Third generation cognitive-behavioral therapies for major depressive disorder- a literature review

Introduction

Cognitive behavioral therapies (CBT) represent a heterogeneous group of psychotherapies in continuous development that share a directive, structured, collaborative approach. Due to a high degree of treatment-resistant cases of major depressive disorder (MDD), new augmentation therapies are urgently needed, in order to increase the chance of recovery in these patients.

Objectives

To analyze data that may support the indication of third wave CBT in patients with MDD.

Methods

A literature search was performed in the main electronic databases, and papers published between January 2000 and August 2020 were included.

Results

Acceptance and commitment therapy has been associated with positive results, but data are derived from low quality trials (n=2). Dialectical-behavioral therapy (DBT)-based skill group have been also associated with favorable outcome, in MDD patients (n=2). Mindfulness-based cognitive therapy (MBCT) was also proven effective in the treatment in MDD (n=4), treatment-resistant MDD included, but the difference between MBCT and active comparators was not always significant. Metacognitive therapy (MCT) has been evaluated in good quality clinical trials (n=4), and its efficacy was confirmed. Mild and moderate MDD patients may benefit from compassion-focused therapy (CFT) (n=1). Behavioral activation (BA) is dedicated to MDD patients and according to a meta-analysis (n=26 randomized controlled trials) BA is superior to other active comparators, although the quality of clinical trials was modest.

Conclusions

Third generation CBT could be useful in MDD patients as augmentative strategy, but more good-quality data are necessary before recommending them in an evidence-based treatment guideline as a distinctive intervention from classical CBT.

Changes in sleep quality amidst COVID-19 pandemic among psychiatric patients in Romania

Introduction

Sleep disturbances can occur as a result of major stressful events. Additionally, research evidence suggests that COVID-19 pandemic may have negatively impacted the quality of sleep among various populations. However, individuals respond differently to the stress, uncertainty and social isolation related with COVID-19 pandemic.

Objectives

This study aimed to explore the changes in sleep quality and pattern among voluntary psychiatric patients visiting our clinic in Romania during COVID-19 pandemic.

Methods

We implemented a cross-sectional study over a period of 3 months, utilizing a Romanian-translated version of the Pittsburgh Sleep Quality Index (PSQI) which was administered through Google Forms web application. Participants lacking digital skills were provided with guidance for completing the questionnaire. Informed consent was obtained prior to participating in this study and data anonymity and confidentiality were ensured.

Results

Among a total of 98 responders, 63% reported a global PSQI score greater than 5, indicating poor sleep. Approximately 25% of participants subjectively marked their sleep as either fairly bad or very bad. When analysing the 7 components of PSQI, our participants struggled most with long sleep latency. About a third of participants reported using sleep medication (both prescription and over-the-counter) three or more times a week within the past month.

Conclusions

Considering the fact that the current situation is likely to evolve for an unknown period of time, there is a dire need to assess the effect of prolonged adjustments in daily routine and their impact on the sleep and the quality of life of our patients.

Psychotherapies for neurocognitive disorder due to alzheimer’s disease- the current level of evidence

Introduction

Psychosocial interventions for Alzheimer’s dementia (AD) may increase patients quality of life and overall functioning, while it decreases caregivers burden. Therefore psychotherapies represent an important component of the case management, beside pharmacological approaches.

Objectives

To review the current psychotherapeutic options available for patients diagnosed with AD, that may be added to their ongoing pharmacological treatment.

Methods

A literature review was conducted through main electronic databases, and papers published between January 2000 and August 2020 were included in the analysis.

Results

Cognitive stimulation therapy is based on general cognitive abilities training, with an accent over the social interaction, and it has been associated with significant improvement when compared to wait list or standard care. Reminiscence therapy, usually administered in a group format, focuses on past experinces, triggered by photos, newspaper fragments, music tunes etc., and according to a meta-analysis it may increase communicational, cognitive, and affective abilities. Validation therapy is based on a very empathic communication and tries to acknowledge patients perspective over the world, but the data to support its efficacy is limited for AD. Multisensorial stimulation is based on the assumption that stimuli deprivation is involved in the onset of anxiety, restlessness, insomnia etc, and may lead to short-term non-cognitive symptoms. Music therapy, art therapy, and animal-assisted therapy are also indicated, but more trials are needed to confirm their efficacy.

Conclusions

A large number of psychotherapeutic interventions are explored for AD patients, but most of them have low levels of evidence.

Evaluation of executive dysfunction in clinical practice- pragmatic challenges and solutions

Introduction

Executive dysfunction (ED) is an important clinical dimension that need to be evaluated in neurologic and psychiatric disorders, due to this factor’s impact over patients functionality, quality of life, and overall prognosis. Working memory, inhibition, set shifting, and fluency are the most widely accepted dimensions of ED. The evaluation of these aspects in clinical practive should be more frequently implemented, because they may offer an image about the patients ability to cope with new situations, stressful events, social challenges being included.

Objectives

To determine the most appropriate methods of ED evaluation in psychiatric practice.

Methods

A literature review was conducted through main electronic databases, and papers published between January 2000 and August 2020 were included in the analysis.

Results

Wisconsin Card Sorting Test (WCST), Halstead-Reitan Neuropsychological Battery, Cambridge Neuropsychological Automated Battery (CANTAB), Wechsler Adult Intelligence Scale (WAIS), and Controlled Oral Word Association Test (COWAT) have been the most frequently cited instruments for ED evaluation. The neuropsychiatric disorders in which ED was recommended in clinical trials were schizophrenia and other psychotic disorders, neurocognitive disorders, bipolar disorders, and major depressive disorders. An integrated approach, that combines initial evaluation and periodic monitoring of symptoms severity, global functioning, quality of life, and ED severity should be considered standard-of-practice for neuropsychiatric disorders.

Conclusions

ED is an important dimension of clinical evaluation in many psychiatric disorders that is useful because the results may correlate to the patients prognosis, quality of life, and overall functional evolution.

Conflict of interest

No significant relationships.

Mindfulness-based cognitive therapy for major depressive disorder- a literature review

Introduction

Mindfulness-based cognitive therapy (MBCT) is a third wave cognitive-behavioral therapy (CBT) that incorporates meditation exercises in the classical, structured intervention. Mindfulness has been associated with psychological well-being, and certain symptoms that occur in major depressive disorder (MDD), e.g. worries, ruminations, ideas of incapacity or self-devaluation, are considered potential targets for MBCT.

Objectives

To evaluate the current level of evidence for the MCBT efficacy in MDD.

Methods

A literature serach was performed in the main electronic databases, targeting clinical trials that evaluated in a randomized manner the efficacy of MCBT versus active comparators or placebo in patients with MDD.

Results

MBCT was efficient in a 10-week randomized controlled trial (RCT) versus standard treatment, and it decreased ruminations, increased patients quality of life, mindfulness abilities, and self-compassion. In another randomized, 8-week RCT, MBCT prevented relapses in MDD, with similar rates when compared to psychoeducation and standard treatment. A 26-month follow-up study evidenced the persistence of symptoms improvement detected after 12 months of the trial, when compared to active control group and treatment as usual. MCBT was compared to cognitive therapy in a randomized 8-week trial, and both treatments had similar efficacy in MDD relapse prevention.

Conclusions

MCBT may be an useful adjuvant to the current treatment in acute MDD, but it may also decrease the risk of relapse after psychotherapy termination.

Evidence-based therapeutic management of binge-eating disorder

Introduction

Binge-eating disorder (BED) is a difficult-to-manage clinical entity, that may associate both organic (e.g., obesity, metabolic syndrome) and psychiatric (e.g., anxiety, mood, or substance use disorders) co-morbidity. Psychotherapeutic and pharmacological approaches are usually combined in order to reach the best outcome for these patients, but the disorder seems to have prolonged evolution even under appropriate therapeutic managment.

Objectives

To evaluate the most evidence-based therapies focused on BED.

Methods

A literature review was conducted through main electronic databases, and papers published between January 2000 and August 2020 were included in the analysis.

Results

Cognitive-behavioral therapy (CBT) is supported by multiple trials, and it led to decreased number of binge episodes and increased rates of remission. Behavioral activation may improve certain symptoms of BED (depressive mood, anxiety), but not the binge episodes frequency. Interpersonal group therapy (IPT) may be helpful for BED patients with an external locus of control and significant interpersonal dificulties. Dialectical behavior therapy (DBT) has been applied in BED patients, but the results have been inconclusive. Lisdexamfetamine dimesylate is the only FDA approved drug for this indication, as dasotraline was rejected by FDA and its research discontinued by the manufacturer. Fluoxetine, sertraline, escitalopram, duloxetine, bupropion, atomoxetine, reboxetine, armodafinil, disulfiram, baclofen, zonisamide, lamotrigine, topiramate, samidorphan, liraglutid, and orlistat need more trials in order to validate their efficacy, especially on long term.

Conclusions

There is only one drug currently FDA approved for this indication, lisdexamfetamine, and a number of psychotherapies, with CBT and IPT being the most supported by evidence.

Cognitive Behavioral Therapy in Internet Addiction – A Case Series

Internet use increased significantly in the last decade through the development of portable technologies, like laptops, smart-phones, tablets etc. Time spent on Internet could became a problem for many users, some of them reporting a sense of control loss, as they begin to stay more on-line than they initially wanted. Gaming, shopping, gambling, social networking, visiting pornographic sites, e-mailing, all these activities could transform an apparently inoffensive mean of communication into the trigger of a behavioral addiction. We applied individual cognitive-behavioral therapy (CBT) in three cases of Internet addiction, with cognitive re-structuring based on a diary of dysfunctional thoughts, relaxation techniques, and coping skills training, with good results. CBT was structured in bi-weekly sessions, of 30 minutes duration, for 6 weeks. Time spent on-line and daily functioning were the main variables monitored. A very important issue is to address all potential factors that could maintain the disorder, like social skills deficits, personality disorders, other co-morbid addictions, anxiety or depressive symptoms etc. Elements of motivational interview could be helpful especially at first visit, but also during therapy, when danger of relapse surfaces. Cue exposure with prevention of response is another technique that had proven itself useful in several sessions, when automatic thoughts challenge appeared to have reached a dead point. An informant like a close relative of the patient should be involved in the therapy whenever possible, due to the fact that Internet addiction therapy, like any other addiction therapy, need a third party to offer feed-back regarding patient's changes under treatment.

Disclosure of interest

The presenting author was speaker for Astra Zeneca, Bristol Myers Squibb, CSC Pharmaceuticals, Eli Lilly, Janssen Cilag, Lundbeck, Organon, Pfizer, Servier, Sanofi Aventis and participated in clinical research funded by Janssen Cilag, Astra Zeneca, Eli Lilly, Sanofi Aventis, Schering Plough, Organon, Bioline Rx, Forenap, Wyeth, Otsuka Pharmaceuticals, Dainippon Sumitomo, Servier.

Health-related Quality of Life in Old Age Institutionalized Patients with Neurocognitive Disorders

Health-related quality of life (HRQOL) is an important indicator of how a patient perceives hi/her own physical and mental status. Evaluating this dimension in old age patients which are institutionalized for neurocognitive disorders is useful from several perspectives: (1) determination of an initial value for HRQOL parameters could help the case manager in structuring an individualized therapeutic intervention, adapted for psychological, somatic or psychosocial needs of each patient; (2) monitoring the evolution of HRQOL dimensions could help in improving through feedback the quality of therapeutic intervention(s), especially if the case manager is permanently in contact with the patient, as is usually the case of institutionalized subjects; (3) correlation between HRQOL and other important variables, like therapeutic adherence, regression of comorbidities, daily functioning etc. could modulate the therapeutic intervention. We suggest a plan for HRQOL evaluation in institutionalized patients diagnosed with neurocognitive disorder, consisting in monthly scoring of SF-36 or EuroQoL questionnaire, corroborated with MMSE and ADAS-Cog scoring. Psychotherapeutic interventions tailored to the needs identified through HRQOL periodic evaluations could be useful in this population, for example a perceived isolation could be compensated by increasing the rhythm of social interaction by group therapy under the direction of a counsellor, a reduced self-efficacy could be compensated by activation techniques, music or art-therapy, while dissatisfaction with own memory capacities could be mitigated using reminiscence therapy. Switching from a paternalistic way of perceiving the patient as the object of an intervention, to a more interactive style of communication, involves obtaining feed-back through HRQOL instruments.

Disclosure of interest

COI: The presenting author was speaker for Bristol Myers Squibb and Servier, and participated in clinical research funded by Janssen Cilag, Astra Zeneca, Eli Lilly, Sanofi Aventis, Schering Plough, Organon, Bioline Rx, Forenap, Wyeth, Otsuka Pharmaceuticals, Dainippon Sumitomo.

Genetic counselling in patients with bipolar disorder–ethical challenges

Background

Genetic counselling in psychiatric patients is almost always a challenge on multiple levels of communication, because the mental health specialist is situated between the need to validate the freedom of procreation, and the duty to inform patients about the risk of transmitting their disease to off-springs. Bipolar disorder (BPD) is reputed to be one of the most heritable psychiatric disorder, a factor that complicate even more the ethical situation.

Objectives

To assess how psychiatrists and psychologists conducted genetic counseling for patients with BPD and the challenges that mental health professionals consider important when they need to make this type of counseling.

Methods

Standardized interviewing of 15 psychiatrists and psychologists who experienced during their clinical practice aspects of genetic counseling in patients with BPD.

Results

The most commonly reported problems related to the genetic counseling in bipolar patients were: lack of reliable data on family history (53.3%), amplification of patient stigmatization (46.6%), controversies in the literature on the assessment of the disease risk (40%), difficulties in maintaining a nondirective attitude (33.3%), lack of genetic counseling follow-up (33.3%), disproportionate interest from the partner without mental disorder, when compared to patients, in terms of aspects of genetic counseling (26.6%), alteration of the therapeutic relationship and patients interest in treatment (26.6%).

Conclusions

Genetic counseling is a challenge for mental health professionals, who must cope with the lack of reliable data on the pathogenesis of BPD, negative reactions from the patients’ partners, patient disinterest or hostility and possible negative effects on the therapeutic relationship.

Disclosure of interest

The presenting author was speaker for Astra Zeneca, Bristol Myers Squibb, CSC Pharmaceuticals, Eli Lilly, Janssen Cilag, Lundbeck, Organon, Pfizer, Servier, Sanofi Aventis and participated in clinical research funded by Janssen Cilag, Astra Zeneca, Eli Lilly, Sanofi Aventis, Schering Plough, Organon, Bioline Rx, Forenap, Wyeth, Otsuka Pharmaceuticals, Dainippon Sumitomo, Servier.

Between creativity and death: Abstract expressionists and alcohol use disorders

American Expressionists were a group of American artists who valued free expression of unconscious elements, combining emotional intense expressions with anti-figurative abstract style. Their main place of creative debates was Cedar Tavern in New York City, considered by art critics an important incubator of the Abstract Expressionism. Jackson Pollock, one of the most prominent figures of this movement, suspected of having bipolar disorder, abused alcohol during long periods of his life, for which he even underwent psychotherapy. Unfortunately, he died in a car accident while driving under influence, after decades of innovative work, during which he created a new painting method and produced compositions which are nowadays between the most expensive works of art. Mark Rothko also had periods of heavy drinking, and finally he died by cutting his arms with a razor. He is considered a genius, who created a completely new perspective over painting, and his works are also between the most expensive paintings in the world. Willem de Kooning was affected by alcoholism since his early years, and developed dementia, at least partially induced by abusive drinking. Although affected by neurocognitive disorder, he continued to produce amazingly creative paintings until his final years and in 2016 one of his works obtained the record for the most expensive painting ever sold. Using alcohol as a tool for increasing creativity risks to expose the creator to severe disorders or even death, the subject walking on a narrow line between sublimation of unconscious impulses and tragic resignation before them.

Disclosure of interest

The presenting author was speaker for Bristol Myers Squibb and Servier, and participated in clinical research funded by Janssen Cilag, Astra Zeneca, Eli Lilly, Sanofi Aventis, Schering Plough, Organon, Bioline Rx, Forenap, Wyeth, Otsuka Pharmaceuticals, Dainippon Sumitomo.

Quetiapine XR as Add-on to Antidepressants in Treatment-resistant Late-life Major Depression

Objective

To assess the efficacy and tolerability of quetiapine as add-on to antidepressant agents in treatment-resistant late-life major depression.

Methods

A group of 15 patients, 8 male and 7 female, mean age 68.2, evaluated in our department for clinical symptoms that made possible a DSM 5 diagnosis of major depressive disorder, were initiated on quetiapine XR, flexible daily dose 50–300 mg QD. All patients were on treatment with an antidepressant–either a selective serotonin reuptake inhibitor (SSRI) (n = 10), or venlafaxine (n = 5)–for at least 6 weeks and presented no improvement during current treatment administered at therapeutic doses. Patients were assessed using Montgomery Asberg Depression Rating Scale (MADRS), Clinical Global Impression–Severity (CGI-S), Global Assessment of Functioning (GAF), and Columbia Suicide Severity Rating Scale (C-SSRS) every 4 weeks for 3 months.

Results

After 12 weeks, patients had a mean improvement in MADRS score of 45.7 ± 2.3%, with a final mean MADRS score of 13.5 (P < 0.01). No variations were registered depending on the specific SSRI or venlafaxine concomitant treatment. Quetiapine XR mean daily dose administered during the study was 125 mg. C-SSRS didn’t registered significant variations in suicidal ideation or behavior throughout the trial. Overall GAF score increased with 22.1 points, and CGI-S decreased with a mean of 1.5 points at week 12 (P < 0.01). Tolerability of add-on quetiapine was very good, no serious adverse event being reported.

Conclusions

Quetiapine was efficient and well tolerated in late-life resistant major depression, as add-on to SSRIs or venlafaxine, during the 12 weeks of the trial.

A MSFD complementary approach for the assessment of pressures, knowledge and data gaps in Southern European Seas: The PERSEUS experience

PERSEUS project aims to identify the most relevant pressures exerted on the ecosystems of the Southern European Seas (SES), highlighting knowledge and data gaps that endanger the achievement of SES Good Environmental Status (GES) as mandated by the Marine Strategy Framework Directive (MSFD). A complementary approach has been adopted, by a meta-analysis of existing literature on pressure/impact/knowledge gaps summarized in tables related to the MSFD descriptors, discriminating open waters from coastal areas. A comparative assessment of the Initial Assessments (IAs) for five SES countries has been also independently performed. The comparison between meta-analysis results and IAs shows similarities for coastal areas only. Major knowledge gaps have been detected for the biodiversity, marine food web, marine litter and underwater noise descriptors. The meta-analysis also allowed the identification of additional research themes targeting research topics that are requested to the achievement of GES.

The surgical treatment of chronic pancreatitis: a clinical series of 17 cases

INTRODUCTION

Despite the fact that in the last few years, new invasive non-surgical therapies were introduced, surgical treatment of chronic pancreatitis still plays an important part.The aim of the study is to evaluate pain remission and quality of life after surgical approach.

MATERIAL AND METHOD

We present 17 cases of chronic pancreatitis that were operated between 2007-2011. Surgical treatment was decided for after the failure of pain control therapy (14 cases)and by the suspicion of cancer in the head of the pancreas (3 cases). Imaging data for all the cases, CT-CE and ERCP, guided us in choosing the right therapy. Surgical techniques performed were pancreatico-jejunostomy (PJ) in eleven cases and duodenopancreatectomy(DP) in six cases.

RESULTS

Good pain control was achieved in 10 patients: 6-PJ and 4-DP. Moderate results were observed in 4 cases: 2-PJ and 2-DP. In 3 patients symptoms remained the same.

CONCLUSION

There is no consensus over the surgical treatment in chronic pancreatitis. Surgical approach, strongly motivated and personalised for each patient is followed by good results. It is possible that in the future, limited resections become the therapy of choice, replacing classic ones.

CML patients in the molecular era - report of five years experience of diagnosis and treatment in a single center

Chronic myeloid leukemia (CML) represents about 15% of all leukemia cases. Although the incidence of the disease is rather low, the therapeutic progress of the last decade has dramatically changed the evolution of this disease, whose survival considerably increased and in whom we now speak even about cure. The success of the therapy is strongly connected to the precocity of the diagnosis and molecular targeted therapy that implies a close monitoring of the patient. The specific molecular assay, that developed a lot in the last years, became an important tool in the management of these patients, providing the possibility of efficient changing in therapy. The purpose of our study was to identify the characteristics of our CML patients in terms of clinical and biological behavior. We analyzed 21 patients diagnosed between October 2007 and December 2010 and compared the data with a historical group of patients, also diagnosed in our department between March 2005 and September 2007. We found a better outcome and overall survival in the study group, due to improved diagnosis and monitoring techniques as well as to better access to therapy.

Severe acute pancreatitis - a serious complication of leptospirosis

Leptospirosis is a disease caused by pathogenic spirochetes of genus Leptospira. It is considered the most common zoonosis in the world. Acute pancreatitis is a rare complication of leptospirosis (25%). We present the case of a 34-year-old male patient with severe leptospirosis complicated with acute renal failure. After 9 days from the onset of the disease, the patient developed acute necrotizing pancreatitis, infected from the very beginning, associated with multiple organ failure, septic shock and severe anemia. The diagnosis was clinically and biologically stated and confirmed by CT-scan. The patient underwent surgery for infected necrotizing acute pancreatitis of the head and neck of the pancreas, with left retroperitoneal expansion down to the left iliac fossa. We performed a necrosectomy with the evacuation of the tisular debris, multiple drainage of the peritoneal cavity, followed by an open abdomen with synthetic mesh. The postoperative evolution was difficult but constantly progressive. Two reinterventions were necessary. The patient left the hospital in good condition after 75 days postoperatively.

CD 200 - A useful marker in chronic B lymphoprolipherative disorders

Background: The diagnosis and management of the patients with chronic lymphoproliferative diseases have become dependent on immunological criteria. Flow cytometry immunophenotyping is used for rapid and specific diagnosis but there are cases when we are not facing a typical immunophenotype, so there is a constant need to find new markers and new combinations of markers that would allow the improvement and the development of our diagnosis. Aim: Our aim was to evaluate CD 200 expression in different B-cell chronic lymphoproliferative disorders. CD200 is a membrane glycoprotein belonging to the immunoglobulin superfamily and the over-expression of CD200 has been reported in a number of malignancies, including CLL, as well as on cancer stem cells. Methods: We analyzed the CD200 expression in 122 patients diagnosed with chronic lymphoproliferative disorders (100 patients with CLL, 10 patients with splenic marginal zone lymphoma (SMZL), 10 patients with MCL and 2 patients with hairy cell leukemia), in the Department of Hematology of the University Emergency Hospital, Bucharest. We performed immunophenotypical analysis of peripheral blood and bone marrow aspiration on BD FACS Calibur flowcytometer. Results: CD200 was brightly expressed in all 100 CLL patients (100%). In SMZL patients, CD200 was dim positive (40%-60%), in patients with HCL. CD200 was also bright positive (96% and 97%) and in patients with MCL CD200 was negative (1-10%); CD 200 was significantly higher in CLL patients compared with other B-cell chronic lymphoproliferative disorders. We found 14 patients with CD19, CD5 positive population and CD23- , but with high expression of CD 200. Cyclin D1 was negative on bone marrow biopsy in 13/14 of these patients. (1/14 patients were without bone marrow involvement); Conclusions: CD200 has a great impact in diagnosing B- chronic lymphoproliferative disorders, especially when we want to determine the origin of a CD19, CD5 positive population and distinguish between CLL and MCL. CD 23 is a reliable marker in those cases, but, as we showed, CD23 might have a lower specificity than CD200 for CLL. We added CD200 in our panels in order to diagnose chronic lymphoproliferative disorders, not to replace CD 23, but to improve and save time in our diagnostic process. The high expression of CD200 in CLL and HCL could open the option for new- targeted therapy (anti-CD200).

Spectrum, antibiotic susceptibility and virulence factors of bacterial infections complicating severe acute pancreatitis

Secondary infection of pancreatic necrotic tissue and peripancreatic fluid is a serious complication of acute pancreatitis resulting in significant morbidity and mortality. The aim of this study was to find out the spectrum of bacterial infections, their antibiotic susceptibility patterns and virulence features in patients with severe acute pancreatitis (SAP). A total of 19 patients with acute pancreatitis were consecutively selected from 153 clinical cases of septic abdominal surgical emergencies (age 29-80, 12 males, 7 females) admitted during 2009-2011, in the First Surgical Clinic of the University Emergency Hospital of Bucharest. All 19 SAP cases were submitted to pre-operatory antibiotic empiric treatment. Ten cases were culture negative, in spite of the positive microscopy registered in eight of them. The rest of nine cases were culture positive, 17 different bacterial strains being isolated and identified as belonging to eight aerobic and four anaerobic species. Polymicrobial infection was seen in six patients and the etiology was dominated by Gram-negative bacilli, followed by gut anaerobic bacteria, attesting their colonic origin. The susceptibility testing of the isolated strains confirmed in vitro in all cases the efficiency of the antibiotics that had been used in the empiric pre-operatory treatment. Out of 19 cases submitted to pre-operatory empiric treatment, 14 proved a favorable evolution and five a lethal outcome. The host depending factors (sepsis and other co-morbidities), as well as the aggressivity of the isolated microbial strains (mediated by the presence of different factors implicated in adherence, toxicity and invasion) were found to contribute to the unfavorable, even lethal clinical outcome of SAP cases. In spite of all theoretical controversies, the antibiotic therapy remains at present a very important therapeutic mean for the SAP treatment; although it cannot solve the septic necrotizing pancreatitis in 100% of cases, however, associated with the surgery and all other medical means of intensive therapy, the antibiotic treatment can influence the clinical evolution to the benefit and recovery of patients in a significant number of cases.

[Emergency pancreatoduodenectomy for severe iatrogenic duodenal injury--case report]

We present the case of a male patient admitted for high flow biliary fistula (> 2000 ml/24h) as a consequence of a prior right nephrectomy by lumbar approach. The patient was operated after the failure of the medical conservative treatment and continous declining medical status. We noted the complete absence of the gastric antrum, duodenum I and II with the intraperitomeal direct display and opening of the Vater papilla, witch was difficult to identify unless common bile duct (CBD) was catheterized by supraduodenal choledocotomy. We performed emergency pancreatoduodenectomy with a good postoperative outcome , excepting a residual postnephrectomy abscess, witch was consequently evacuated and drained. The patient left the clinic 28 days postoperatively. The two years after follow up notes that the patient is in a good condition

Therapeutic efficacy of duloxetine versus selective serotonin reuptake inhibitors in irritable bowel syndrome

Introduction

Selective serotonin reuptake inhibitors (SSRIs) are frequently used for irritable bowel syndrome, while duloxetine was evaluated in other similar psycho-somatic syndromes.

Objective

This prospective, single-blind trial intends to compare the efficacy of SSRIs and duloxetine in the treatment of irritable bowel syndrome.

Methods

A group of 22 patients, 15 female and 7 male, mean age 50.2, diagnosed with irritable bowel syndrome according to the Rome II Diagnostic Criteria (1992) were treated with either an SSRI (escitalopram 20 mg/day, n = 6 or fluoxetine 40 mg/day, n = 6) or duloxetine (90 mg/day, n = 10). Patients were evaluated initially and every 4 weeks, for 6 months, using Hamilton Anxiety Rating Scale (HAMA), Hamilton Depression Rating Scale 17 items version (HAMD), Clinical Global Impressions -Severity/Improvement (CGI-I/S) and a 7-points Likert scale (LS) for self-evaluated severity.

Results

Duloxetine improved anxiety and depressive symptoms, as reflected by the significant decrease of HAMA (−17.6 points, p < 0.05) and HAMD scores (−18.2 points, p < 0.05) at week 12. SSRIs also reduced the affective symptoms, significantly to baseline (p < 0.05), but less than duloxetine (−14.3, −15.2) at week 12, with no significant difference at week 24 (p = 0.120). The CGI-I results paralleled the decrease of HAMD and HAMA, while the LS evaluation of gastrointestinal symptoms improved similarly in both groups, with no significant difference (p = 0.09).

Conclusion

Duloxetine is an efficient agent in the treatment of irritable bowel syndrome, because it decreases the mood symptoms more rapidly than SSRIs. The overall efficacy of SSRIs and duloxetine at 6 months is nevertheless similar.

Cognitive behavioral therapy focused upon communicational skills enhancement in anorexia nervosa- a case series

Introduction

Anorexia nervosa (AN) has been approached from multiple medical, social and psychological perspectives, but it still stands as a major challenge for the clinician, due to its resistance to treatment, low therapeutic compliance and severe complications.

Objective

To asses the efficacy of an interpersonal focused cognitive-behavioral therapy (CBT) in patients diagnosed with AN.

Methods

We enrolled in 12 weeks, 3 sessions a week, CBT program a number of three patients, females, admitted successively in our departments, diagnosed with AN, who didn’t have previously any kind of psychotherapy. The first patient was 22, diagnosed with AN-restricting type, had a BMI of 14.5 and a score on Eating Attitudes Test (EAT) of 34. The second patient was 19, presented AN-binge eating-purging, had a BMI of 14 and an EAT score of 35. The third patient was 25, had also AN-binge eating-purging, a BMI of 15 and an EAT score of 32.

Results

The first two patients responded well to the CBT program, but the first signs of recovery (EAT decreases of at least 5 points and increases of at least 1 unit on BMI) appeared after 10 weeks (15 sessions). The third patient discontinued rather fast the psychological treatment. The follow up (12 weeks after endpoint) showed relapse in one CBT-treated patient and a severe status of the patient that discontinued psychotherapy.

Conclusion

The CBT focused on communicational skills enhancement is beneficial in patients with AN, but responses appear rather late and need to be boosted by frequent follow-up sessions.

Incidence of axis I and axis II dual diagnosis in hospitalised patients with somatization disorder

Introduction

Somatization disorder is frequently associated in epidemiologic trials with depressive, anxiety, other somatoform or substance related disorders, as well as with personality disorders. An examination of psychiatric comorbidity in patients diagnosed with somatization disorder is strongly advised due to the impact of these associated conditions over the prognosis and treatment.

Objective

To establish the incidence of psychiatric dual diagnosis in hospitalized patients with somatization disorder.

Methods

A group of 37 patients, 22 female and 15 male, mean age 45.9, were evaluated using Structured Clinical Interview for DSM Axis I (SCID-I) and Axis II (SCID-II) disorders at the admission in our department for a diagnosis of somatization disorder. All patients included in this trial were known with somatization disorder for at least one year prior to this admission.

Results

Patients diagnosed with somatization disorder presented mostly depressive disorders (46%, n = 17), anxiety disorders (37.8%, n = 14), substance related disorders (16.2%, n = 6) and personality disorders (67.5%, n = 25). A more detailed analysis on axis I established major depressive disorder as the most frequent diagnosis (37.8%, n = 14), followed by panic disorder (27%, n = 10) and alcohol dependence (13.5%, n = 5), while on axis II the histrionic (21.6%, n = 8) and obsessive-compulsive (19%, n = 7) personality disorders were the most frequently associated conditions. A number of 21 patients presented at least three axis I and/or II simultaneous diagnosis (64.8%).

Conclusion

The most frequently comorbidities in somatization disorder are major depressive disorder and panic disorder on axis I, as well as histrionic and obsessive-compulsive personality disorder on axis II.

Valproate and cognitive therapy combined treatment efficacy in pathological gambling

Introduction

Valproate is used in psychiatry as a mood-stabilizer and has efficacy in controlling impulsivity, therefore it seems to be a useful pharmacologic agent in pathologic gambling.

Objective

To assess the efficacy of valproate in the treatment of pathologic gambling.

Methods

A group of 13 patients, 9 male and 4 female, mean age 32.6, diagnosed with pathologic gambling, according to the DSM-IV-TR criteria, received treatment with flexible dose of valproate (600–1400 mg/day, mean dose 850 mg/day) and 2 times/week cognitive therapy sessions. Patients with other axis I and II conditions were excluded. Also, none of these patients received valproate or structured cognitive therapy prior to this trial. Patients were monitored for 3 months using monthly administered Gambling Symptoms Assessment Scale (G-SAS), Clinical Global Impressions (CGI) and 10 points self-evaluated Visual Analogue Scale (VAS).

Results

Valproate was associated with a mean decrease of 10.5 points on G-SAS at week 12, compared to baseline (p < 0.05), while the CGI decreased with only 1.3 points (p = 0.122) and the VAS improved with 2.3 points (p < 0.05). The combined treatment was associated with good tolerability profile, since no drop-out was recorded in the study group due to side events and only 7 reports of mild and medium adverse events were recorded.

Conclusion

Valproate treatment associated with cognitive therapy could be a useful strategy in the management of pathologic gambling. Valproate's tolerability profile is good and the cognitive therapy offer an opportunity to ventilate the negative automatic thoughts, emotional distress and low impulse control strategies.

Bacteriological aspects implicated in abdominal surgical emergencies

The purpose of the present study was to establish the microbial etiology of abdominal surgical emergencies as well as the relationship between the bacterial etiology and the virulence factors produced by the respective isolated strains. 110 bacterial strains were isolated from 100 randomized clinical cases, operated during 2009-2010 in the First Surgical Clinic of the University Hospital of Bucharest. The clinical cases (sex ratio 52 M/48F aged between 22-85 years old) were classified into three risk groups, as related to their severity. The isolated strains were characterized by cultural, microscopic and biochemical methods. After identification, the bacterial strains were investigated for their virulence potential (adherence to abiotic surface and production of soluble virulence factors).

RESULTS

The specimens were collected from different clinical pathologies: diffuse acute peritonitis, biliary duct infections, severe acute pancreatitis followed by septic processes etc. The 110 bacterial (72 aerobic and 38 anaerobic) strains were isolated only in 70 out of 100 cases. Out of these 70 cases, in 45 already submitted to pre-operatory empiric broad spectrum antibiotic therapy, there were isolated 74 strains, whereas in 25 cases without any treatment, there were isolated 36 strains. The etiology was either mono-specific or multi-specific (aerobic-anaerobic associations, especially in old persons). Out of the 30 negative culture cases, 16 were already submitted to pre-operatory parenteral empiric antibiotic therapy at the moment of specimen collection. The aerobic etiology was dominated by Enterobacteriaceae. The most frequent anaerobic species belonged to Clostridium, Peptococcus and Bacteroides genera. It is to be mentioned that the isolation of Bifidobacterium and Veillonella spp. in 11 (10%) severe cases of the studied abdominal surgical emergencies is pleading for the fact that in certain conditions, bacteria belonging usually to commensal gut flora can turn to pathogenic becoming responsive for life-threatening cases. All aerobic and anaerobic strains exhibited some of the following virulence factors: mucinase, esculinase, pore-forming toxins (lecithinase), proteolytic enzymes, adherence ability (slime factor). The presence of these virulence factors (VF) could explain the severity of the clinical aspects.

CONCLUSIONS

The bacterial etiology of the abdominal surgical emergencies exhibited a very large spectrum, the highest number of strains being of endogenous origin (Enterobacteriaceae and anaerobic strains). It was demonstrated that the isolated strains produced (cell associated and soluble) VF proving in this way their role as important virulence sources in the hospital environment and explaining the large diversity and severity of the clinical abdominal pathology. The results of the present study are also pleading for periodical readjustments of the pre-operatory empiric antibiotic therapy.

[Duodenal carcinoid]

Carcinoid tumors of the duodenum are extremely rare. We present two cases (observation) of duodenal carcinoid tumors. The main clinical manifestation in both cases was upper GI tract hemorrhage associated to severe anemia.The tumors were high dimension (2.5 cm and 6.5 cm respectively) and were discovered by upper GI endoscopy. First observation presented a lymph node metastasis and the second one a massive invasion of the pancreas. In both cases the diagnosis was precised only postoperatively, through histological and immunohistochemical analisys. In the first observation we performed local transduodenal resection and in the second one cephalic duodenopancreatectomy. After six months we had a reintervention at the first case for a retroduodenal carcinoid tumoral reoccurrence--extirpation completed with total gastrectomy for neuroendocrine carcinoma. Despite the locoregional aspect of advanced evolution of the disease, the long-term evolution of the patient was satisfactory. Both patients are alive 42 months respectively 15 months after the operation. Carcinoid tumors of the duodenum are indolent and their impact on survival is uncertain.

Clinical and therapeutical importance of HBV genotyping in Romania

In a country with a high prevalence (16%) of chronic serum HBsAg carriers like Romania there is a special interest in the diagnosis, epidemiology, clinics, pathology and treatment of HBV infection The idea of HBV genotyping arose from the need of understanding the complex interactions between virus and host. The purpose of this article is to present a study which aimed to identify the circulating HBV genotypes in Romania. correlate them with the clinical outcome and by HBV genotyping, to make a selection of patients for the most appropriate antiviral therapy. 130 patients were selected from different areas of the spectrum of HBV infection in which a quantitative determination of HBV-DNA was performed. HBV A genotype is associated with the inactive carrier status: a symptomatic HBV-HDV was identified in the double infection. The HBV D genotype has the most common HBV genotype (66%) and is associated with active viral infection and hepatocellular carcinoma. Long term HBV chronic infection revealed a mixture of A and D genotypes in most cases. For a proper selection of patient for the antiviral therapy, we should mandatorily genotype the HBV virus before the onset of treatment and all genotyping data must be correlated with liver biopsy assessments.

[Short bowel syndrome due to a severe complication related to Meckel's diverticulum]

A 17 years old patient, admitted and operated in emergency with acute diffuse peritonitis which had been had the onset four days before. During surgery, a huge volvulus of the small intestine is revealed due to an adherence between Meckel's diverticulum and mesentery, with large intestinal necrosis. Extended enterectomy is performed with jejunostomy. The postoperative outcome is difficult due to severe metabolic insufficiencies which are managed by intensive therapy measures. The patient is readmitted to surgery and an anastomosis between 30 cm jejunum and 20 cm ileum is performed. Then the outcome is good, with digestive function recovery and weight gain. Unfortunately, the patient died one year after surgery, due to severe haematological and neurological disorders caused by the mal-absorbtion syndrome.