A time-driven, activity-based costing methodology for determining the costs of red blood cell transfusion in patients with beta thalassaemia major

OBJECTIVES

To describe the methodology to estimate the total cost of administration of a single unit of red blood cells (RBC) in adults with beta thalassaemia major in an Australian specialist haemoglobinopathy centre.

BACKGROUND

Beta thalassaemia major is a genetic disorder of haemoglobin associated with multiple end-organ complications and typically requiring lifelong RBC transfusion therapy. New therapeutic agents are becoming available based on advances in understanding of the disorder and its consequences. Assessment of the true total cost of transfusion, incorporating both product and activity costs, is required in order to evaluate the benefits and costs of these new therapies.

METHODS

We describe the bottom-up, time-driven, activity-based costing methodology used to develop process maps to provide a step-by-step outline of the entire transfusion pathway. Detailed flowcharts for each process are described. Direct observations and timing of the process maps document all activities, resources, staff, equipment and consumables in detail. The analysis will include costs associated with performing these processes, including resources and consumables. Sensitivity analyses will be performed to determine the impact of different staffing levels, timings and probabilities associated with performing different tasks.

RESULTS

Thirty-one process maps have been developed, with over 600 individual activities requiring multiple timings. These will be used for future detailed cost analyses.

CONCLUSIONS

Detailed process maps using bottom-up, time-driven, activity-based costing for determining the cost of RBC transfusion in thalassaemia major have been developed. These could be adapted for wider use to understand and compare the costs and complexities of transfusion in other settings.

The wake-promoting drug modafinil stimulates specific hypothalamic circuits to promote adaptive stress responses in an animal model of PTSD

Pharmacotherapeutic intervention during traumatic memory consolidation has been suggested to alleviate or even prevent the development of posttraumatic stress disorder (PTSD). We recently reported that, in a controlled, prospective animal model, depriving rats of sleep following stress exposure prevents the development of a PTSD-like phenotype. Here, we report that administering the wake-promoting drug modafinil to rats in the aftermath of a stressogenic experience has a similar prophylactic effect, as it significantly reduces the prevalence of PTSD-like phenotype. Moreover, we show that the therapeutic value of modafinil appears to stem from its ability to stimulate a specific circuit within the hypothalamus, which ties together the neuropeptide Y, the orexin system and the HPA axis, to promote adaptive stress responses. The study not only confirms the value of sleep prevention and identifies the mechanism of action of a potential prophylactic treatment after traumatic exposure, but also contributes to understanding mechanisms underlying the shift towards adaptive behavioral response.

Microinfusion of a corticotrophin-releasing hormone receptor 1 antisense oligodeoxynucleotide into the dorsal hippocampus attenuates stress responses at specific times after stress exposure

Corticotrophin-releasing hormone (CRH) plays a key role in the adjustment of neuroendocrine and behavioural adaptations to stress. Dysregulation in CRH systems has been implicated in a variety of stress-related psychiatric disorders such as post-traumatic stress disorder (PTSD). The present study examined the relationship between stress-induced PTSD-like behavioural response patterns and levels of CRH, CRH receptor (CHR-R)1 and phosphorylated extracellular signal-regulated kinase (pERK1/2) in the rat hippocampus subregions. The effects of pharmacological manipulations on behavioural, physiological and response patterns of brain-derived neurotrophic factor (BDNF) and pERK1/2 expression using a CRH receptor (CRH-R)1-antisense oligodeoxynucleotide (CRH-R1-ASODN) were evaluated. CRH and CRH-R1 mRNA and pERK1/2 protein levels were assessed in the hippocampus subregions 7 days after exposure to predator scent stress (PSS). The effects of CRH-ASODN versus CRH-Scrambled-ODN microinfusion to the dorsal hippocampus either 1 h or 48 h post-exposure on behavioural tests (elevated plus maze and acoustic startle response) were evaluated 7 days later, 14 days after PSS exposure. Localised brain expression of BDNF and ERK1/2 was subsequently assessed. All data were analysed in relation to individual behaviour patterns. A distinct pattern associated with extreme behavioural response (EBR) was revealed in the bioassay of behavioural study subjects, classified according to their individual patterns of behavioural response at 7 days. These EBR individuals displayed significantly higher CRH and CRH-R1 mRNA levels in the CA1 and CA3 areas, mediating down-regulation of pERK1/2 protein levels. Microinfusion of a CRH-R1-ASODN into the dorsal hippocampus 48 h after stress exposure, although not immediately after exposure (1 h), significantly reduced behavioural disruption and was associated with concomitant up-regulation of BDNF and pERK1/2 protein levels compared to CRH-R1-Scrambled -ODN controls. CRH/CRH-R1 is actively involved in the neurobiological response to predator scent stress processes and thus warrants further study as a potential therapeutic avenue for the treatment of anxiety-related disorders.

[Implementing mindfulness based therapies as part of the comprehensive treatments in the Beer Sheba Mental Health Center]

In recent years, there has been a growing interest and popularity in mindfulness-based therapies. Theories and practices that, until lately, have been considered esoteric and practiced in private by only a few therapists, are now progressively becoming part of mainstream establishment therapies and are gaining greater interest and recognition. The therapies can be carried out either in an individual or in a group setting and most include formal mindful sitting practice, developing awareness, mindful movement, psycho-education and often include a cognitive component. Furthermore, these therapies are becoming increasingly validated by widespread research pointing to promising results in the treatment of various cLinicaL disorders including anxiety, depression and relapse prevention, personality disorders, attention disorders and psychotic disorders, in both an in-patient and out-patient setting. The aim of this overview is to describe the deveLopment that has taken place in the fast decades within the field of mindfulness-based therapies and to present the most up-to-date research in this area: to show which therapeutic interventions have been proven to be effective; the background of the ideas; and the relevance of these approaches to the mental health system in Israel.

Hippocampal microinfusion of oxytocin attenuates the behavioural response to stress by means of dynamic interplay with the glucocorticoid-catecholamine responses

The neurohypophysial hormone oxytocin acts as a central nervous system neurotransmitter/neuromodulator. We evaluated the effects of oxytocin on behavioural responses to stress, as well as associated biophysiological responses, in a controlled, prospective animal model. The long-term effects of exogenous oxytocin microinjected to the hippocampus of male rats were assessed. Animals were exposed to predator scent stress and treated 1 h or 7 days later with oxytocin or vehicle. Behaviours were assessed with the elevated plus-maze and acoustic startle response tests, 7 days after microinjection and freezing behaviour upon exposure to a trauma-related cue on day 8. These data served for classification into behavioural response groups. Trauma cue response, circulating corticosterone and oxytocin, hippocampal expression of glucocorticoid and mineralocorticoid receptors, and oxytocin receptor mRNA levels were assessed. The interplay between oxytocin, corticosterone and norepinephrine was assessed. Microinfusion of oxytocin both immediately after predator scent stress exposure or 7 days later, after exposure to trauma cue significantly reduced the prevalence rates of extreme responders and reduced trauma cue freezing responses. Post-exposure treatment with oxytocin significantly corrected the corticosterone stress response, decreased glucocorticoid receptor expression and increased mineralocorticoid receptor expression in the hippocampus compared to vehicle treatment. High-dose corticosterone administration together with norepinephrine caused release of plasma oxytocin and hippocampal oxytocin receptor. Oxytocin is actively involved in the neurobiological response to predator scent stress processes and thus warrants further study as a potential therapeutic avenue for the treatment of anxiety-related disorders.

An association between stress-induced disruption of the hypothalamic-pituitary-adrenal axis and disordered glucose metabolism in an animal model of post-traumatic stress disorder

Retrospective clinical reports suggesting that traumatic stress populations display an increased propensity for glucose metabolism disorders were examined in a controlled prospective animal model. Stress-induced behavioural and hypothalamic-pituitary-adrenal (HPA) axis response patterns were correlated to central and peripheral parameters of glucose metabolism and signalling, and to body measurements in Sprague-Dawley rats exposed to predator scent stress. Forty days post-exposure, fasting blood glucose and insulin levels, oral glucose tolerance test, body weight and white adipose tissue mass, systemic corticosterone levels and brain expression of insulin receptor (IR) and insulin-sensitive glucose transporter 4 (GLUT4) protein levels were evaluated. In a second experiment inbred strains with hyper- (Fischer) and hypo- (Lewis) reactive HPA axes were employed to assess the association of metabolic data with behavioural phenomenology versus HPA axis response profile. For data analysis, animals were classified according to their individual behavioural response patterns (assessed at day 7) into extreme, partial and minimal response groups. The exposed Sprague-Dawley rats fulfilling criteria for extreme behavioural response (EBR) (20.55%) also exhibited significant increases in body weight, abdominal circumference and abdominal white adipose tissue mass; a hyperglycaemic oral glucose tolerance test; and fasting hyperglycaemia, hyperinsulinaemia and hypercorticosteronemia, whereas minimal responders (MBR) and control animals displayed no such disturbances. Hippocampal and hypothalamic expression of IR and GLUT4 protein were significantly lower in EBR than in MBR and control rats. The inbred strains showed no metabolic differences at baseline. Exposed Fischer rats displayed hyperglycaemia and hyperinsulinaemia, whereas Lewis rats did not. A significant protracted disorder of glucose metabolism was induced by exposure to a stress paradigm. This metabolic response was associated with the characteristic pattern of HPA axis (corticosterone) response, which underlies the behavioural response to stress.

Use of radiofrequency ablation in the treatment of malignant liver lesions

BACKGROUND/AIMS

The authors present their experience with the option of using radiofrequency ablation (RFA) in the treatment of malignant focal liver lesions.

METHODOLOGY

In a prospective study conducted in the period from 2002-2005, 60 patients were treated using RFA during a total of 72 sessions and treating 108 lesions of various size, number and localisation. The method of RFA was applied either percutaneously under computed tomography (CT) or ultrasonographic (USG) navigation (22 patients) or surgically--during opened laparotomy or laparoscopy (42 patients).

RESULTS

Median observation time was 12.7 months (with the range 3-36 months). Authors did not observe any serious complications after RFA treatment in the study population. Median time of local recurrence in the ablated lesion position was 13.5 months in the observed population, median time of metastatic progression in the residual liver parenchyma was 12 months, and overall median survival was 22 months. Percutaneous RFA application demonstrated significantly worse results when compared with surgical application in previously the mentioned parameters. Lesions larger than 3cm in diameter also showed statistically more frequent local recurrence.

CONCLUSIONS

RFA is appreciated as minimally invasive method of treatment for liver malignancies with promising perspectives of therapeutic effects.

[An unusual cause of the chronic ileus state--the absence of the intestinal wall muscularis layer]

In this study the authors describe a rare histological finding in the resected small intestine, which was a cause of continuous ileal difficulties in a young female patient, and which increased in their intensity and finally resulted in an acute state which had to be solved by an urgent surgical procedure. The situation was defined as "absence of the muscularis layer" of the intestinal wall by a pathologist. The pathologist also stated that he had never come across such a case, neither in our literature, nor in the foreign one and that the condition was diagnosed with difficulties when using a standard visualization examination methods.

[Implantations of venous ports--the latest advances]

A continuously growing spectrum of cytostatic preparations used to treat oncological patients, as well as a growing spectrum of indications to treat patients with disseminated or locally advanced findings even in the elderly patients, brings on a subject of long-term venous portae problems to solve. The venous port is a smart solution of this problem. The method minimalizes risks resulting from long-term canylations of the central venous system and, primarily, substantially improves comfort of patients. This argument takes in consideration not only periods between chemotherapy applications, but also administration of the cytostatic preparation itself. The following article summarizes long-term experience with port implantations in the MOU. It points out increasing rates of patients with implanted ports and highlights frequency rates of observed complications connected with both the port implantation and the port use.

[Sentinel node biopsy in colorectal carcinoma--pilot study]

BACKGROUND

Sentinel lymph node biopsy is a widely accepted method for staging melanoma and breast cancer in indicated cases. However, the use of the method in colorectal cancer is under clinical investigation. The aim of the pilot study was to introduce the technique into the surgical practice in colon carcinoma, to determine the feasibility and potential problems and to evaluate the first experience.

METHODS

Twenty patients with colon cancer underwent lymphatic mapping and sentinel node biopsy using blue dye, fluorescein or lymphoscintigraphy followed by standard surgical resection. The acquired sentinel nodes were investigated with both standard hematoxylin-eosin staining and immunohistochemical staining for cytokeratin.

RESULTS

Lymphatic mapping adequately identified at least one sentinel node (SN) intraoperatively or by a modified ex vivo technique in 20 patients (100%). The average number of SN was 1.5 (range 1-3), non-SN 13.6 (range 1-38) per patient. SN correctly predicted the regional lymphatic basin status in 14 cases (70%). The false negative rate was 40%. No patient has been upstaged on the basis of immunohistochemical staining.

CONCLUSIONS

Lymphatic mapping and sentinel node biopsy in colon cancer is feasible and safe method with a high SN identification rate. The role and significance of sentinel node biopsy in colon cancer is not as clear as its role in other tumors and remains controversial. Further large prospective studies with standardized techniques are needed to evaluate the potential benefit of this new method.

[Segmental absence of intestinal musculature]

Herein we describe a case of 33-year old woman repeatedly affected by incomplete ileus. Primary segmental absence of lamina muscularis propria has been found in this patient. Histological examination revealed areas of small intestine with total absence of muscularis propria followed by areas of the intestinal wall characterised by normal histological structure. No necrosis, inflammation, and fibrosis supporting the secondary origin of this lesion was found.

Generalized cognitive impairment in male adolescents with schizotypal personality disorder

Schizotypal Personality Disorder (SPD) shares common genetic and biological substrates with schizophrenia, and patients with SPD have been reported to suffer both from specific cognitive impairments, and from a generalized cognitive dysfunction, similar to those found in schizophrenia. The aim of this cross-sectional, population-based study was to assess general cognitive functioning in adolescents with SPD. The Israeli Draft Board systematically assesses cognitive functioning and administers psychiatric screening in all 16-17-year-old males in the population. Of 341,511 males assessed, the cognitive test scores of adolescents with SPD (N = 326) were retrieved, and compared to the scores of adolescents diagnosed as suffering from schizophrenia (N = 901), and adolescents with no neurological or psychiatric diagnosis (controls, N = 293,820). Male adolescents with SPD or with schizophrenia scored lower on all measures compared to healthy individuals (effect sizes ranging from 0.6-0.88, all P < 0.001). The SPD patients scored significantly higher than the schizophrenia patients on the sub-tests of similarities and Ravens Progressive Matrices, tests that reflect abstract reasoning. On the sub-tests of arithmetic and instruction comprehension, tests that rely on concentration, SPD and schizophrenia patients' scores did not differ significantly from each other. These results might be interpreted to imply that a generalized cognitive impairment, in the presence of schizotypal personality traits and in the absence of psychosis, might be conceptualized as being the core of the schizotaxia syndrome. The greater impairment in abstract reasoning in the schizophrenia patients might be correlated with the psychotic symptoms that differentiate schizophrenia from SPD.

[Do we comply with the standard classification of staging in colorectal carcinoma after curative resection?]

BACKGROUND

Lymph node status is the most important prognostic and predictive factor in curatively resected colorectal cancer. According to TNM staging system, a minimum number of 12 regional lymph nodes is to be examined for the correct staging. In addition to the status of lymph nodes other important prognostic factors should be reported by the pathologist.

METHODS

A retrospective study was performed to analyze how many of regional lymph nodes were examined in colorectal cancer specimens in two hospitals (Czech Republic) during the last few years. Availability of other prognostic factors important for the management of the disease after surgery was always investigated.

RESULTS

In the hospital "A", the examination of lymph nodes were not sufficient in 43.8% of 121 cases analyzed, in the hospital "B", the number of examined lymph nodes was less than a minimum of 12 in all 162 cases. There were often no data available regarding to a histological examination of resection margins, grading and angioinvasion.

CONCLUSION

Reporting of the standard and most important prognostic factors in colorectal cancer was not sufficient in two selected hospitals and it may not be much better in others. It might have a deteriorating influence on the outcomes despite of successfully performed primary surgery. Search for the new prognostic and predictive factors, that would help us to stratify the patients for the optimal tailored therapy is surely needed, but the standard staging parameters, as are the lymph node involvement, resection margins, grading and angioinvasion, must not be forgotten as occurred to be in many cases of our study.

[Importance of peroperative identification and evaluation of sentinel biopsies in colorectal carcinoma--review]

The authors discuss the problem of sentinel biopsy from the aspect of its history, they mention its application in solid tumours, describe the technique and identification proper of sentinel lymph nodes and their own experience with the application of this method in colorectal carcinoma.

Association between nonpsychotic psychiatric diagnoses in adolescent males and subsequent onset of schizophrenia

BACKGROUND

Nonpsychotic psychiatric symptoms may occasionally herald the later development of schizophrenia. This study followed a population-based cohort of adolescents with nonpsychotic, non-major affective psychiatric disorders to ascertain future hospitalization for schizophrenia.

METHODS

Results of the medical and mental health assessments on 124 24416- to 17-year-old males screened by the Israeli draft board were cross-linked with the National Psychiatric Hospitalization case registry, which contains data on all psychiatric hospitalizations in the country, during a 4- to 8-year-long follow-up through age 25 years. In the cohort, 9365 adolescents were assigned a nonpsychotic, non-major affective diagnosis by the draft board.

RESULTS

After excluding 167 adolescents who were hospitalized before or up to 1 year after the draft board assessment, 1.03% of the adolescents assigned a nonpsychotic, non-major affective psychiatric diagnosis, compared with only 0.23% of the adolescents without any psychiatric diagnosis, were later hospitalized for schizophrenia. Of the patients with schizophrenia, 26.8%, compared with only 7.4% in the general population, had been assigned a nonpsychotic, non-major affective psychiatric diagnosis in adolescence (overall odds ratio [OR], 4.5; 95% confidence interval [CI], 3.6-5.6), ranging from OR, 21.5 (95% CI, 12.6-36.6) for schizophrenia spectrum personality disorders to OR, 3.6 (95% CI, 2.1-6.2) for neurosis.

CONCLUSION

These results reflect the relatively common finding of impaired functioning in patients later hospitalized for schizophrenia and the relatively low power of these disorders in predicting schizophrenia.

A review of psychological debriefing after extreme stress

Preventive intervention after exposure to traumatic events is a subject of increasing interest among mental health professionals. Psychological debriefing, which aims to reduce the risk of posttraumatic stress disorder and other psychopathological sequelae of traumatic experiences, is an example of such an intervention. The authors review the history of psychological debriefing and examine its efficacy. They conclude that psychological debriefing might be an effective intervention after extreme stress, although more support from controlled studies is required.

Rehospitalization rates of chronically ill schizophrenic patients discharged on a regimen of risperidone, olanzapine, or conventional antipsychotics

OBJECTIVE

The purpose of this study was to compare the rehospitalization rates of patients discharged from the hospital while being treated with risperidone, olanzapine, or conventional antipsychotics.

METHOD

By using Israel's National Psychiatric Hospitalization Case Registry, rehospitalization status was monitored for all patients with schizophrenia who were discharged from any inpatient psychiatric facility in Israel while taking risperidone (N=268) or olanzapine (N=313) between Jan. 1, 1998, and Dec. 31, 1998, and a group of patients discharged during that time who were treated with conventional antipsychotics (N=458). Time to readmission over the course of 2 years was measured by the product-limit (Kaplan-Meier) formula.

RESULTS

The readmission rate for patients discharged while taking conventional antipsychotics was higher than the rates for patients treated with either risperidone or olanzapine. At 24 months, 67% of the risperidone-treated patients and 69% of the olanzapine-treated patients remained in the community, as compared to 52% of the patients treated with conventional antipsychotics.

CONCLUSIONS

This study suggests that the rehospitalization rates of patients taking the novel antipsychotics risperidone and olanzapine are not different from each other and are considerably lower than the rate for patients treated with conventional antipsychotics. The results confirm findings of previous studies suggesting that the levels of overall effectiveness of risperidone and olanzapine are not very different and offers evidence that these drugs are more effective in preventing rehospitalization than conventional antipsychotic drugs.

Comparison of cost, dosage and clinical preference for risperidone and olanzapine

BACKGROUND

Because risperidone and olanzapine have similar efficacy and tolerability in the treatment of schizophrenia, costs, physician experience, and preference become relevant considerations in making treatment decisions. The purpose of this paper is to compare daily treatment costs of risperidone and olanzapine, and to examine psychiatrists' clinical preferences.

METHOD

Dosage information was obtained from a national Ministry of Health registry and a national survey of psychiatrists. In addition, psychiatrists' clinical preference of antipsychotic medication and dosage for patient subtypes were examined by the national survey.

RESULTS

Data from the registry and national survey estimated the mean daily dose of risperidone to be one-third that of olanzapine, irrespective of patient subtype. Taking into account drug costs and dosage requirements, the average daily retail price was US $6.85 for risperidone and US $13.60 for olanzapine. Psychiatrists preferred risperidone for first-episode psychosis and elderly psychosis, and olanzapine for patients sensitive to EPS. They rated the drugs equally effective on positive and negative symptoms, for chronic patients, for treatment-refractory patients and relapse prevention.

CONCLUSIONS

Risperidone has a substantial cost advantage over olanzapine, and was preferred by psychiatrists for more indications.

Administration of high-dose ketoconazole, an inhibitor of steroid synthesis, prevents posttraumatic anxiety in an animal model

Acute psychological stress is the presumed immediate cause of post-traumatic stress disorder (PTSD), and may also contribute to other anxiety disorders. Abnormal activity of the hypothalamic-pituitary-adrenal (HPA) axis has been tentatively implicated in some of the features of these disorders. Ketoconazole (KTCZ), an imidazole derivative, is a potent inhibitor of gonadal and adrenal steroidogenesis. The aim of this study was to explore the effects of KTCZ blockade of adrenal steroidogenesis, and consequent elevation of adreno-corticotropic hormone (ACTH), on a model of chronic post-traumatic anxiety in rats. Amelioration of anxious behaviors after reduction of corticosterone would suggest that corticosterone (and by implication cortisol in humans) is an important mediator of anxious symptoms: exacerbation of such behaviors would suggest that corticosterone elevations are only secondary, and possibly implicate corticotropin releasing hormone (CRH) and/or ACTH in the pathogenesis of anxious symptoms. We exposed rats for 10 min to cat scent, a prima facie valid model for acute psychological stress, with and without high dose KTCZ for 14 days. Treatment with KTCZ abolished the chronic behavioral effects of acute exposure to a cat scent. Lower levels of anxious behavior in KTCZ-treated and exposed rats were accompanied by lower plasma corticosterone, ACTH and prolactin (PRL) levels compared to untreated exposed rats. Results in this model implicate corticosterone, but not ACTH, in the pathogenesis of chronic anxiety following acute psychological stress.

Sexual dysfunction in male posttraumatic stress disorder patients

BACKGROUND

Previous studies have suggested that sexual dysfunction may be associated with posttraumatic stress disorder (PTSD). Yet such studies have not examined a full range of sexual functioning and have not accounted for the possibility that medication used to treat PTSD may contribute to sexual dysfunction.

OBJECTIVE

The current study compares the various components of sexual functioning among three groups of males: (1) untreated PTSD patients (n = 15), (2) PTSD patients currently treated with selective serotonin reuptake inhibitor (SSRI) agents (n = 27) and (3) a group of normal controls (n = 49).

METHODS

All participants completed an 18-item questionnaire for assessment of sexual functioning. Those with PTSD also completed the Impact of Events Scale and the Symptom Check List-90 (SCL-90).

RESULTS

Untreated and treated PTSD patients had significantly poorer sexual functioning in all domains (desire, arousal, orgasm, activity and satisfaction) as compared to normal controls. Those treated with SSRI had greater impairment in desire, arousal and frequency of sexual activity with a partner. There was a high correlation between sexual dysfunction among the PTSD group and the anger-hostility subscale of the SCL-90.

CONCLUSIONS

PTSD appears to be associated with pervasive sexual dysfunction that is exacerbated by treatment with SSRIs. PTSD may represent a heterogeneous syndrome. Patients with PTSD have a high rate of comorbid panic disorder, major depression and anxiety, and it could thus be argued that these comorbid disorders, rather than PTSD, accounted for the observed result. Future research aimed at understanding comorbidity and heterogeneity should help to illuminate the psychobiology of PTSD and eventually guide both medication and psychosocial treatments.

Gender differences in premorbid cognitive performance in a national cohort of schizophrenic patients

Despite significant research, there are still inconsistent findings regarding gender differences in cognitive performance in individuals already diagnosed with schizophrenia; studies have found that males suffering from schizophrenia are more, less or equally impaired compared with females. Gender differences in cognitive performance in individuals suffering from schizophrenia may be influenced by gender differences in premorbid cognitive performance; the very few and very small N studies published indicated that males have a poorer pre-morbid cognitive performance than females. This study examined the gender differences in premorbid cognition, utilizing cognitive assessments performed on female and male adolescents before induction into military service. The Israeli Draft Board Registry, which contains cognitive assessments equivalent to IQ scores on 16-18 year old Israeli adolescents, was linked with the Israeli National Psychiatric Hospitalization Case Registry, which records all psychiatric hospitalizations in the country. Scores on premorbid cognitive performance in schizophrenia were examined in 90 female-male case pairs matched for school attended as a proxy for socio-economic status. The mean age of first hospitalization was 20. 1+/-1.8 years of age for males and 19.6+/-1.8 years of age for females. A repeated-measures ANCOVA with age of first hospitalization and years of formal education as covariates, and controlling for gender differences in cognitive performance in healthy adolescents, revealed a significant difference in pre-morbid cognitive performance between males and females on all four cognitive measures [F(1,87)=8.07, P=0.006] with females scoring lower (worse) than males. In this national cohort, pre-morbid cognition was poorer in female, compared with male, adolescents who will suffer from schizophrenia in the future, a result consistent with some, but not all, similar studies. These results may be valid only for patients with first hospitalization around age 20. Hence, gender differences in premorbid cognition should be taken into account when assessing gender differences in cognition in schizophrenia.

Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks

Power spectral analysis (PSA) of heart rate variability (HRV) offers reliable assessment of cardiovascular autonomic responses, providing a 'window' onto the interaction of peripheral sympathetic and parasympathetic tone. Alterations in HRV are associated with various physiological and pathophysiological processes, and may contribute to morbidity and mortality. Previous studies of posttraumatic stress disorder (PTSD) found lower resting HRV in patients compared to controls, suggesting increased sympathetic and decreased parasympathetic tone. This article describes the analysis of HRV at rest and after psychological stress in panic disorder (PD) patients, in an enlarged sample of PTSD patients, and in healthy control subjects. Standardized heart rate (HR) analysis was carried out in 14 PTSD patients, 11 PD patients and 25 matched controls. ECG recordings were made while subjects were resting ('rest 1'), while recalling the trauma implicated in PTSD, or the circumstances of a severe panic attack, as appropriate ('recall'), and again while resting ('rest 2'). Controls were asked to recall a stressful life event during recall. While both patient groups had elevated HR and low frequency (LF) components of HRV at baseline (suggesting increased sympathetic activity), PTSD patients, unlike PD patients and controls, failed to respond to the recall stress with increases in HR and LF. HRV analysis demonstrates significant differences in autonomic regulation of PTSD and PD patients compared to each other and to control subjects. HRV analysis may augment biochemical studies of peripheral measures in these disorders.

[Adenocarcinoma of the appendix--case report]

The authors describe a case with a rare diagnosis of adenocarcinoma of the appendix in an adult female patient. The patient was indicated for surgical revision on account of acute appendicitis with a peroperative finding suspect of malignity of the vermiform appendix. A radical resection of the ileocoecal area was performed along with part of the ascendant colon and appropriate mesocolon as a primary operation. According to the postoperative histological evaluation of the resected portion the diagnosis of adenocarcinoma of the appendix was confirmed.

[Endoscopic stricturotomy--possible treatment of stenoses of colorectal anastomoses based on a stapling technique]

The authors present the possibility of using colonoscopic stricturotomy by means of a papillotomy commonly used for sphinctertomy of the Papilla Vateri in order to influence a stenosis of a colorectal anastomosis implemented by the stapler technique. The operation proper and postoperative course were without any complications.

Premorbid functioning in a national population of male twins discordant for psychoses

OBJECTIVE

The goal of the current study was to compare premorbid behavioral and cognitive functioning between co-twins discordant for psychotic disorder and between these pairs of twins and pairs of twins with no psychotic disorders.

METHOD

The authors linked data from the Israeli Draft Board Registry, which contains cognitive and behavioral assessments of all 16-17-year-old male Israeli twins, with data from the National Psychiatric Hospitalization Case Registry. Pairs of male twins who were healthy at the time of testing but discordant for psychoses later on were compared with one another and with pairs of healthy male twins.

RESULTS

The affected twins performed significantly worse than healthy twins on measures of individual autonomy, social functioning, and physical activity and nonsignificantly worse on measures of abstract reasoning. There were no significant differences in cognitive or behavioral scores between the co-twins who did or did not develop psychotic disorders.

CONCLUSIONS

The authors conclude that these findings underscore the familial nature of behavioral and cognitive deficits antecedent to psychoses.

[Late postoperative colonic stenosis caused by the biofragmentable anastomosis ring (BAR)]

The authors focused their attention on the prevalence of late postoperative stenoses of anastomoses following resection of the colon. In 42 patients the anastomosis was implemented by means of a Valtrac ring--i.e. by compressive biofragmentable seamless technique. Within an interval of 6 months after surgery the majority of these patients were subjected to colonoscopic examination with direct visualization of the intestinal anastomosis. The authors did not record any late postoperative stenoses of the BAR anastomosis of the colon. Moreover on colonoscopic examination in the majority of patients the original intestinal anastomosis was only difficult to detect.

Cognitive and behavioural functioning in men with schizophrenia both before and shortly after first admission to hospital. Cross-sectional analysis

BACKGROUND

The extent of premorbid changes associated with the onset of schizophrenia are debated.

AIMS

The study examined cognitive and behavioural functioning prior to, and after, first hospitalisation for schizophrenia.

METHOD

Data from the Israeli Draft Board Register of intelligence, social functioning and behaviour testing for all Israeli males aged 16-17 was linked with data from the National Psychiatric Hospitalisation Case Register. This identified 692 men who had been admitted to hospital for schizophrenia. Cases and non-cases matched on age and school were compared, as were cases aggregated by the time that had elapsed between testing and first admission to hospital.

RESULTS

Cases performed worse than non-cases on all measures. On Social Functioning and on Raven's Progressive Matrices-R, differences between cases and non-cases were progressively greater for cases admitted closer to the time of testing. These differences were greatest for persons tested after first psychiatric hospitalisation.

CONCLUSIONS

The results confirm premorbid deficits associated with schizophrenia and support the hypothesis that decline is progressive.

Normalization of heart rate variability in post-traumatic stress disorder patients following fluoxetine treatment: preliminary results

BACKGROUND

Spectral analysis of heart rate variability has been shown to be a reliable non-invasive test for quantitative assessment of cardiovascular autonomic regulatory responses, providing a window reflecting the interaction of sympathetic and parasympathetic tone. Alterations in autonomic function are associated with a variety of physiologic and pathophysiologic processes and may contribute substantially to morbidity and mortality. Our previous study shows that patients with post-traumatic stress disorder have significantly lower HRV compared to controls, reflecting a basal autonomic state characterized by increased sympathetic and decreased parasympathetic tone.

OBJECTIVES

To apply this tool to PTSD patients treated with selective serotonin re-uptake inhibitors in order to assess the impact of such treatment on the autonomic dysregulation characterizing these patients.

METHODS

Standardized heart rate analysis was carried out in nine PTSD patients treated with SSRI agents and compared to that in a matched control group of nine healthy volunteers and in nine untreated PTSD patients, based on a 15 minute resting electrocardiogram.

RESULTS

Our preliminary results show that the HRV parameters indicating autonomic dysregulation, which characterize PTSD patients at rest, are normalized in responding patients by use of SSRIs. Neither the clinical implications of these findings nor their physiological mechanisms are clear at present, although we presume that they reflect a central effect, since the peripheral autonomic effects of SSRIs are relatively negligible.

[Compression anastomosis in acute resection of the colon]

The authors draw attention to the possible use of a biofragmentable anastomotic ring (BAR) for anastomosis of the gut, used by the authors for construction of an anastomosis after acute resection of the colon under particularly risky conditions with infection and advanced deterioration of the intestinal wall. In both instances when this alternative method was used the postoperative course was uneventful and the patients were discharged without complications into domiciliary treatment.

Behavioral and intellectual markers for schizophrenia in apparently healthy male adolescents

OBJECTIVE

Subtle behavioral and intellectual abnormalities are often present in apparently healthy adolescents who later develop schizophrenia. The authors investigated whether these abnormalities can predict vulnerability for schizophrenia before the first psychotic manifestation.

METHOD

The study consisted of linking the Israeli Draft Board Registry with the National Psychiatric Hospitalization Case Registry. The draft board tests measure intelligence, social functioning, organizational ability, interest in physical activity, and individual autonomy. Patients (N = 509) were compared to nonpatients, i.e., adolescents not appearing in the National Psychiatric Registry (N = 9,215), matched to patients by age, gender, and school attended at time of testing.

RESULTS

Healthy male adolescents who were later hospitalized for schizophrenia had significantly lower test scores on all measures than adolescents not reported to the National Psychiatric Registry. The strongest predictors for schizophrenia were deficits in social functioning, organizational ability, and intellectual functioning. When patients were compared to matched nonpatients, the prediction model had a 75% sensitivity, a 100% specificity, a positive predictive value of 72%, and an overall rate of correct classification of 87.5%. Applied to the Israeli Draft Board Registry, the model yielded a sensitivity of 74.7%, a validated specificity of 99.7%, and a positive predictive value of 42.7%.

CONCLUSIONS

This study demonstrated that simple assessment tools can predict predisposition to schizophrenia in healthy male adolescents. The model's predictive ability does not change as a function of the time elapsed between testing and first hospitalization. This suggests that the model identifies apparently healthy individuals who will manifest the disease later who are not prodromal to psychosis. Easily applied tools allowing early identification of schizophrenia or vulnerability to it may enable early intervention.

The goals and limitations of Israel's psychiatric case register

The Israeli Ministry of Health maintains a psychiatric case register that includes basic demographic and clinical information for all psychiatric hospital admissions since 1950. Currently, the case register includes information about some 130,000 people who have been hospitalized. The case register is an important tool in many aspects of mental health care planning, such as delineating problem populations, developing interventions, assessing the ramifications of policies, enacting programs for quality control, and conducting research. In certain situations stipulated by law, some information in the case register is shared with other authorities. Although the full potential of the psychiatric case register has not been exploited so far, creation of additional linkages with other databases and increased application of case register data in field studies could enhance its usefulness.

Stress and intervention strategies in mental health professionals

There is growing evidence to show that mental health professionals by the nature of their work are particularly vulnerable to stress with all its detrimental effects on service delivery and quality of care. This comes at a time when mental health services in many countries are under considerable strain. The present paper examines the multifaceted stressors encountered by the mental health team and recommends possible ways of reducing burnout through innovative intervention strategies. The detection of emotional distress and psychological dysfunctioning in mental health providers is outlined and their management carefully considered.

[Continuous loop stitch in single-layer laparotomy suturing]

The authors evaluate their favourable experience with the use of a new absorbable loop suture for one-layer closure laparotomy. The percentage of dehiscences of surgical wounds was lower in the group of patients where Safil Loop suture was used than in the control group. The speed of completing the suture was also greater and the safety of closure of laparotomy was more favourable.

Power spectral analysis of heart rate variability in psychiatry

Power spectrum analysis of heart rate variability (PSA of HRV) is a promising method, which can be used as an index of cardiac autonomic balance. PSA of HRV is a noninvasive technique, based on ECG sampling of RR interval variation, thus providing a dynamic assessment of sympathetic and parasympathetic tone, reflecting the interactions between the two. It has been shown to have potential value in various laboratory and clinical conditions. It is influenced by many factors such as age, sex, position, breathing, smoking, hour of the day and medications. Different methods of data processing by various authors have often elicited conflicting results. Standard values are not yet available to be used or compared in different settings. From the interest it has raised, it may be expected that this method will be in widespread use in clinical practice in the future, providing a useful tool, both for diagnostic and prognostic purposes, as well as serving as a further aid towards monitoring therapeutic interventions. This review highlights techniques of dynamic assessment of HRV and studies of its clinical applications in psychiatry in particular. It raises the potentially important prognostic implications of protracted autonomic dysfunction in psychiatric patient populations, especially for cardiovascular morbidity and mortality.

Suicide risk and coping styles in posttraumatic stress disorder patients

BACKGROUND

Suicide and suicidal behavior have been found to be increased among posttraumatic stress disorder (PTSD) patients. The present study examined suicide risk and Plutchik's coping styles in PTSD patients.

METHOD

47 PTSD patients were compared with 42 patients with mixed non-PTSD anxiety disorders and 50 healthy control subjects, matched for age and gender, on a measure of suicide risk.

RESULTS

The PTSD patients scored significantly higher than the two control groups on the suicide risk measure. Furthermore, in the PTSD group, suicide risk was significantly negatively correlated with the coping mechanisms of mapping, minimization and replacement and positively correlated with the coping style of suppression. Furthermore, the coping styles significantly explained the variance of the suicide risk measure for all three groups.

CONCLUSIONS

The cognitive map of PTSD patients highly resembles other populations with high suicide risk. Clinicians treating victims of traumatic events should focus on problem-solving therapies in order to help these patients deal less rigidly with everyday stresses and by this decrease the suicide risk.

Validity study of the EDI-2 in Israeli population

This study was designed to validate the EDI-2 (1) in an Israeli population. The sample consisted of 29 anorectic patients and 18 recovering anorectics, recruited from six hospitals, and 67 female control subjects matched by age. Results of the validity study indicate that the translated EDI-2 was reliable and valid. Anorectic patients scored higher than the recovering anorectics on most scales. Recovering anorectics resembled the control subjects on most scales except Perfectionism.

Analysis of heart rate variability in posttraumatic stress disorder patients in response to a trauma-related reminder

BACKGROUND

Spectral analysis of heart rate variability has recently been shown to be a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory responses, providing a dynamic map of sympathetic and parasympathetic interaction. In a prior study exploring the state of hyperarousal characterizing the posttraumatic stress disorder (PTSD) syndrome, the authors described standardized heart rate analysis carried out in 9 PTSD patients at rest, which demonstrated clear-cut evidence of a baseline autonomic hyperarousal state.

METHODS

To examine the dynamics of this hyperarousal state, standardized heart rate analysis was carried out in 9 PTSD patients compared to a matched control group of 9 healthy volunteers. Twenty-minute recordings of electrocardiogram in response to a trauma-related cue as opposed to a resting state were performed and analyzed. The PTSD patients were asked to recount the presumed triggering traumatic event, and the control subjects recounted a significant stressful negative life event.

RESULTS

Our results show that, whereas the control subjects demonstrated significant autonomic responses to the stressogenic stimulus supplied by the recounting of a major stressful experience, the PTSD patients demonstrated almost no autonomic response to the recounting of the triggering stressful event. The PTSD patients demonstrated a degree of autonomic dysregulation at rest which was comparable to that seen in the control subjects' reaction to the stress model.

CONCLUSIONS

The lack of response to the stress model applied in the study appears to imply that PTSD patients experience so great a degree of autonomic hyperactivation at rest, that they are unable to marshal a further stress response to the recounting of the triggering trauma, as compared to control subjects.

Disadvantages of local repair in acute type A aortic dissection

BACKGROUND

In acute type A dissection of the aorta, local repair with glue-aortoplasty was compared with aortic replacement.

METHODS

Between 1992 and 1996, 106 consecutive patients (mean age, 59 years; 84 men) were operated on average 14.5 hours after onset of dissection. A local repair (gelatin-resorcine-formaldehyde/glutaraldehyde glue, Trigon AG, Monchengladbach, Germany) without graft replacement was performed in 21 patients. Graft replacement and reinforcement of aortic stumps with gelatin-resorcine-formaldehyde/glutaraldehyde glue was performed in 85 patients (supracoronary graft, 68; aortic root replacement, 17).

RESULTS

Survival was 79% after 30 days and 69% after 2 years. There was no difference in early mortality (p = 0.2240) and survival (p = 0.07649). Risk factors for early mortality were preoperative shock, neurologic disorder, duration of crossclamp, and extracorporeal circulation. The rate of reoperation on the proximal aorta was 31.6% (6 of 19) after local repair and 9% (6 of 64) after aortic replacement (p = 0.0157). Local repair was a significant predictor for reoperation (p = 0.0087), with decreased reoperation-free survival (p = 0.01164). In all reinterventions (four supracoronary grafts, including two valve replacements; two composite grafts; two arch replacements) breakdown of the aortoplasty was confirmed.

CONCLUSION

Local repair has satisfactory early results but an increased incidence of reoperations due to a breakdown of the glue-aortoplasty. Indications for local repair should be restricted to high-risk patients requiring a minimal emergency surgical procedure.

Inhibition of anxiety in rats by antisense to cholecystokinin precursor protein

BACKGROUND

Cholecystokinin (CCK) and its analogs generates anxiety in humans and measurable anxiety-like behaviors in rats. CCK receptor blockers have had mixed results as a treatment approach for anxiety disorders. Since CCK is a peptide, we explored another strategy to reduce CCK levels in brain by antisense oligodeoxynucleotide inhibition of DNA transcription or messenger RNA (mRNA) translation for CCK precursor protein.

METHODS

Antisense oligodeoxynucleotide complementary to the start coding region of rat CCK-precursor was intracerebroventricularly (icv) infused into rats three times at 24-hour intervals. Control groups received infusions of either a scramble sequence oligodeoxynucleotide or vehicle. On the fourth day, rats were assessed in the elevated plus maze paradigm.

RESULTS

Compared to vehicle and scramble sequence oligodeoxynucleotide control, icv CCK-antisense exogenous administration for 3 days significantly diminished anxiety behavior in rats.

CONCLUSIONS

Antisense inhibition of CCK-mediated anxiety could have therapeutic potential in human anxiety disorders.

Debriefing with brief group psychotherapy in a homogenous group of non-injured victims of a terrorist attack: a prospective study

This study describes a follow-up of 15 non-injured women, all from the same socio-economic background, who were exposed to a terrorist attack in Israel. All of the women participated in group debriefing with brief group psychotherapy, involving six meetings during the first 2 months following the event. Two days after the attack, and 2 months and 6 months after the event, the women were administered a post-traumatic stress disorder (PTSD) diagnostic scale, the Impact of Event Scale (IES) and the SCL-90. At 6 months, four subjects (27%) were diagnosed with full PTSD. The IES showed significantly higher scores at the first measure than at the other two measures. Furthermore, the phobic anxiety subscale score immediately after the event was significantly associated with the General Severity Index of the SCL-90 and the severity of PTSD symptomatology at 6 months. The present paper discusses the effectiveness of psychological intervention following trauma, and raises questions concerning the need to invest public resources in this kind of intensive intervention. Suggestions are proposed regarding the desired emphasis of the psychological treatment in order to improve its benefits to victims.

Effect of transcranial magnetic stimulation in posttraumatic stress disorder: a preliminary study

BACKGROUND

Transcranial magnetic stimulation (TMS) has become, over the last few years, a promising avenue for new research in affective disorders. In this study we have evaluated the clinical effect of slow TMS on posttraumatic stress disorder (PTSD) symptoms.

METHODS

Ten PTSD patients were given one session of slow TMS with 30 pulses of 1 m/sec each, 15 to each side of the motor cortex.

RESULTS

Symptoms of PTSD were assessed by using three psychological assessment scales, at four different time points. In this first, pilot, open study, TMS was found to be effective in lowering the core symptoms of PTSD: avoidance (as measured by the Impact of Event Scale), anxiety, and somatization (as measured by the Symptom Check List-90). A general clinical improvement was found (as measured by the Clinical Global Impression scale); however, the effect was rather short and transient.

CONCLUSIONS

The present study showed TMS to be a safe and tolerable intervention with possibly indications of therapeutic efficacy for PTSD patients.

[Laparoscopy in oncology patients]

In a group of 23 patients with suspected malignant disease in the abdominal cavity laparoscopy was indicated and 11 times positive findings were obtained--six time a primary tumourous process and five times secondaries. The authors demonstrate on case-histories the advantages of laparoscopy when other examination fail or give dubious results. In their group of patients it always helped to establish a definite diagnosis.

Posttraumatic stress disorder, tenderness and fibromyalgia

The aims of the present study were to inquire into the prevalence of fibromyalgia syndrome, to assess nonarticular tenderness, to measure fibromyalgia syndrome-related symptoms, quality of life, and functional impairment among posttraumatic stress disorder (PTSD) patients as compared with control subjects. Furthermore, the differences between the PTSD patients with and without fibromyalgia syndrome were studied. Twenty-nine PTSD patients and 37 control subjects were assessed as to the diagnosis of fibromyalgia syndrome according to the American College of Rheumatology. Tenderness was assessed manually and with a dolorimeter. Fibromyalgia syndrome-related symptoms, quality of life, physical functioning, PTSD symptomatology, and psychiatric features were assessed by valid and reliable self-report inventories. Results showed that the prevalence of fibromyalgia syndrome in the PTSD group was 21% vs. 0% in the control group. Furthermore, the PTSD group was more tender than the control group. PTSD subjects suffering from fibromyalgia syndrome were more tender, reported more pain, lower quality of life, higher functional impairment and suffered more psychological distress than the PTSD patients not having fibromyalgia syndrome. It is suggested that previous reports on diffuse pain in PTSD in fact described undiagnosed fibromyalgia syndrome. The link between psychological stress and pain syndromes is emphasized.

Inositol has behavioral effects with adaptation after chronic administration

Inositol is a simple dietary polyol that serves as a precursor in important second messenger systems. Inositol in pharmacological doses has been reported recently to be therapeutic in depression, panic disorder and obsessive compulsive disorder. We hereby report effects of inositol on the elevated plus maze model of anxiety. These results should allow development of new inositol analogs that could expand psychoactive drug development possibilities via second messenger manipulation.