Surgical outcomes of minimally invasive trephine surgery for pilonidal sinus disease with and without laser therapy: a comparative study

BACKGROUND

Over the last decades, novel therapeutic options have emerged for the surgical treatment of pilonidal sinus disease (PSD). The aim of this study was to evaluate the outcomes of trephine/pit excision surgery with or without laser therapy in patients with PSD.

METHODS

A retrospective cohort study was conducted at a large tertiary medical center, including all adult patients with PNS who underwent trephine surgery with/without laser therapy between 2016 and 2021[AUTHORS TO INSERT MONTH]. Propensity score matching was used to address confounding factors, and the primary outcome was the 1-year recurrence rate.

RESULTS

The study included 221 patients with PSD, with a mean age of 23.73 years (87.7% male). In the unmatched cohort (130 trephine surgery alone, 91 trephine surgery + laser therapy), significant differences were observed in mean age (23 vs. 25 years; p < 0.01)[AUTHROS TO USE MEDIAN PLUS RANGE OR ADD SD] and surgeons' experience (p = 0.014). Propensity score matching was applied to overcome confounding factors, resulting in a matched cohort including 73 patients in each group. The addition of laser therapy demonstrated a significantly lower recurrence rate (8.2% vs. 32.9%; p < 0.001) compared to pit excision without laser therapy. Logistic regression analysis showed that the addition of laser was significantly associated with a lower risk for recurrence (OR 0.23; 95% CI 0.089-0.633; p < 0.01).

CONCLUSION

The incorporation of laser therapy along with trephine/pit excision surgery significantly reduces the recurrence rate in patients with PNS. Further prospective studies are needed to confirm our findings.

Gracilis muscle interposition for pouch-vaginal fistulas: a single-centre cohort study and literature review

BACKGROUND

First described by Parks and Nicholls in 1978, the ileal pouch-anal anastomosis (IPAA) has revolutionized the treatment of mucosal ulcerative colitis (MUC) and familial adenomatous polyposis (FAP). IPAA is fraught with complications, one of which is pouch-vaginal fistulas (PVF), a rare but challenging complication noted in 3.9-15% of female patients. Surgical treatment success approximates 50%. Gracilis muscle interposition (GMI) is a promising technique that has shown good results with other types of perineal fistulas. We present the results from our institution and a comprehensive literature review.

METHODS

A retrospective observational study including all patients with a PVF treated with GMI at our institution from December 2018-January 2000. Primary outcome was complete healing after ileostomy closure.

RESULTS

Nine patients were included. Eight of nine IPAAs (88.9%) were performed for MUC, and one for FAP. A subsequent diagnosis of Crohn's disease was made in five patients. Initial success occurred in two patients (22.2%), one patient was lost to follow-up and seven patients, after further procedures, ultimately achieved healing (77.8%). Four of five patients with Crohn's achieved complete healing (80%).

CONCLUSION

Surgical healing rates quoted in the literature for PVFs are approximately 50%. The initial healing rate was 22.2% and increased to 77.8% after subsequent surgeries, while it was 80% in patients with Crohn's disease. Given this, gracilis muscle interposition may have a role in the treatment of pouch-vaginal fistulas.

A network meta-analysis of surgical treatments of complete rectal prolapse

PURPOSE

Surgical treatment of complete rectal prolapse can be undertaken via an abdominal or a perineal approach. The present network meta-analysis aimed to compare the outcomes of different abdominal and perineal procedures for rectal prolapse in terms of recurrence, complications, and improvement in fecal incontinence (FI).

METHODS

A PRISMA-compliant systematic review of PubMed, Scopus, and Web of Science was conducted. Randomized clinical trials comparing two or more procedures for the treatment of complete rectal prolapse were included. The risk of bias was assessed using the ROB-2 tool. The main outcomes were recurrence of full-thickness rectal prolapse, complications, operation time, and improvement in FI.

RESULTS

Nine randomized controlled trials with 728 patients were included. The follow-up ranged between 12 and 47 months. Posterior mesh rectopexy had significantly lower odds of recurrence than did the Altemeier procedure (logOR, - 12.75;  95% credible intervals, - 40.91, - 1.75), Delorme procedure (- 13.10; - 41.26, - 2.09), resection rectopexy (- 11.98; - 41.36, - 0.19), sponge rectopexy (- 13.19; - 42.87, - 0.54), and sutured rectopexy (- 13.12; - 42.58, - 1.50), but similar odds to ventral mesh rectopexy (- 12.09; - 41.7, 0.03). Differences among the procedures in complications, operation time, and improvement in FI were not significant.

CONCLUSIONS

Posterior mesh rectopexy ranked best with the lowest recurrence while perineal procedures ranked worst with the highest recurrence rates.

Outcomes of gracilis muscle interposition for rectourethral fistulas caused by treatment of prostate cancer

BACKGROUND

Gracilis muscle interposition (GMI) has been associated with favorable outcomes in treating complex perianal fistulas. Outcomes of GMI may vary according to the fistula etiology, particularly between rectovaginal fistulas in women and rectourethral fistulas (RUF) in men. The aim of this study was to assess the outcome of GMI to treat RUF acquired after prostate cancer treatment.

METHODS

This retrospective cohort study included male patients treated with GMI for RUF acquired after prostate cancer treatment between January 2000 and December 2018 in the Department of Colorectal Surgery, Cleveland Clinic Florida. The primary outcome was the success of GMI, defined as complete healing of RUF without recurrence. Secondary outcomes were length of hospital stay and postoperative complications.

RESULTS

This study included 53 male patients with a median age of 68 (range, 46-85) years. Patients developed RUF after treatment of prostate cancer with radiation (52.8%), surgery (34%), or transurethral resection of the prostate (TURP) (13.2%). Median hospital stay was 5 (IQR, 4-7) days. Twenty (37.7%) patients experienced 25 complications, the most common being wound infection and dehiscence. Primary healing after GMI was achieved in 28 (52.8%) patients. Fifteen additional patients experienced successful healing of RUF after additional procedures, for a total success rate of 81.1%. Median time to complete healing was 8 (range, 4-56) weeks. The only significant factor associated with outcome of GMI was wound dehiscence (p = 0.008).

CONCLUSIONS

Although the initial success rate of GMI was approximately 53%, it increased to 81% after additional procedures. Complications after GMI were mostly minor, with wound complications being the most common. Perianal wound dehiscence was significantly associated with failure of healing of RUF after GMI.

Outcomes of graciloplasty in the treatment of fecal incontinence: a systematic review and meta-analysis of the literature

BACKGROUND

Patients with refractory fecal incontinence symptoms can be treated with several surgical procedures including graciloplasty. Reported outcomes and morbidity rates of this procedure are highly variable. The aim of this study was to assess continence rate and safety of dynamic and adynamic graciloplasty.

METHODS

PubMed and Google Scholar databases were systematically searched from inception until January 2022 according to preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Reviews, animal studies, studies with patients < 18 years or < 10 patients, with no success rate reported or non-English text, were excluded. Main outcome measures were overall continence and morbidity rates of each technique.

RESULTS

Fourteen studies were identified, incorporating a total of 450 patients (337 females), published between 1980 and 2021. Most common etiology of incontinence (35.5%-n = 160) was obstetric trauma followed by anorectal trauma (20%-n = 90). The weighted mean rate of continence after dynamic graciloplasty was 69.1% (95% CI 0.53-0.84%, I2 = 90%) compared to 71% (95% CI 0.54-0.87, I2 = 82.5%) after adynamic. Although the weighted mean short-term complication rate was lower in the dynamic group (26% versus 40%), when focusing on complications requiring intervention under general anesthesia, there was a much higher incidence (43.4% versus 10.5%) in the dynamic group. The weighted mean rate of long-term complications was 59.4% (95% CI 0.13-1.04%, I2 = 97.7%) in the dynamic group, almost twice higher than in the adynamic group [30% (95% CI - 0.03 to 0.63), I2 = 95.8%]. Median follow-up ranged from 1 to 13 years.

CONCLUSIONS

Our data suggest that graciloplasty may be considered for incontinent patients. Dynamic graciloplasty may harbor higher risk for reoperation and complications compared to adynamic. The fact that the functional results between adynamic and dynamic graciloplasty are equivalent and the morbidity rate of adynamic graciloplasty is significantly lower reinforce the graciloplasty as an option to treat appropriately selected patients with fecal incontinence.

Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease

BACKGROUND

The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF).

METHODS

We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers.

RESULTS

We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m². Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05).

CONCLUSION

ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

Postoperative complications and waiting time for surgical intervention after radiologically guided drainage of intra-abdominal abscess in patients with Crohn's disease

BACKGROUND

In patients with active Crohn's disease (CD), treatment of intra-abdominal abscess usually comprises antibiotics and radiologically guided percutaneous drainage (PD) preceding surgery. The aim of this study was to investigate the risk of postoperative complications and identify the optimal time interval for surgical intervention after PD.

METHODS

A multicentre, international, retrospective cohort study was carried out. Details of patients with diagnosis of CD who underwent ultrasonography- or CT-guided PD were retrieved from hospital records using international classification of disease (ICD-10) diagnosis code for CD combined with procedure code for PD. Clinical variables were retrieved and the following outcomes were measured: 30-day postoperative overall complications, intra-abdominal septic complications, unplanned intraoperative adverse events, surgical-site infections, sepsis and pathological postoperative ileus, in addition to abscess recurrence. Patients were categorized into three groups according to the length of the interval from PD to surgery (1-14 days, 15-30 days and more than 30 days) for comparison of outcomes.

RESULTS

The cohort comprised 335 CD patients with PD followed by surgery. Median age was 33 (i.q.r. 24-44) years, 152 (45.4 per cent) were females, and median disease duration was 9 (i.q.r. 3.6-15) years. Overall, the 30-day postoperative complications rate was 32.2 per cent and the mortality rate was 1.5 per cent. After adjustment for co-variables, older age (odds ratio 1.03 (95 per cent c.i. 1.01 to 1.06), P < 0.012), residual abscess after PD (odds ratio 0.374 (95 per cent c.i. 0.19 to 0.74), P < 0.014), smoking (odds ratio 1.89 (95 per cent c.i. 1.01 to 3.53), P = 0.049) and low serum albumin concentration (odds ratio 0.921 (95 per cent c.i. 0.89 to 0.96), P < 0.001) were associated with higher rates of postoperative complications. A short waiting interval, less than 2 weeks after PD, was associated with a high incidence of abscess recurrence (odds ratio 0.59 (95 per cent c.i. 0.36 to 0.96), P = 0.042).

CONCLUSION

Smoking, low serum albumin concentration and older age were significantly associated with postoperative complications. An interval of at least 2 weeks after successful PD correlated with reduced risk of abscess recurrence.

The efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome: a systematic review and meta-analysis

BACKGROUND

Sacral neuromodulation (SNM) has become one of the main treatment options in patients with fecal incontinence. The aim of this study was to determine the efficacy of sacral neuromodulation in the treatment of low anterior resection syndrome (LARS).

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was conducted using the Pubmed, Embase, Ovid, and Cochrane databases, restricted to the English language and to articles published from 2000 to November 2018.

RESULTS

A total of 434 articles on the efficacy of SNM in the treatment of LARS were retrieved, and 13 studies were included in the final analysis, with a total of 114 patients treated with SNM for LARS The overall success rate excluding study heterogeneity was 83.30% [95% CI (71.33-95.25%)]. Improvement in anal continence was seen in several clinical and functional parameters, including the Wexner Score [10.78 points, 95% CI (8.55-13.02), p < 0.0001], manometric maximum resting pressure [mean improvement of 6.37 mm/Hg, 95% CI (2.67-10.07), p = 0.0007], maximum squeeze pressure [mean improvement of 17.99 mm/Hg, 95% CI (17.42-18.56), p < 0.0001] and maximum tolerated volume [mean improvement of 22.74 ml, 95% CI (10.65-34.83), p = 0.0002]. Quality of life questionnaires also demonstrated significant improvement in patients' quality of life, but were reported only in a small group of included patients.

CONCLUSIONS

SNM significantly improves symptoms and quality of life in patients suffering from fecal incontinence following low anterior resection.

Intent, lethality and psychological characteristics of medically serious suicide attempters

Introduction

The study of near fatal suicide attempters may provide insight into the minds of persons who die by suicide. Such attempts are characterized by high suicide intent, together with high medical lethality. The ability to fully understand the specific psychological profiles associated with severe of suicide intent can provide insights for suicide prevention.

Objectives & aims

The objective of the present study was to investigate the relationship of suicide intent to lethality among medically serious suicide attempters. Our aim was to examine specific psychological variables related to the subjective and objective components within suicide intent.

Methods

102 suicide attempters belonged to one of two groups: 35 subjects who made medically serious suicide attempts were compared with 67 non- medically serious suicide attempters. All were interviewed and completed questionnaires covering mental pain, communication difficulties, and seriousness of the suicide intent.

Results

The objective component of the suicide intent scale (SIS) was highly correlated the lethality, as well as to communication difficulties, such as self disclosure while the subjective component of the SIS was related to mental pain variables such as depression and hopelessness. A significant interaction between mental pain and communication difficulties was found to predict severity of the objective suicide intent.

Conclusions

The suicidal person whom suffers from depression and hopelessness and cannot signal his pain to others because of communication difficulties can be a risk for a serious suicide attempt - which is more planned, with more precautions against discovery and without communication before or during the attempts.

Famotidine: a supplemental drug for the treatment of schizophrenia

In an open-label study, famotidine was added to the regular neuroleptic regimen of 11 schizophrenic patients for 4 weeks. Each patient was scored weekly with SAPS, SANS, CGI and HAM-D-17 scales. The results suggest that famotidine is indeed effective as an adjunctive drug to neuroleptics in the treatment of schizophrenia.

Timing of colostomy reversal following Hartmann's procedure for perforated diverticulitis

AIM

Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome.

PATIENTS AND METHODS

A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome.

RESULTS

One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P=0.43) correlating between days to HR from the index procedure showed no specific cut-off point regarding post-operative complications (P=0.16), Major (Clavien-Dindo score of 3 or more) complications (P=0.19), Minor (Clavien Dindo 1-2) and no complications (P=0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P=0.4).

CONCLUSION

Hartmann's Reversal is a complex surgical procedure associated with high rates of complications. In our series, timing of surgery did not affect surgical complications rate or severity or the length of hospital stay.

Correlation Between Intraoperative and Pathological Findings for Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

This study aimed to examine the correlation between intraoperative and pathological findings for patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) and to determine their prognostic significance.

METHODS

Pathological reports of all colorectal cancer (CRC) patients undergoing CRS/HIPEC between 2009 and 2016 were retrospectively reviewed. Pathological specimens lacking tumor cells were defined as negative pathological specimens (NPS). The intraoperative peritoneal cancer index (PCI) and pathological PCI (excluding NPS) were calculated separately. Receiver operating characteristic (ROC) curves were applied to compare the prognostic value of intraoperative and pathological scoring systems.

RESULTS

For 108 CRC patients, 113 CRS/HIPEC procedures were performed. Of 959 pathological specimens examined, 178 (18.6%) were NPS. Overall, 78 procedures (69%) showed NPS. In 52 procedures (46%), the pathological PCI differed from the intraoperative PCI (∆PCI > 0). The ROC areas for intraoperative PCI and pathological PCI were similar in predicting 1-year overall survival (OS), 2-year OS, and 1-year disease-free survival (all p values not significant). However, for the patients with NPS, the number of positive specimens (containing tumor tissue) was superior to intraoperative PCI in predicting 2-year OS (ROC under the curve areas, 0.69 vs. 0.58, respectively; p = 0.012). In addition, a subgroup of 15 patients with a high ∆PCI (≥ 3) had a more favorable median OS than a matched group of 30 patients with similar intraoperative PCI and a ∆PCI of 0 (median survival not reached vs. 21.6 months, respectively; p = 0.05).

CONCLUSIONS

In the majority of CRC CRS/HIPEC procedures, NPS may be found. Among patients with NPS, pathological correlation may have a prognostic significance.

Colonoscopy after the first episode of acute diverticulitis: challenging management paradigms

BACKGROUND

Colonoscopy is commonly recommended after the first episode of acute diverticulitis to exclude colorectal neoplasia. Recent data have challenged this paradigm due to insufficient diagnostic yield. The aim of this study was to assess whether colonoscopy after the first episode of acute diverticulitis is needed to exclude colorectal neoplasia.

METHODS

We performed a retrospective cohort analysis of medical records of patients admitted for the first episode of acute diverticulitis between January 2008 and December 2012. Ambulatory colonoscopy was routinely recommended at discharge. Clinical follow-up and telephone surveys were used for data collection.

RESULTS

Four hundred and twenty-five patients with a mean age of 62.6 years (range 21-98 years) were admitted during the 5-year period. Three hundred and ten (72.9 %) patients underwent colonoscopy at median time of 3.2 months after discharge. Five patients (1.6 %) of the 310 available for evaluation had malignant findings in colonoscopy. Of those, one patient had rectal carcinoma away from the inflamed site and one had colonic lymphoma. None of the 95 patients <50 years of age was found to have adenocarcinoma of the colon.

CONCLUSIONS

Cancer is rarely detected in colonoscopy following the first episode of acute diverticulitis. These results question this indication for colonoscopy, especially in patients under 50.

Laparoscopic cholecystostomy tube-guided hepatotomy and cholecystolithotomy: alternative strategy for treatment of severe chronic cholecystitis

Laparoscopic cholecystectomy can be a challenging procedure in gallbladders with chronic disease. We describe a patient with chronic cholecystitis and difficult visualisation of the gallbladder at surgery who underwent laparoscopic hepatotomy along the drainage tube of the cholecystostomy. In this way, the gallbladder was identified to avoid non-visualisation of ductal anatomy. This exceptional solution should be added to the surgical options if anatomical recognition is difficult and complete removal of the gallbladder is too risky.

Father-daughter relationship and the severity of eating disorders

BACKGROUND

Mother-daughter relationship was the focus of studies on the development of eating disorders (ED) for many years. This study aimed to examine the association between the father-daughter relationship and ED and depressive symptoms.

METHODS

Fifty-three women diagnosed with ED were compared to a psychiatric control group (n=26) and to healthy participants (n=60) regarding their perception of their fathers and the relationship with them. Assessments were done using the Parental Bonding Instrument, the Eating Disorders Questionnaire, the Body Shape Questionnaire, the Eating Attitude Test, and the Beck Depression Inventory as well as narrative-based methods.

RESULTS

Fathers' negative attributes were significantly associated with ED and depressive symptom. Two profiles of father-daughter relationship were found, the "caring and benevolent" relationship and the "overprotective and avoidant" one. In the latter, patients displayed significantly higher levels of food-restraint, more concerns about eating and about their body shape and appearance, and higher levels of depression.

DISCUSSION

Negative perception of the father's parenting style as well as the quality of the relationship with him are crucial for the understanding of the development and persistence of ED. Therapeutic programs for ED should focus not only on the relationship with the mother but must also address the relationship with the father.

Self-report vs. computerized measures of impulsivity as a correlate of suicidal behavior

OBJECTIVES

To compare the use of a self-report form of impulsivity versus a computerized test of impulsivity in the assessment of suicidal adolescent psychiatric inpatients.

METHODS

Sixty consecutive admissions to an adolescent in patient unit were examined. The severity of suicidal behavior was measured with the Childhood Suicide Potential Scale (CSPS), and impulse control was measured with the self report Plutchik Impulse Control Scale (ICS) and with the Test of Variables of Attention (TOVA), a continuous performance test (CPT). The TOVA is used to diagnose adolescents with attention deficit disorder.

RESULTS

There was a significant but low correlation between the two measures of impulsivity. Only the TOVA commission and omission errors differentiated between adolescent suicide attempters and nonattempters.

CONCLUSIONS

Computerized measures of impulsivity may be a useful way to measure impulsivity in adolescent suicide attempters. Impulsivity appears to play a small role only in nondepressed suicidal adolescents, especially boys.

Self-report vs. computerized measures of impulsivity as a correlate of suicidal behavior

OBJECTIVES

To compare the use of a self-report form of impulsivity versus a computerized test of impulsivity in the assessment of suicidal adolescent psychiatric inpatients.

METHODS

Sixty consecutive admissions to an adolescent in patient unit were examined. The severity of suicidal behavior was measured with the Childhood Suicide Potential Scale (CSPS), and impulse control was measured with the self report Plutchik Impulse Control Scale (ICS) and with the Test of Variables of Attention (TOVA), a continuous performance test (CPT). The TOVA is used to diagnose adolescents with attention deficit disorder.

RESULTS

There was a significant but low correlation between the two measures of impulsivity. Only the TOVA commission and omission errors differentiated between adolescent suicide attempters and nonattempters.

CONCLUSIONS

Computerized measures of impulsivity may be a useful way to measure impulsivity in adolescent suicide attempters. Impulsivity appears to play a small role only in nondepressed suicidal adolescents, especially boys.

Psychosocial diagnosis in psychiatrically hospitalized adolescents

This study examines the relevance of a psychosocial diagnostic system developed by the World Health Organization (WHO; International Classification of Diseases [ICD] 10 axis V) for psychiatrically hospitalized inpatient adolescents and assesses the reliability of semistructured interviews for making these psychosocial diagnoses. Seventy-one consecutive patients admitted to an adolescent unit and their parents were interviewed. The semistructured interviews were derived from the criteria for each psychosocial (axis V) diagnosis. Inter-rater and test-retest reliability were measured for both child and parent interviews on a subsample of 57 and 25 subjects, respectively. Results showed high inter-rater reliability (kappa = 0.8 to 1.0). Some test-retest reliabilities were high and others were low (kappa = 0.4 to 1.0). Parent-child agreement was erratic (kappa = 0.2 to 0.7). All of the psychosocial diagnostic entities were common and relevant to our patient population. We conclude that it is possible to make reliable and relevant psychosocial diagnoses in severely ill adolescents.

Relationship between self-disclosure and serious suicidal behavior

The ability to predict which suicidal patient is at high risk for a serious attempt is an important clinical problem. On the basis of our clinical research, we hypothesized that self-disclosure may be an important personality variable differentiating suicide attempters and completers. We assessed 80 patients with depressive disorder, divided into four groups of 20 each: suicidal ideation only, nonserious suicide attempts, severe suicide attempts, and no suicidal behavior. Comparisons were also made with 20 healthy controls. All subjects completed Jourad's Self-Disclosure Questionnaire (JSDQ), as well as scales measuring depression/anxiety and hopelessness. The lack of willingness for self-disclosure significantly differentiated the serious attempters from the suicide ideators and mild attempters. The relationship of self-disclosure and more lethal suicide attempts did not appear to be mediated by depression, anxiety, or hopelessness. This preliminary study indicates that self-disclosure may be a promising field for assessment, therapy, and prevention in suicidal patients. Further studies are needed to investigate related variables, wider patients groups, and the use of different instruments.

Internalized anger, self-control, and mastery experience in inpatient anorexic adolescents

OBJECTIVES

To evaluate the implications of internalized anger, self-control and experience of mastery for adolescent girls with severe anorexia nervosa (AN).

METHODS

Internalized and externalized anger, internal and external control, mastery, use of methods for self-control, and severity of anorexic symptoms were measured by self-report questionnaires in inpatient anorexic teenagers (N=26), inpatient female adolescent psychiatric patients (N=24), and a normal female comparison group (N=29).

RESULTS

Internalized anger was significantly higher in both the anorexic and general psychiatric patients as compared to normal controls, but this difference was significant only for the anorexic patients. Anorexic and general psychiatric patients experienced significantly less mastery than normal controls, but again this difference was significant only in the anorexic group. Within the anorexic group, severity of symptoms correlated significantly with internalized anger, low mastery, and external locus of control, and negative significant correlations among control measures and anger were found. Total length of hospitalization correlated positively with internalized anger only for the anorexics.

CONCLUSION

The findings support the notion that internalized anger and defective experience of self-control are important factors in the psychopathology of adolescent anorexic inpatient females The results may have implications for the clinical management of patients with severe AN.

Close relationships and social competence of hospitalized and nonhospitalized adolescents

This study was designed to examine the social relationships of adolescents with severe disorders. The study sample consisted of 33 adolescent inpatients in a psychiatric unit, as well as 33 nonhospitalized adolescents. Participants completed the Network of Relationship Inventory for an assessment of the quality of their relationships with mother, father, close friend, and other significant adults. In addition, friendship intimacy was assessed. Results showed nonhospitalized adolescents describing a close relationship with their parents, as well as with their close friends. Their relationships with their friends were mature. Hospitalized adolescents described a less close relationship with their parents, whereas they were close to and valued their relationships with their friends and other significant adults. Though both groups described similar levels of emotional closeness, hospitalized adolescents tended more to exert control or to evince a penchant for similarity to the other in their friendships. Results are discussed within the framework of adolescent social tasks.

Perception of ill spouse and dyadic relationship in couples with affective disorder and those without

BACKGROUND

This study compares the perception of spouses and the quality of the dyadic relationship of patients with severe affective disorders in remission with healthy couples.

METHOD

The sample included spouses of patients between the ages of 20 and 65 who had been hospitalized with severe affective illness and who were currently in remission (depressive, n=23; bipolar, n=11) and a control group matched by socioeconomic status. Both groups completed three instruments measuring the quality of the dyadic relationship, attributed characteristics of the spouse and non-formal social support.

RESULTS

The spouses of patients, as compared to spouses of controls, scored lower on consensus, unity and expressions of affection in their marital relationship, ranked their ill spouses lower on the positive qualities and higher on the negative qualities and reported receiving less emotional and practical support.

LIMITATIONS

The limitations of the study are the small sample size and cross sectional design.

CONCLUSIONS

The results suggest that severe affective disorders are associated with marital dysfunction, even during periods of symptom remission.

Impulsivity as a correlate of suicidal behavior in adolescent psychiatric inpatients

One hundred and eighteen inpatient adolescents in a psychiatric hospital were evaluated to determine the relationship of aggression, self injury, and suicidal behavior to impulsivity. It was hypothesized that all these variables would be significantly and positively correlated with one another. This hypothesis was in part based on the results of psychobiological research that found serotonin dysfunction to be the common denominator of these psychopathological dimensions. As predicted, a significant correlation was found between the measures of suicidal behavior, aggressive behavior, and impulsivity. This correlation between suicidal behavior and impulsivity remained after partialing out the factor of aggression. Furthermore, the correlations between impulsivity and suicidality appeared greater in males than in females. Since male suicide attempters are more likely to eventually commit suicide than female suicide attempters, these findings may have a bearing on suicide prediction.

Alexithymia, affect intensity and emotional range in suicidal patients

BACKGROUND

Although negative affect in general has been widely associated with suicide, the role of specific emotions and affect features in depression and suicidality is unclear. This study examined the potential of three major components of the affect structure as predictors of suicidal behavior.

METHODS

Twenty suicidal depressed (SD) inpatients were compared with 20 nonsuicidal depressed (NSD) inpatients and 20 healthy controls for alexithymia, emotional range (ER; i.e. variety of emotions experienced by the subjects) and affect intensity (AI; i.e. the intensity of their emotional responsiveness).

RESULTS

Both the SD and the NSD patients had a narrower range of emotions, a stronger AI and a higher degree of alexithymia than did the healthy controls. No differences were found between the scores of the two inpatients groups.

CONCLUSIONS

The three affect components examined (alexithymia, AI and ER) did not prove to represent sensitive predictors of suicidal behavior. Hopelessness and depression severity were found to be more reliable in the prediction of suicidal risk. We discuss the implications of this study, particularly the possibility of early detection and intervention in patients at risk.

Adult attachment style and the perception of others: the role of projective mechanisms

In 3 reported studies the authors examined attachment-style differences in the perception of others and the hypothesis that projective mechanisms underlie these differences. In these studies, participants reported on their attachment style and generated actual-self-traits and unwanted-self-traits. Then, a 2nd session was conducted, in which impression formation about new persons (Study 1), the ease of retrieval of memories about known persons (Study 2), or memory inferences about learned features of fictional persons (Study 3) were assessed. Findings indicate that whereas anxious-ambivalent persons' impression formation, memory retrieval, and inferences about others reflected the projection of their actual-self-traits, avoidant persons' responses reflected the projection of their unwanted-self-traits. Findings are discussed in terms of the regulatory goals and strategies that characterize the mental representations of each attachment style.

Impulsivity as a correlate of suicidal behavior in adolescent psychiatric inpatients

One hundred and eighteen inpatient adolescents in a psychiatric hospital were evaluated to determine the relationship of aggression, self injury, and suicidal behavior to impulsivity. It was hypothesized that all these variables would be significantly and positively correlated with one another. This hypothesis was in part based on the results of psychobiological research that found serotonin dysfunction to be the common denominator of these psychopathological dimensions. As predicted, a significant correlation was found between the measures of suicidal behavior, aggressive behavior, and impulsivity. This correlation between suicidal behavior and impulsivity remained after partialing out the factor of aggression. Furthermore, the correlations between impulsivity and suicidality appeared greater in males than in females. Since male suicide attempters are more likely to eventually commit suicide than female suicide attempters, these findings may have a bearing on suicide prediction.

Adult attachment style and the perception of others: the role of projective mechanisms

In 3 reported studies the authors examined attachment-style differences in the perception of others and the hypothesis that projective mechanisms underlie these differences. In these studies, participants reported on their attachment style and generated actual-self-traits and unwanted-self-traits. Then, a 2nd session was conducted, in which impression formation about new persons (Study 1), the ease of retrieval of memories about known persons (Study 2), or memory inferences about learned features of fictional persons (Study 3) were assessed. Findings indicate that whereas anxious-ambivalent persons' impression formation, memory retrieval, and inferences about others reflected the projection of their actual-self-traits, avoidant persons' responses reflected the projection of their unwanted-self-traits. Findings are discussed in terms of the regulatory goals and strategies that characterize the mental representations of each attachment style.

The treatment of kleptomania with serotonin reuptake inhibitors

Kleptomania is characterized by an irresistible impulse to steal objects not needed for personal use or for their monetary value. Several recent case reports have shown that Serotonin Specific Reuptake Inhibitors (SSRIs) could be effective in the treatment of kleptomania just as it is in other obsessive-compulsive spectrum disorders. We report five cases of kleptomania patients who were successfully treated with fluoxetine or paroxetine in combination with a psychotherapeutic intervention. In one case, the discontinuation of the medication repeatedly led to the resurgence of the kleptomanic behavior. Our case series illustrates the effectiveness of SSRIs in kleptomania. It thus supports the assumption that this syndrome involves a dysfunctional serotoninergic mechanism.

The contribution of adult attachment style to the adjustment to infertility

This study examines the contribution of adult attachment style to the adjustment to infertility. Both husbands and wives of 80 infertile couples undergoing medical treatment completed the Attachment Style Scale, the Mental Health Inventory and the Dyadic Adjustment Scale. One year later, data were collected on whether women became pregnant. Diagnosis of male infertility was significantly more distressing than diagnosis of female infertility. Significant differences were found among attachment groups: secure persons, either men or women, reported more well-being, less distress and more dyadic adjustment than avoidant and anxious-ambivalent persons. Partners of secure persons also reported significantly higher levels of well-being and dyadic adjustment and significantly lower levels of distress than partners of anxious-ambivalent persons. However, these effects of attachment style were significant mainly when male infertility was diagnosed. Husbands' secure attachment made a significant positive contribution to pregnancy likelihood and this effect was mediated by adjustment measures. Results are discussed in terms of attachment theory.

Life events in childhood, adolescence and adulthood and the relationship to panic disorder

The aim of this study was to explore the association between stressful life events (SLE) and the development of panic disorder (PD) in an Israeli sample. A total of 44 PD patients and a matched control group were studied with regard to SLE over the life cycle (in childhood, adolescence, adulthood and the year preceding the outbreak of the disorder). The major findings were as follows. (i) With regard to the total number of life events experienced in childhood and adolescence, the PD group had experienced significantly more life events than the control group. (ii) No differences were detected in the total amount of SLE between the PD group and the control group with regard to adulthood and the year preceding the outbreak of the disorder, although the PD group had more life events relating to loss in adulthood, whereas in the year before the outbreak of PD life events relating to 'love and family', negative and loss events were more prevalent. These results expand previous findings by demonstrating that SLE in childhood and adolescence may contribute to the development of PD in adulthood.

Personality differences between obsessive-compulsive disorder subtypes: washers versus checkers

Personality differences between 'washer' and 'checker' subtypes of obsessive-compulsive disorder (OCD) were explored. Fifty-one OCD patients were recruited from several outpatient clinics in Central Israel. OCD was diagnosed according to DSM-III-R using the Structured Clinical Interview for DSM-III-R, and personality disorders were diagnosed using the Structured Clinical Interview for DSM-III-R Personality Disorders. Washers were much more likely to have personality disorders than checkers. Personality disorders were diagnosed in 12 of 13 washers vs. three of 11 checkers (chi 2 = 10.75, Fisher's exact test, P < 0.001, d.f. = 1, odds ratio = 32, CI = 2.8-365) and 21 of 27 patients with mixed OCD symptoms. The results support the validity of the washer-checker subdivision and might explain the relative refractoriness of washers to conventional intervention.

Anger, impulsivity and suicide risk

BACKGROUND

To examine the relationship between anger, impulsivity and suicidality.

METHODS

Thirty psychiatric inpatients admitted for suicidal behavior were compared with 30 nonsuicidal psychiatric inpatients and 32 healthy controls on measures of anger, impulsivity and suicide risk.

RESULTS

The three groups were similar on demographic variables, but the suicidal group scored higher on the suicide risk scale, impulsivity scale and anger scale. Anger and impulsivity correlated significantly with suicide risk. High anger and impulsivity contributed synergistically to the suicide risk. Whereas anger was specific to both psychiatric groups, suicidals and nonsuicidals, only impulsivity was specific to the suicidal group.

CONCLUSIONS

These findings may have important implications for therapists and primary prevention workers, and may pave the way for the recognition of risk factors and for effective intervention in patients with a high suicide risk.

Abnormal psychosocial situations and eating disorders in adolescence

OBJECTIVE

To assess the relationship between abnormal psychosocial situations and eating disorders in adolescents.

METHOD

Twenty girls with eating disorders, 20 girls with major psychiatric conditions, and 20 healthy controls took part in the study. They were interviewed using a semistructured interview designed by the World Health Organization to diagnose the psychosocial situations included in the International Classification of Disease Axis 5 classification for child and adolescent psychiatry. All subjects were also given the Eating Attitudes Test.

RESULTS

Many life events and psychosocial adversities differentiated significantly between the patients and controls. Inappropriate parental pressure was specific only for the subjects with eating disorders compared with the other psychiatric patients. In addition, Eating Attitudes Test scores correlated significantly with hostility toward child, sibling disability, parental overprotection, inappropriate parental pressures, and negative changes in family relationships.

CONCLUSION

These results support the growing literature on the interrelationship between disordered family relationships and eating disorders. They point the way for developing treatment programs dealing with these issues.

Coping styles and suicide risk

A total of 30 psychiatric in-patients admitted because of suicidal behaviour were compared with 30 non-suicidal psychiatric in-patients and 32 healthy controls on measures of suicide risk and coping styles. The three groups were similar with regard to demographic variables, but the suicidal group scored higher on the suicide risk scale. Suicidal patients were significantly less likely to use the coping styles of minimization and mapping. They were unable to de-emphasize the importance of a perceived problem or source of stress. They also lacked the ability to obtain new information required to resolve stressful life events. Four coping styles correlated negatively with the suicide risk (minimization, replacement, mapping and reversal), while another three (suppression, blame and substitution) correlated positively. These findings may have important implications for therapists and primary prevention workers, and might pave the way towards recognition of the role played by coping styles in predicting suicide and its use for cognitive intervention in these high-risk patients.

Life events and severe anorexia nervosa in adolescence

The purpose of the study was to study the influence of life events on adolescent patients suffering from anorexia nervosa. Twenty one hospitalized adolescent inpatients with severe anorexia nervosa were compared with 79 adolescent nonanorectic psychiatric inpatients and 40 healthy adolescents for stressful life events throughout their lives. The nonanorectic patients suffered from schizophrenia, affective disorders, anxiety disorders, borderline personality disorder or conduct disorder. The assessment of the contribution of life events to the development of anorexia and the control mental disorders was based on semistructured interviewing of the patients, their parents and the patients' therapists. The instrument used was that developed by Pfeffer. The anorectic patients showed significantly higher negative life event scores than healthy controls in all the areas of life events examined. In addition, they showed significantly more negative life events concerning parents than patients in the other psychiatric diagnostic categories. These findings have relevance for the growing literature on the association between eating disorders and certain forms of child abuse.

Life satisfaction and adjustment in lithium-treated affective patients in remission

The aim of this study was to assess life satisfaction and adjustment of lithium-treated affective patients in remission. Scores of life satisfaction and adjustment in four areas were obtained for two experimental groups of 50 unipolars and 50 bipolars and for two control groups of 50 healthy individuals and 50 patients with personality disorders. Subjects' self-assessments and psychiatrists' evaluation were rated using a modification of Cantril's ladder device. No significant differences were found between affective patients and healthy controls regarding life satisfaction and adjustment, whereas psychiatric controls scored significantly less on most indices. Moreover, the treating psychiatrists rated affective patients significantly higher than psychiatric controls and perceived them as actualizing their potential to a greater degree. Thus, it is concluded that neither the affective illness nor lithium as a prophylactic agent interfered with the patients' feelings of satisfaction or with manifest functioning while in remission.

Long-term lithium prophylaxis in recurrent unipolar depression. A controversial indication?

The authors assessed results obtained with long-term lithium maintenance in a group of 33 recurrent unipolar patients, followed regularly in the outpatient clinic of the Chaim Sheba Medical Center for 1-15 years. They analyzed changes of frequency, severity and duration of depressive relapses, rate and duration of hospitalization, suicidal ideas or attempts, and various assessments of outcome. A significant reduction was found on all indices during lithium management as compared to before lithium treatment, attesting to the efficacy of long-term prophylactic lithium in recurrent unipolar depression. These results are discussed and compared with those from other reports.

Bilateral electrodermal activity in depressive patients

Integrated bilateral skin conductance response and reactive lateral eye movements were studied in 19 depressive patients and 14 normal subjects during visual and verbal tasks and tone habituation sequence. Distinct right-left differences between depressed and normal subjects in reactive lateral eye movements were revealed. Both endogenous and reactive depression patients were classified as 'left-movers'. Marked bilateral differences were observed in electrodermal activity (EDA) in patients during verbal and visual tasks. In endogenous depression EDA was higher on the left hand compared with the right under all the conditions studied (visual and verbal, and tone habituation sequence). In reactive depression EDA was higher on the left side during the verbal task and tone habituation sequence and on the right side in the visual task. Neither result in reactive depression group attained significance. The results are interpreted as a reflection of a different pathophysiology underlying reactive and endogenous depression.