The impact of potential islet precursor cells on islet autotransplantation outcomes

Islet autotransplant patients represent excellent subjects to assess the posttransplant impact of islet precursors, as chronic pancreatitis (CP) causes an elevation of ductal cells, pancreatic precursors cells, and hormone-positive acinar cells. The relationship between these cell types and autograft outcomes should be more apparent than would be the case in the context of an allograft program with confounding immunological variables. To improve diabetic control following total pancreatectomy for CP, nonpurified islets were autotransplanted into the liver. Pancreas specimens were recovered from 23 patients and stained for antigens including: insulin, glucagon, cytokeratin 19, cytokeratin 7, and PDX-1. In line with previous reports, the prevalence of ductal cells, non-islet endocrine cells and non-islet PDX-1-expressing cells was significantly higher in CP glands compared with normal pancreata. When correlating follow-up data (i.e., fasting and stimulated C-peptide/glucose levels and HbA1c%) with pancreas immunoreactivity, high levels of ductal cells, non-islet PDX-1-positive cells, and non-islet glucagon-positive cells were associated with superior outcomes, detectable up to 2 years posttransplant. To conclude, the acinar parenchyma and ductal epithelium of the CP pancreas show an upregulation of both endocrine and pre-endocrine cell types, which appear to have a positive effect on islet graft outcomes in autotransplantation setting.

A fuller understanding of pancreatic neuroendocrine tumours combined with aggressive management improves outcome

BACKGROUND

Neuroendocrine tumours of the pancreas (PNETs) represent 1-2% of all pancreatic tumours. The terms 'islet cell tumours' and 'carcinoids' of the pancreas should be avoided. The aim of this review is to offer an overview of the history and diagnosis of PNETs followed by a discussion of the available treatment options.

METHODS

A search on PubMed using the keywords 'neuroendocrine', 'pancreas' and 'carcinoid' was performed to identify relevant literature over the last 30 years.

RESULTS

The introduction of a revised classification of neuroendocrine tumours by the World Health Organisation (WHO) in 2000 significantly changed our understanding of and approach to the management of these tumours. Advances in laboratory and radiological techniques have also led to an increased detection of PNETs. Surgery remains the only treatment that offers a chance of cure with increasing number of non-surgical options serving as beneficial adjuncts. The better understanding of the behaviours of PNETs together with improvements in tumour localisation has resulted in a more aggressive management strategy with a concomitant improvement in symptom palliation and a prolongation of survival.

CONCLUSION

Due to their complex nature and the wide range of therapeutic options, the involvement of specialists from all necessary disciplines in a multidisciplinary team setting is vital to provide optimal treatment of this disease.

Cystic lesions of the pancreas. A diagnostic and management dilemma

BACKGROUND/AIMS

Due to enhanced imaging modalities, pancreatic cysts are being increasingly detected, often as an incidental finding. They comprise a wide range of differing underlying pathologies from completely benign through premalignant to frankly malignant. The exact diagnostic and management pathway of these cysts remains problematic and this review attempts to provide an overview of the pathology underlying pancreatic cystic lesions and suggests appropriate methods of management.

METHODS

A search was undertaken with a Pubmed database to identify all English articles using the keywords 'pancreatic cysts', 'serous cystadenoma', 'intraductal papillary mucinous tumour', 'pseudocysts', 'mucinous cystic neoplasm' and 'solid pseudopapillary tumour'.

RESULTS

The mainstay of assessment of pancreatic cysts is cross-sectional imaging incorporating CT and MRI. Fine-needle aspiration (FNA) (often with endoscopic ultrasound) may provide valuable additional information but can lack sensitivity. Symptomatic cysts, increasing age and multilocular cysts (with a solid component and thick walls) are predictors of malignancy. A raised cyst aspirate CEA, CA 19-9 and mucin content (including abnormal cytology), if present, can accurately distinguish premalignant and malignant cysts from benign ones.

CONCLUSION

In summary, all patients with pancreatic cystic lesions, whether asymptomatic or symptomatic, must be thoroughly investigated to ascertain the underlying nature of the cyst. Small asymptomatic cysts (<3 cm) with no suspicious features on imaging or FNA may be safely followed up. Follow-up should continue for at least 4 years, with a repeat FNA if needed. An algorithm for the management of pancreatic cystic tumours is also suggested. and IAP.

Late-life-onset panic disorder: clinical and demographic characteristics of a patient sample

Although panic disorder is generally believed to begin in young adulthood, 13 cases of panic disorder with an initial onset after age 60 years have recently been seen at our clinics. Other than the time of life in which the first panic attack occurred, clinical and demographic profiles of these 13 patients were similar to those that have been reported for panic disorder patients whose panic began earlier in life. These findings indicate that panic disorder can affect older adults with no previous history of panic attacks, but further research is needed to determine the clinical and theoretical significance of late-life-onset panic disorder.

Sexual history and quality of current relationships in patients with obsessive compulsive disorder: a comparison with two other psychiatric samples

It has been hypothesized that sexual conflict is a causal factor in the development of obsessive compulsive disorder. This study investigated the relationship between obsessive compulsive disorder and variables related to the individual's sexual history, present life, sexual satisfaction, and marital adjustment. Of inpatient admissions, 363 who met criteria for obsessive compulsive disorder, panic disorder, and depressive disorder completed a standard history questionnaire and the Marital Adjustment Test. Findings showed that obsessive compulsive individuals cannot be distinguished from either depressive or panic disordered groups by a particular sexual history. Future studies should use measures that do not rely on patient self-report.

Perceived parental characteristics of patients with obsessive compulsive disorder, depression, and panic disorder

It has been hypothesized that parents of patients with obsessive compulsive disorder exhibit specific traits. 320 consecutive inpatient admissions who met criteria for OCD, depression, and panic disorder checked a list of adjectives to describe their parents. Patients with OCD were 1) less likely to perceive their mothers as disorganized than depressives, 2) more likely to perceive their mothers as overprotective than depressives and 3) less likely to perceive their fathers as demanding than patients with panic.

Use of mobile phones in the behavioral treatment of driving phobias

Results of two case studies are presented to illustrate the use of mobile phones with in vivo exposure treatment of refractory driving phobias. Number of miles driven and subjective ratings of anxiety were recorded during a baseline phase and 8 weeks of treatment involving a total of 24 driving practices. One subject's use of a mobile phone increased the number of miles driven alone, but the second subject made little progress and regressed following removal of the phone. These two cases and our experience with other patients suggest that mobile phones can benefit many individuals whose therapeutic progress is impeded by a fear of driving alone, but that phones are counterproductive for certain patients. The potential benefits and disadvantages of using mobile phones are discussed.

Help-seeking patterns of community residents with depressive symptoms

From a community sample, fifty-five individuals identified as having three or more symptoms of depression were asked if and where they had sought help and how they found or would find treatment. Only 20 subjects (33.9%) reported having sought professional help. No demographic differences were found between help-seekers and non-help-seekers. Eighty percent of the help-seekers had seen a mental health professional while 20% had seen a non-psychiatric physician. However, non-psychiatric physicians and friends or personal acquaintances were most frequently cited as the first point of contact for locating treatment. Results suggest that most individuals with a moderate number of depressive symptoms do not seek professional assistance but that, among those who do, a majority is eventually seen by a mental health professional. Virtually all utilize intermediaries other than mental health professionals, however, to locate assistance. The non-psychiatric physician plays a prominent role in locating help for depressed individuals, which suggests the need to educate physicians about appropriate treatment referral.

Prevalence of various depressive symptoms in a sample of the general population

Data on prevalence of and demographics associated with various symptoms of depression are reported for a sample of the general population. Of the nine symptoms assessed, the most frequently occurring were dysphoric mood (17.8%), increased sleep (15%), and loss of interest in other people or activities previously enjoyed (11.8%). 39% of subjects reported one or more symptoms of depression. 8% of subjects reported wondering if life is worth living, a symptom that in and of itself is suggestive of clinically significant depression. The number of depressive symptoms reported was related to income, education, age, and residence (city versus county), but not to sex. The findings provide evidence that various symptoms of depression may be more common in the general population than previously suspected.

Clomipramine treatment of trichotillomania: a follow-up report on four cases

Four consecutive patients treated for trichotillomania (hair pulling) with clomipramine reported initially dramatic reductions in symptoms. However, three of the four patients had relapsed completely at 3-month follow-up, although all four were still taking previously effective levels of the drug. The fourth patient relapsed for about 2 weeks but regained initial treatment benefits. Implications for the treatment of trichotillomania are discussed.

Panic attacks and related disorders in alcohol-dependent, depressed, and nonclinical samples

Although several studies have indicated that a substantial portion of alcoholics have an anxiety disorder, relatively little information exists specifically regarding panic disorders. In addition, prior studies have been marred by the absence of appropriate contrast groups. The present investigation compared the lifetime prevalence of panic attacks and panic-related disorders diagnosed according to DSM-III criteria in a group of 79 alcohol-dependent patients, 64 depressed patients, and 70 nonclinical subjects. Panic attacks, panic disorder, and agoraphobia with panic attacks were more prevalent in the alcohol-dependent and depressed samples than among nonclinical subjects. Men in both clinical samples were more likely than women to have had nonagoraphobic panic disorder, but male alcoholics were less likely to have developed agoraphobia than were female alcoholics or depressed patients of either sex. No consistent chronological relationship between onset of panic attacks and alcohol abuse was found. Results indicate that there is an unusually high prevalence of panic attacks and panic-related disorders among alcoholics, but comparable prevalence rates can be found in depressed and perhaps some other psychiatric populations. Implications for the assessment and treatment of alcohol-dependent and panic-disordered patients are discussed.

Reexamination of the relationship between birth order and obsessive-compulsive disorder

In order to examine the hypothesis that being a firstborn or only child is specifically associated with obsessive-compulsive disorder, the birth order positions and sibship sizes of 62 patients with obsessive-compulsive disorder were compared with those of 60 agoraphobic and 92 depressed patients. No significant group differences were found for men, women, or both sexes combined. Results conflict with earlier findings which supported the hypothesized relationship between birth order status and development of obsessive-compulsive patterns in men. In addition to possible differences in methodology, discrepancies between the present findings and those of earlier studies may reflect a decline over the past 20 years in the percentage of male obsessive compulsives that were either firstborn or only children.

Validity study of the Anxiety Symptoms Interview

The Anxiety Symptoms Interview (ASI) is a diagnostic instrument designed to identify agoraphobia (with and without panic attacks), panic disorder, social phobia, and obsessive compulsive disorder according to DSM-III criteria. The present study evaluated the diagnostic validity of this instrument by examining the extent to which ASI diagnoses assigned to 73 clinic patients agreed with diagnoses determined by clinicians. Most kappa coefficients and other concordance indicators were in the acceptable range or above, a finding that held for diagnoses overall and for specific diagnoses of agoraphobia with panic attacks, social phobia, and obsessive compulsive disorder. However, none of the 73 patients had clinician-assigned diagnoses of panic disorder (that is, without agoraphobia) or agoraphobia without panic. Limitations and applications of the ASI are discussed.

Managing panic attacks in emergency patients

Patients experiencing panic attacks often seek help at emergency departments. However, the symptoms of panic can be difficult to distinguish from some common medical emergencies. Furthermore, many emergency medicine clinicians may not be equipped to deal effectively with panic attacks and related psychiatric conditions such as panic disorder and agoraphobia. Early misdiagnosis and inadequate management of panic attacks can have devastating long-term clinical and financial consequences. The purpose of this paper is to provide information designed to increase the comfort and efficacy of emergency physicians and allied professionals in dealing with panic attacks. The authors offer guidelines regarding differential diagnosis, present strategies for management of acute symptoms of panic and anxiety, and make recommendations for brief postpanic clinical intervention.

Panic onset and major events in the lives of agoraphobics: a test of contiguity

Major life events were reported in greater numbers and by a higher percentage of 50 index agoraphobics during a time period around panic onset than during either a within-subjects or a between-subjects control period. These differences were found for analyses of life events in general, events that preceded panic, and foreseeable events that occurred shortly after panic onset. Though many events involved separation or interpersonal conflict, other types of events were frequently reported. Results provide more convincing evidence than prior studies of a contiguous relationship between life events and onset of panic attacks associated with agoraphobia.

Panic onset and major events in the lives of agoraphobics: A test of contiguity

Major life events were reported in greater numbers and by a higher percentage of 50 index agoraphobics during a time period around panic onset than during either a within-subjects or a between-subjects control period. These differences were found for analyses of life events in general, events that preceded panic, and foreseeable events that occurred shortly after panic onset. Though many events involved separation or interpersonal conflict, other types of events were frequently reported. Results provide more convincing evidence than prior studies of a contiguous relationship between life events and onset of panic attacks associated with agoraphobia.

Three types of obsessive compulsive disorder in a community sample

Until recently, prior estimates of the prevalence of obsessive compulsive disorder (OCD) have been based on clinical data. The present investigation studied point prevalence and demographic data that pertain to three ritual-based forms of OCD in a sample of the adult general population of the greater St. Louis area. Two hundred fifty male and 247 female subjects were administered a structured interview designed to identify the presence of symptoms associated with OCD according to DSM-III criteria. The overall prevalence rate of OCD was 2.8%. The most prevalent form of OCD involved checking (1.6%), followed by a miscellaneous category that included repeating, counting and collecting rituals (1.0%) and, finally, washing compulsions (.8%). Subjects with OCD did not differ demographically from the rest of the sample except that they were more likely to live in the city. Results indicate that OCD is more prevalent than previously supposed and that checking compulsions may be the most common form of ritual in nonclinical samples.

Four types of social phobia in a community sample

Point prevalence rates and demographic characteristics associated with four specific forms of social phobia (public speaking/performing, writing in front of others, eating in restaurants, and use of public restrooms) were examined in a sample of adult residents of the greater St. Louis area. Diagnoses were determined by structured interview in accordance with DSM-III criteria. An unadjusted prevalence rate of 22.6% was found for all four social phobias combined. Application of DSM-III significant distress criteria resulted in a prevalence rate of 2.0%. Public speaking/performing phobias were by far the most common (20.6%). Prevalence rates of 2.8%, 1.2%, and 0.2% were found for phobias related to writing, eating, and use of public restrooms, respectively. Social phobias were more common among women than men. No other demographic differences were found between social phobics and the rest of the sample. Results of this study suggest a higher prevalence of social phobia than has been indicated by prior research. Explanations for and implications of these findings are discussed.

Social-evaluative anxiety in panic disorder and agoraphobia

18 agoraphobics with panic attacks had significantly higher scores on the Willoughby Personality Schedule, a measure of social-evaluative anxiety, than 18 matched patients with panic disorder. Results are compatible with the position that hypersensitivity to criticism is associated with and may contribute to the development of agoraphobia following panic attacks, but further research is needed.

Inpatient treatment of complicated agoraphobia and panic disorder

Despite recent advances in the treatment of agoraphobia and panic disorder, some patients do not respond to standard outpatient regimens of biological and psychosocial intervention and may require more intensive, closely supervised care. The authors describe a specialized inpatient program that integrates pharmacotherapy, intensive levels of exposure and other behavioral therapies, a structured and strategically reinforcing environment, panic and anxiety management strategies, and other interventions designed specifically for patients with complicated panic-based disorders. Outcome data for 25 patients indicate that after a mean stay of 35 days, 19 patients were significantly improved. These preliminary results suggest that appropriately designed inpatient programs offer an effective treatment option for some patients with refractory conditions of agoraphobia or panic disorder.

The Pain Disability Index: psychometric and validity data

The Pain Disability Index (PDI) is a brief instrument that was developed to assess pain-related disability, providing information that complements assessment of physical impairment. This paper presents the results of two studies concerning the psychometric properties and the validity of the PDI. In study I, PDI scores of 108 patients appeared internally consistent (alpha = .86), although a factor analysis revealed two factors. The first factor (59.3% of variance) seemed to include more discretionary, less obligatory activities. The second factor (14.3% of variance) included activities more basic to daily living and survival. Study II found that the PDI scores of 37 former inpatients were significantly higher than 36 former outpatients who responded to a follow-up questionnaire. These findings support the validity of the PDI. Several methodologic issues are discussed, and suggestions are made for future uses of the instrument.

Habituation to fear stimuli in a case of obsessive compulsive disorder: examining the generalization process

The purpose of this investigation was to determine if habituation of anxiety to a visual form of the number 13 would generalize to other forms (auditory, behavioral and cognitive) of the number 13 in a 20-year-old male with obsessive compulsive disorder. Treatment included exposure and response prevention. A multiple baseline design across fear stimulus forms was used. Habituation to the visual form began generalizing to other forms of the number 13 before prolonged exposures to these three stimulus forms were instituted. Results suggest that exposure to a single stimulus form may result in sufficient generalization of treatment effects in cases involving seemingly independent fear responses to several forms of a stimulus.

Applying modern management principles to clinical administration of a behaviorally oriented inpatient unit

Very few clinical administrators are trained managers, and the combined role of clinician-manager is laden with conflicting expectations. This paper describes the planning, inception, and administration of a new, behaviorally oriented inpatient psychiatric unit in a university medical center that was designed by the unit's clinical director and assistant clinical director. Contemporary management practices were adapted and applied to the development and administration of the unit. The unit's clear boundaries have allowed it to maintain its integrity within the hospital system, and its decentralized horizontal organizational structure has fostered a sense of ownership and responsibility on the part of staff at the operating level. A participative, personnel-oriented approach to unit operations has led to minimal staff turnover and high morale.

Inpatient behavior therapy: the St. Louis University model

Many of the problems that impede the practice of behavior therapy on traditional psychiatric and medical inpatient services can be avoided by a separate behaviorally-oriented inpatient unit, but few guidelines exist for establishing such a unit. The present paper describes the inpatient Behavioral Treatment Unit developed at St. Louis University Medical Center. Critical administrative and clinical features of the Unit are discussed, including the administrative philosophy which emphasizes unit autonomy and participative management, the central role of nursing staff, the importance of the clinical team system, the development of referral sources, admission procedures and criteria, and basic approaches to assessment and treatment.

Respiratory distress during panic attacks associated with agoraphobia

59 patients with agoraphobia and panic attacks completed check lists of physical and cognitive panic-related symptoms to estimate the extent to which respiratory distress is associated with panic. Over half of the patients reported experiencing difficulty breathing during most or all panic attacks, but respiratory difficulty was not consistently associated with panic. Further research is needed using alternative methods of assessment, but these findings suggest that biologically oriented explanations of panic which ascribe a precipitative role to respiratory dysfunction cannot account for many of the panic attacks experienced by agoraphobics.

Family history and severity of disability associated with chronic low back pain

76 patients with chronic low back pain were asked to complete the Pain Disability Index and a family history pain checklist. A significant positive relationship was found between severity of chronic pain disability and the number of chronic pain conditions in the patients' families of origin and genesis. These findings support the position that pain disability is learned from family members, but controlled research is needed before dismissing the possible role of genetic and other factors.

Comprehensive behavioral management of complex tinnitus: a case illustration

This paper describes a comprehensive program for behavioral management of complex tinnitus. The clinical characteristics and typical treatment of tinnitus are reviewed. Psychosocial sequelae are discussed in terms of their exacerbation of the symptom and their potential as foci of treatment. The management problems of tinnitus are considered analogous to those of chronic pain. A case illustration is provided with a description of the treatment process. The comprehensive behavioral program discussed in the present paper included biofeedback therapy, pain management training, social skills training, assertion training, in vivo exposure to being alone, cognitive treatment of depression, and marital therapy. Outcomes were monitored multidimensionally. Self-report of tinnitus severity decreased after the 6th treatment day and stabilized at a "mild" rating after the 9th day. Skin temperature readings at baseline increased and stabilized after the 8th day, and the patient was able to reliably increase skin temperature on request. Scores on the Beck Depression Inventory and the Willoughby Personality Schedule, and a self-rating of Fear of Being Alone dropped markedly by the end of treatment. Follow-up data at 3 months indicated maintenance of gains.