Objective: Disorders characterized by “distressing unexplained somatic symptoms” are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample. Methodology: As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed. Results: The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with “being a BSS” case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72). Conclusion: Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

BACKGROUND: Annual surveillance of Lynch Syndrome patients from the rural Northern Cape Province of South Africa is conducted with a mobile colonoscopic unit. Excellent preparation of the colon is essential to detect small right sided lesions. We wished to evaluate a two litre polyethylene glycol (PEG) electrolyte solution containing ascorbic acid and sodium ascorbate Moviprep® as preparation for colonoscopy in this cohort. METHODS: Six weeks prior to the colonoscopy surveillance week, a team travelled to the area to prepare the patients for colonoscopy. Patients were individually counselled on the importance of bowel cleansing and the use of Moviprep®. Prior to their colonoscopy, subjects completed a product acceptability questionnaire. At the procedure, the quality of bowel preparation was assessed by a single individual (DJdV) using the Harefield cleansing scale grades; grades A or B were defined as good preparation and grades C or D as poor preparation. RESULTS: Sixty four of the 71 subjects seen on the preparation trip completed the questionnaire and took their Moviprep®. The questionnaire responses showed that 53 (83%) had used other colon preparations previously and 57 (89%) would prefer Moviprep® for their next colonoscopy. Eighteen patients did not undergo colonoscopy due to time constraints. Forty-one of the 46 subjects (89%) who underwent colonoscopy had successful colonic preparation 7 of whom received an extra litre of Moviprep due to stool based nursing assessment prior to colonoscopy. Side effects of nausea and hunger were occasionally troublesome but did not affect compliance. CONCLUSION: When patients are pre-councelled, Moviprep® provides adequate colonic cleansing in 73% with the standard regimen and 89 % after additional prep in subjects undergoing surveillance colonoscopy in a rural setting. Moviprep was tolerated well and 88% of subjects would choose the same preparation for their next colonoscopy.

Our research is based on a systematic psychoanalytical method for discourse analysis, the David Liberman algorithm (DLA), to study the therapeutic alliance and clinical change in the prevailing connection between patient and therapist. The sample was made up of three session segments pertaining to two patients, about 11 and 12 years old. Speech acts, motor acts and paraverbal acts were analyzed to detect 1) obstacles and contributions that patient and therapist bring to the therapeutic alliance as well as to clinical change, 2) relations between therapeutic alliance and clinical change taking place in peak moments of the sessions. The article closes with an overview of the state of the art.

En nuestra investigación utilizamos un método sistemático psicoanalítico de análisis del discurso, el algoritmo David Liberman (ADL) para estudiar la alianza terapéutica y el cambio clínico en el vínculo concreto entre paciente y terapeuta. La muestra se constituyó con tres fragmentos de sesión de dos pacientes, de entre 11 y 12 años. Analizamos frases, actos motrices y para verbales para detectar 1) escollos y contribuciones que paciente y terapeuta aportan a la alianza terapéutica y el cambio clínico 2) relaciones entre alianza terapéutica y cambio clínico en el momento óptimo de la sesión. Finalizamos el trabajo haciendo un panorama del estado del arte.

This is a systematic research on clinical change in children. The psychoanalytic link and in particular the stylistic complementarity of the primary oral language are studied. David Liberman, in his original proposal, stated that the primary oral and the genital phallic styles were complementary. This study led us to propose that the secondary anal sadistic style could: a) boost the genital phallic and b) adopt by itself a function complementary to that of the primary oral language.

Se trata de una investigación sistemática de cambio clínico en niños. Se estudia el vínculo analítico y, en particular, la complementariedad estilística del lenguaje oral primario. David Liberman en su propuesta original sostuvo que el estilo oral primario y fálico genital eran complementarios. Este estudio nos condujo a proponer que el estilo anal secundario puede: a) potenciar al fálico genital b) adoptar por sí mismo una función complementaria del lenguaje oral primario.

O transplante simultâneo de pâncreas/rim tem indicações específicas, riscos e benefícios. O procedimento, cada vez mais realizado, traz vantagens se comparado ao paciente em diálise, em relação à qualidade de vida, anos de vida ganhos e evolução das complicações crônicas. Se o paciente tiver a opção de realizar o transplante de rim com doador vivo, que apresenta sobrevida semelhante do enxerto e do paciente aos dez anos, o procedimento deverá ser considerado. O transplante de pâncreas após rim, quando efetivo, pode melhorar a evolução das complicações cardiovasculares, mas em contrapartida provoca maior mortalidade nos primeiros meses após a cirurgia. O transplante isolado de pâncreas também ocasiona a maior mortalidade pós-operatória, resultado da complexidade do procedimento e da imunossupressão. O transplante de ilhotas tem sua indicação para um seleto grupo de diabéticos com instabilidade glicêmica.

Pancreas and kidney transplants have specific indications, benefits and risks. The procedure has become more common and more often as long-term success has improved and risks have decreased. Compared with a patient being on dialysis, simultaneous pancreas-kidney transplant offers a distinct advantage when it comes to mortality, quality of life and diabetic complications. Since there can be a living-donor kidney transplant,, a possibly similar patient and graft survival by 10 years follow-up, this procedure should be considered. Pancreas after kidney transplants, when successful, can improve microvascular complications compared with kidney transplant alone, but immediate mortality may be higher. Solitary pancreas transplantation can improve the quality of life in selected patients, but it may also increase the immediate risk of mortality due to the complexity of the surgery and the risks of immunosupression. The results of Islet transplantation differ from the higher metabolic performance achieved by whole pancreas allotransplantation and its applicability is limited to selected adult diabetic patients.

OBJECTIVE: To facilitate mental health reform in one Russian oblast (region) using systematic approaches to policy design and implementation. METHODS: The authors undertook a three-year action-research programme across three pilot sites, comprising a multifaceted set of interventions combining situation appraisal to inform planning, sustained policy dialogue at federal and regional levels to catalyse change, introduction of multidisciplinary and intersectoral-working at all levels, skills-based training for professionals, and support for nongovernmental organizations (NGOs) to develop new care models. FINDINGS: Training programmes developed in this process have been adopted into routine curricula with measurable changes in staff skills. Approaches to care improved through multidisciplinary and multisectoral service delivery, with an increase in NGO activities, user involvement in care planning and delivery in all pilot sites. Hospital admissions at start and end of the study fell in two pilot sites, while the rate of readmissions in all three pilot sites by 2006 was below that for the region as a whole. Lessons learned have informed the development of regional and federal mental health policies. CONCLUSION: A multifaceted and comprehensive programme can be effective in overcoming organizational barriers to the introduction of evidence-based multisectoral interventions in one Russian region. This can help facilitate significant and sustainable changes in policy and reduce institutionalization.

OBJETIVO: Facilitar la reforma de la atención de salud mental en un oblast (región) de Rusia utilizando métodos sistemáticos para formular y aplicar las políticas. MÉTODOS: Los autores emprendieron en tres sitios piloto un programa de acción-investigación de tres años que abarcaba un conjunto multifacético de intervenciones como la evaluación de la situación para fundamentar la planificación, un diálogo de política sostenido a nivel federal y regional para catalizar los cambios, la acción multidisciplinaria e intersectorial a todos los niveles, medidas de formación práctica para los profesionales y el apoyo a organizaciones no gubernamentales (ONG) para desarrollar nuevos modelos de asistencia. RESULTADOS: Los programas de capacitación desarrollados a lo largo este proceso han sido incorporados en los programas de estudios habituales, con cambios cuantificables en las aptitudes del personal. La asistencia mejoró gracias a la prestación de servicios multidisciplinarios y multisectoriales, con un aumento de las actividades de ONG y la participación de los usuarios en la planificación y prestación de la asistencia en todos los sitios piloto. Los ingresos hospitalarios, determinados al comienzo y al final del estudio, disminuyeron en dos sitios piloto, mientras que la tasa de reingresos en los tres sitios piloto en 2006 fue inferior a la del conjunto de la región. Las enseñanzas extraídas han fundamentado el desarrollo de las políticas de salud mental regionales y federales. CONCLUSÍON: Un programa multifacético e integral puede ayudar a superar eficazmente las barreras organizacionales a la aplicación de intervenciones multisectoriales basadas en la evidencia en una región de Rusia, y ello puede facilitar la introducción de cambios considerables y sostenibles en las políticas y reducir los internamientos.

OBJECTIF: Faciliter la réforme de la santé mentale dans une région (oblast) russe par une approche systématique de la conception et de la mise en œuvre des politiques dans ce domaine. MÉTHODES: Les auteurs ont entrepris un programme de recherche pragmatique sur trois ans, couvrant trois sites pilotes et comprenant une série d’interventions selon plusieurs axes : évaluation de la situation pour fournir une base à la planification, maintien d’un dialogue politique aux niveaux fédéral et régional pour catalyser le changement, introduction d’une collaboration multidisciplinaire et intersectorielle à tous les niveaux, organisation de formations pour améliorer les compétences des professionnels et aide aux organisations non gouvernementales (ONG) dans la mise au point de nouveaux modèles de soins. RÉSULTATS: Les programmes de formation développés dans le cadre de ce processus ont été intégrés aux programmes de formation classiques, avec comme conséquence une amélioration mesurable des compétences du personnel. Les démarches thérapeutiques se sont aussi améliorées à travers la délivrance de services multidisciplinaires et multisectoriels, le développement des activités des ONG et l’implication plus poussée des usagers dans la planification et la délivrance des soins dans tous les sites pilotes. Entre le début et la fin de l’étude, le nombre des hospitalisations a chuté dans deux des sites pilotes et dans les trois, le taux de réadmission a atteint en 2006 un niveau plus faible que dans l’ensemble de la région. Les enseignements tirés de ce programme ont servi de base à l’élaboration de politiques de santé mentale aux niveau régional et fédéral. CONCLUSION: Il est possible, dans une région russe, de venir à bout des obstacles organisationnels à l’introduction d’interventions multisectorielles développées à partir d’éléments factuels par un programme complet et pluridimensionnel. Un tel programme pourrait aussi faciliter des changements notables et durables de politique et réduire la bureaucratie.