%. Survival odds by diagnosis predicted a better outcome for meconium aspiration syndrome than for congenital diaphragmatic hernia and sepsis, and a better outcome for persistent fetal circulation than for sepsis. Percent survival for right-to-left patent ductus arteriosus flow (PDA) was 56%; other patent ductus arteriosus flow was 84%. In multivariate analysis, percent survival in congenital diaphragmatic hernia and persistent fetal circulation patients with right-to-left PDA flow suggested a worse outcome (% survival right-to-left vs other: congenital diaphragmatic hernia, 13% vs 70%; persistent fetal circulation, 25% vs 85%), whereas percent survival did not appear to suggest the same in meconium aspiration syndrome or sepsis patients. Similar analysis in non-ECMO patients suggested a worse outcome with right-to-left PDA flow in patients with meconium aspiration syndrome and congenital diaphragmatic hernia. Right-to-left PDA flow, sepsis, and congenital diaphragmatic hernia were associated with a poorer ECMO outcome. Initial assessment of PDA flow helps predict ECMO outcome.

Intranasal midazolam in patients with status epilepticus

The patient in status epilepticus presents many challenges to the emergency physician. IV access is frequently difficult to achieve, and prolonged attempts at access can jeopardize the patient and endanger the caregiver. We present two cases in which the administration of intranasal midazolam appeared to successfully terminate status epilepticus. No adverse effects were noted. Studies are needed to clarify the safety, optimal dosing, and clinical utility of this treatment modality.

Monitoring of intrusions in post-traumatic stress order: a report of single case studies

The effect of monitoring on frequency and duration of intrusions, and on reported symptomatology in patients with a diagnosis of post-traumatic stress disorder (PTSD) was investigated. Six patients were asked to monitor their intrusions over a period of two months. The patients were reassessed after completing the monitoring and followed up after three months. Four patients recovered and no longer met criteria for PTSD, one patient was still experiencing some symptoms, and one still met criteria for a diagnosis of PTSD.

Audits of the treatment of genital warts: closing the feedback loop

An initial audit of the treatment of patients presenting to the GUM Department at Leeds General Infirmary with a first episode of anogenital warts was reported in 1993. Treatment was found to be unselective and poorly monitored and the results of treatment were disappointing. As a consequence, guidelines for the management of new patients presenting with genital warts were devised. In order to establish whether these guidelines had produced any improvements in outcome, a second audit was performed looking at the results of treatment in patients with new genital warts who attended 6 months or more after the new guidelines were introduced. Progress was documented for 6 months after presentation. There was a significant fall in the numbers of patients receiving podophyllin 25% solution as first-line treatment, and corresponding increases in the initial use of cryotherapy, trichloracetic acid and, in men, podophyllotoxin solution. (Podophyllotoxin was not licensed for use in women at the time of the second audit.) There were significant improvements in the outcome of treatment. Originally 44% of men had warts despite receiving treatment for 3 months, and 32% were still attending for treatment 6 months after presentation. After the introduction of treatment guidelines, these figures had fallen to 8% and 3% respectively. In the first audit 38% of women still had warts after 3 months' treatment but in the second audit this figure was reduced to 18%. At 6 months, the percentage of women still attending for treatment was halved from 12% in the first audit to 6% in the second audit. The mean number of clinic visits fell from 5 to 3 in men and from 9 to 6 in women. The treatment protocols have been modified and now include the use of podophyllotoxin cream and solution in both men and women.

Pancreatic blastomatous tumor in a child responding to therapy used for hepatoblastoma: case report and review of the literature

A case is reported of a 7-year old girl diagnosed with initially inoperable metastatic embryonic pancreatic tumor, which showed a significant clinical response to chemotherapeutic agents commonly used to treat hepatoblastoma. This regimen was selected because certain histologic features of the tumor demonstrated characteristics seen in hepatic tissue. After two course of chemotherapy (cis-platinum and adriamycin), there was a significant reduction of the primary mass, and it was completely resected, although the tumor subsequently recurred in the metastatic, unoperated site. The embryological relationship between the tumor in this patient and hepatoblastoma, as well as the literature concerning treatment in pediatric pancreatoblastic tumors are reviewed. Complete eradication of tumor appears to be necessary for cure.

Is Trichomonas vaginalis still a marker for other sexually transmitted infections in women?

Trichomonas vaginalis (TV) has, in the past, been regarded as a useful marker for other asymptomatic sexually transmitted infections such as gonorrhoea and chlamydia in women. The aim of this study was to determine whether TV is still such a marker. All women attending the Department of Genito-urinary Medicine at the Leeds General Infirmary with a diagnosis of TV during 1983 and 1993 were identified and concurrent infections were tabulated. In 1993 approximately 30% of women with TV had at least one other sexually transmitted infection. The prevalence of gonorrhoea in women with trichomoniasis fell from 20% in 1983 to 10% in 1993 whilst the prevalence of chlamydia in these women remained unchanged at 15%. Thus trichomoniasis is still frequently associated with other pathogens in women and screening of these women for other infections remains essential.

Treatment of pneumothorax in the patient with AIDS

With the diagnosis of the adult immunodeficiency syndrome (AIDS), a patient's risk of sustaining a nontraumatic pneumothorax increases to 450 times that of the general population. The approach to pneumothorax that occurs in the patient with AIDS differs from the strategy that is used for spontaneous pneumothorax in immunocompetent young adults. The modifications in treatment are predicated on understanding the etiology of spontaneous lung collapse in the patient with AIDS.

Intestinal bypass of the esophagus

Esophageal replacement by a segment of isoperistaltic ileum with cecum or by transverse or left colon will allow near-normal swallowing for many years. The authors reviewed the course of 59 children who had bypass of their entire esophagus and of four whose distal esophagus was resected and replaced. The follow-up period ranges from 1 to 37 years; in 36 cases, it exceeds 5 years. Thirty children had caustic strictures and 25 had either isolated esophageal atresia or atresia with fistula. Two children with esophageal injury caused by foreign body ingestion and two with congenital strictures also required complete bypass. Four patients required resection and replacement of the distal esophagus only; two had acquired strictures from gastroesophageal reflux, one had varices, and one had a teratoma involving the esophagus. A retrosternal isoperistaltic ileocolic segment is our preference for complete esophageal replacement. Forty-eight patients underwent esophageal reconstruction with this procedure. The esophagus damaged by caustic ingestion was left in place in all patients, without any subsequent problem. The authors have not used the distal esophagus for anastomosis in patients with atresia, because this segment may be abnormal; and, in any case, an isoperistaltic cologastric anastomosis does not reflux. The right or left colon or jejunum was used in the other cases. Three children lost an interposed intestinal segment from necrosis even though the bowel appeared to be well vascularized at the end of the operation. Each patient had successful reconstruction using another type of interposition. An intrathoracic leak occurred in one infant. A cervical anastomotic leak developed in 11 children, and a stricture in 13. Strictures were more common in patients who had caustic burns. Three patients required surgery for adhesive intestinal obstruction. A redundant colon transplant with ulceration, and the herniation of an ileal segment into the pleural cavity with obstruction prompted reoperation in two other patients. There were two deaths early in the series, one of which was secondary to postoperative respiratory arrest. The other death occurred in a child who had a caustic pharyngeal burn and chronic aspiration. All patients were seen in our office recently, or they or their parents were interviewed by phone. All of them are taking all of their nutrition by mouth. Forty-three of the 61 survivors have had no difficulty with swallowing. One required reoperation to enlarge the thoracic inlet. Seventeen other have mild dysphagia that does not require treatment. The patients with esophageal atresia or atresia and fistula consistently have not grown as well as those who required replacement for an acquired condition or injury.

Conversion of unresectable to resectable hepatoblastoma and long-term follow-up study

In children with hepatoblastoma, cure or a prolonged disease-free interval can only be accomplished with surgical resection of the primary tumor. Less than 50% of children with hepatoblastoma are felt to have resectable tumors at the time of diagnosis. Clinical studies have recently focused on the hypothesis that adjuvant chemotherapy can convert the unresectable tumor to a tumor that can be resected. Short-term outcomes for patients treated with adjuvant chemotherapy and subsequent resection are nearly equal to those patients treated with initial resection followed by chemotherapy. This study is a review of the current literature of the chemotherapeutic conversion of unresectable hepatoblastoma and an update on the long-term follow-up of some of these patients.

Peritoneal host defenses are less impaired by laparoscopy than by open operation

There is a growing body of evidence that laparoscopic surgery is physiologically less injurious than open surgery. We hypothesized that the open technique results in a greater impairment of peritoneal and systemic defense mechanisms than does the laparoscopic technique. Nissen fundoplication, standardized in technique and duration, was performed in 16 pigs. The procedure was performed through a standard midline incision (OPEN, n = 8) or with laparoscopic technique and CO2 pneumoperitoneum (LAP, n = 8). The peritoneal cavity was instilled with 400 cc of normal saline, either alone (not contamined, n = 8) or containing 10(9) E. coli/ml (contaminated, n = 8). Quantitative cultures, cell count, and flow cytometry were performed on blood and peritoneal fluid samples obtained at timed intervals. We found that host defense processes were better preserved after LAP than by OPEN surgery. Peritoneal and systemic monocyte class II antigen expression, and serum tumor necrosis factor-alpha activity was greater in the OPEN group compared with the LAP group, but peritoneal bacterial clearance was more efficient in the LAP group. These data may illustrate a potential benefit of laparoscopic surgery in cases of peritoneal contamination.

Carcinoma of the penis: A cluster of cases in young men

Images

Reorganization of central terminals of myelinated primary afferents in the rat dorsal horn following peripheral axotomy

We have investigated the time course and extent to which peripheral nerve lesions cause a morphological reorganization of the central terminals of choleragenoid-horseradish peroxidase (B-HRP)-labelled primary afferent fibers in the mammalian dorsal horn. Choleragenoid-horseradish peroxidase is retrogradely transported by myelinated (A) sensory axons to laminae I, III, IV and V of the normal dorsal horn of the spinal cord, leaving lamina II unlabelled. We previously showed that peripheral axotomy results in the sprouting of numerous B-HRP-labelled large myelinated sensory axons into lamina II. We show here that this spread of B-HRP-labelled axons into lamina II is detectable at 1 week, maximal by 2 weeks and persists for over 6 months postlesion. By 9 months, however, B-HRP fibers no longer appear in lamina II. The sprouting into lamina II occurs whether regeneration is allowed (crush) or prevented (section with ligation), and does not reverse at times when peripheral fibers reinnervate the periphery. We also show that 15 times more synaptic terminals in lamina II are labelled by B-HRP 2 weeks after axotomy than in the normal. We interpret this as indicating that the sprouting fibers are making synaptic contacts with postsynaptic targets. This implies that A-fiber terminal reorganization is a prominent and long-lasting but not permanent feature of peripheral axotomy. We also provide evidence that this sprouting is the consequence of a combination of an atrophic loss of central synaptic terminals and the conditioning of the sensory neurons by peripheral axotomy. The sprouting of large sensory fibers into the spinal territory where postsynaptic targets usually receive only small afferent fiber input may bear on the intractable touch-evoked pain that can follow nerve injury.

Acute biliary pancreatitis. The roles of laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography

Since January 1990, we have treated 113 patients for gallstone pancreatitis; 59 with laparoscopic cholecystectomy (LC), 50 with open cholecystectomy, and 4 with ERCP/sphincterotomy only. In the LC group, 47 had LC during the index admission and 12 underwent delayed LC. Fifty patients had open cholecystectomy, 47 during the index admission. ERCPs were performed in 43 of the 113 patients; CBD stones were identified in 19/43 (44%) and removed endoscopically in 18 (95%). The ERCP complication rate was 6.5%. In total, CBD stones were identified in 29/113 patients (26%). Patients who had imaging of the CBD within the first 4 days from onset of symptoms were more likely to have stones identified than were those patients who were studied after 5 days. Recurrent pancreatitis occurred in in five of 11 patients (45%) who had a > or = 30-day delay to definitive treatment. We conclude that LC can be safely performed in most patients during the index admission for gallstone pancreatitis. This policy should reduce the 30-50% risk of recurrent pancreatitis associated with a delayed operation. ERCP is a helpful adjunct for CBD stones.

(-)-Norcocaine

The title compound, [2R,3S-(2 beta,3 beta)]-methyl 3-(benzoyloxy)-8-azabicyclo[3.2.1]octane-2-carboxylate, C16H19NO4, is a metabolite of the tropane alkaloid cocaine. The molecule crystallized as the free base with the piperidine ring in a chair conformation. The tropane ring system and its methoxycarbonyl and benzoyl groups are rigid; only rotational flexibility is allowed in the conformation of the substituents.