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The application of laparoscopic technique has gained popularity in the past decade. Numerous studies have qualified and quantified the systemic impact of acutely elevated intra-abdominal pressure during pneumoperitoneum at time of laparoscopy. The major hemodynamic effects are increased central venous pressure, increased systemic vascular resistance and systemic hypertension. Reductions in splanchnic and renal blood flow have also been documented, but the clinical significance of these observations is not clear and required further investigation. In our previous work we demonstrated intracranial hypertension secondary to acute elevation in intra-abdominal pressure and described the pathophysiology. Elevated intra-abdominal pressure during induced pneumoperitomeum can serve as a basic model for other disease processes which are characterized by acute or chronic abdominal hypertension. Here we review the current literature and describe our own experience to suggest a unifying model, with emphasis on the key role of the central nervous system in mediating the systemic response to increased intra-abdominal pressure.

Prior studies have reported an association between the presence of the 7 repeat allele of the 48 bp repeat polymorphism of the third cytoplasmic loop of the dopamine D4 receptor gene (DRD4) and novelty seeking behaviors, attention deficit hyperactivity disorder (ADHD), Tourette syndrome (TS), pathological gambling, and substance abuse. However, other studies have failed to replicate some of these observations. To determine whether we could replicate these associations we genotyped 737 individuals from four different groups of control subjects, and 707 index subjects from four different groups of impulsive, compulsive addictive behaviors including substance abuse, pathological gambling, TS, and ADHD. Chi-square analysis of those carrying the 7 allele versus non-7 allele carriers was not significant for any of the groups using a Bonferroni corrected alpha of.0125. However, chi-square analysis of those carrying any 5 to 8 allele versus noncarriers was significant for pathological gambling (p <.0001), ADHD (p

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

In previous studies we reported that an acute elevation in intra-abdominal pressure (IAP) is responsible for the elevation in intracranial pressure (ICP) and mean blood pressure (MBP). Thus far, the reasons for the increased ICP during an acute elevation in IAP and the combined effects of increased IAP and ICP on hemodynamics have not been reported. Five large animals (swine) were studied. Each animal served as its own control. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. ICP, MBP, central venous pressure above (CVPA) and below (CVPB) the diaphragm, and PaC02 were monitored after a pneumoperitoneum with C02 was established at 5, 15, and 30 mm Hg of IAP. Cavography was performed to evaluate the morphology of the inferior vena cava at different increments of IAP. Measurements were obtained in reverse Trendelenburg (group 1), supine (group 2), and Trendelenburg (group 3) positions. Multiple regression analysis was used to examine the effects of IAP and positioning in separate models with different blood pressures as dependent variables. Increased IAP significantly increased CVPA, CVPB, ICP, and MBP. There were no changes in cerebral perfusion pressure. The change in position (from group 1 to group 3) significantly increased CVPA and decreased the CVPB. Cavograms performed on animals in the supine position with increased IAP showed a narrowing of the IVC at the level of the diaphragm. Increases in IAP will increase ICP and MBP without altering the cerebral perfusion pressure. A mechanical effect mediated by compression of the inferior vena cava at the level of the diaphragm with increased central venous pressure and decreased drainage from the lumbar plexus and central nervous system is responsible for this effect.

Background: The side effects of acute elevations in intraabdominal pressure (IAP) are related to a multifactorial etiology. Previous studies have reported that acute elevations in IAP produce an immediate increase in intracranial pressure (ICP). This study was designed to analyze the reasons for increased ICP during acute elevations of IAP and to determine the combined effects of IAP and changes in ventilation indices on ICP and hemodynamic indices., Study Design: Five pigs were studied. A subarachnoid screw was placed for ICP monitoring. The jugular vein, femoral vein, and femoral artery were cannulated. Mean arterial pressure (MAP), central venous pressure (CVP), ICP, and arterial pressure of carbon dioxide (PaCO2) were monitored before and after carbon dioxide pneumoperitoneum was established at 0, 10, and 20 mmHg of IAP Effects of hyperventilation and hypoventilation were recorded and compared with baseline ventilation. Cavography was performed to evaluate the morphology of the inferior vena cava (IVC) at different levels of IAP. Multiple regression and Student's t-test were used to examine the effects of IAP and ventilation on dependent variables., Results: The IVC showed a progressive narrowing at the level of the diaphragm as IAP was increased. There was a simultaneous increase in CVP, MAP, and ICP. The mean changes in ICP with hypoventilation were significantly larger than with hyperventilation., Conclusions: Acutely increased IAP displaces the diaphragm cranially, narrowing the IVC and increasing intrathoracic pressure. This increases CVP and increases ICP by venous stasis and increased pressure in the sagittal sinus with decreased resorption of cerebrospinal fluid. Hemodynamic changes are directly related to the rise in ICP. Hypoventilation and hypercarbia significantly increase ICP when compared with hyperventilation and hypocarbia. Hyperventilation does not significantly decrease ICP during acute elevations of IAP.

Background: The effects of pneumoperitoneum on intracranial pressure (ICP) have received relatively little attention. This study was undertaken to investigate the changes in ICP occurring as a result of increased intraabdominal pressure (IAP) and positioning in animals with normal and elevated ICP., Method: Five pigs (average weight 60 lb) were studied. A subarachnoid screw was placed for ICP monitoring. End tidal CO2 was monitored. Ventilation was performed to keep PCO2 between 30 and 50 mmHg. Measurements of arterial blood gases, mean arterial blood pressure, and ICP were recorded at four different levels of intraabdominal pressure (IAP 0, 8, 16, and 24 mmHg), both in the supine and Trendelenburg positions. A Foley catheter was introduced into the subarachnoid space to elevate the intracranial pressure, and the same measurements were performed., Results: There was a significant and linear increase in ICP with increased IAP and Trendelenburg position. The combination of increased IAP of 16 mmHg and Trendelenburg position increased ICP 150% over control levels., Conclusions: Patient positioning and level of IAP should be taken into consideration when performing laparoscopy on patients with head trauma, cerebral aneurysms, and other conditions associated with increased ICP.

Abnormalities in the dopaminergic reward pathways have frequently been implicated in substance abuse and addictive behaviors. Recent studies by Self and coworkers have suggested an important interaction between the dopamine D1 and D2 receptors in cocaine abuse. To test the hypothesis that the DRD1 gene might play a role in addictive behaviors we examined the alleles of the Dde I polymorphism in three independent groups of subjects with varying types of compulsive, addictive behaviors-Tourette syndrome probands, smokers and pathological gamblers. In all three groups there was a significant in the frequency of homozygosity for the DRD1 Dde I 1 or 2 alleles in subjects with addictive behaviors. The DRD1 11 or 22 genotype was present in 41.3% of 63 controls and 57.3% of 227 TS probands (P = 0.024). When 23 quantitative traits were examined by ANOVA those carrying the 11 genotype consistently had the highest scores. Based on these results, we examined the prevalence of the 11 genotype in controls, TS probands without a specific behavior, and TS probands with a specific behavior. There was a progressive, linear increase, significant at alpha < or = 0.005 for scores for gambling, alcohol use and compulsive shopping. Problems with three additional behaviors, drug use, compulsive eating and smoking were significant at alpha < or = 0.05. All six variables were related to addictive behaviors. In a totally separate group of controls and individuals attending a smoking cessation clinic, and smoking at least one pack per day, 39.3% of the controls versus 66.1% of the smokers carried the 11 or 22 genotype (P = 0.0002). In a third independent group of pathological gamblers, 55.8% carried the 11 or 22 genotype (P = 0.009 vs the combined controls). In the TS group and smokers there was a significant additive effect of the DRD1 and DRD2 genes. The results for both the DRD1 and DRD2 genes, which have opposing effects on cyclic AMP, were consistent with negative and positive heterosis, respectively. These results support a role for genetic variants of the DRD1 gene in some addictive behaviors, and an interaction of genetic variants at the DRD1 and DRD2 genes.

Background: The preferred therapy for acute and chronic liver insufficiency and severe heritable disorders of liver metabolism is whole-organ transplantation. However, due to the shortage of organ donors and high cost, alternative therapeutic approaches have been proposed, including transplantation of normal allogeneic hepatocytes. Recently, it has been reported that many hepatocytes transplanted into the spleen migrated to the liver. We therefore carried out a series of large-animal experiments to reexamine the intrasplenic route and to develop a method for large-scale hepatocellular transplantation in pigs., Methods: Allogeneic porcine hepatocytes were transplanted using the following routes: (1) retrograde injection of cells via the splenic vein, (2) intraarterial injection of cells, (3) direct intrasplenic injection of cells after laparotomy, (4) percutaneous intrasplenic injection of cells under laparoscopic control, (5) laparoscopic intrasplenic injection of cells. The number of cells injected varied from 2 x 10(9) to 10 x 10(9) cells., Results: Of all the methods tested, only direct intrasplenic injection of 2 bln of cells was found to be compatible with survival. However, even with this "small" number of cells (2% original liver mass), there was a significant risk of spleen infarction, perisplenic adhesion formation, and portal vein thrombosis. The laparoscopic approach was found to be reliable, simple, and safe., Conclusion: Even though the spleen is considered by many authors the optimal site for hepatocellular transplantation, transplantation of cells in a number needed to support the failing liver may be associated with significant complications, morbidity, and mortality.

Defects in serotonin metabolism, and abnormalities in both blood serotonin and tryptophan levels, have been reported in many psychiatric disorders. Tryptophan 2,3-dioxygenase (TDO2) is the rate limiting enzyme for the breakdown of tryptophan to N-formyl kenurenine. Functional variants of this gene could account for the observed simultaneous increases or decreases of both serotonin and tryptophan in various disorders. We have identified four different polymorphisms of the human TDO2 gene. Association studies show a significant association of one or more of these polymorphisms and Tourette syndrome (TS), attention deficit hyperactivity disorder (ADHD) and drug dependence. The intron 6G-->T variant was significantly associated with platelet serotonin levels. Only the association with TS was significant with a Bonferroni correction (p = 0.005). Our purpose here is not to claim these associations are proven, but rather to report preliminary results and show that easily testable polymorphisms are available. We hope to encourage additional research into the potential role the TDO2 gene in these and other psychiatric disorders.

Pathological gambling has been termed both the 'pure' and the 'hidden' addiction. 'Pure' because it is not associated with the intake of any addicting substance, and 'hidden' because it is an extension of a common, socially accepted behaviour. The Taq A1 variant of the human DRD2 gene has been associated with drug addiction, some forms of severe alcoholism, and other impulsive, addictive behaviours. We have sought to determine if there is a similar association with pathological gambling. A total of 222 non-Hispanic Caucasian pathological gamblers from multiple sites across the US participated in the study. Of these 171 donated a sample of blood, 127 filled out several questionnaires, and 102 did both. Of the 171 pathological gamblers 50.9% carried the D2A1 allele versus 25.9% of the 714 known non-Hispanic Caucasian controls screened to exclude drug and alcohol abuse, p < 0.00000001, odds ratio (OR) = 2.96. For the 102 gamblers who filled out the questionnaires, 63.8% of those in the upper half of the Pathological Gambling Score (more severe) carried the D2A1 allele (OR versus controls = 5.03), compared to 40.9% in the lower half (less severe). Of those who had no comorbid substance abuse, 44.1% carried the D2A1 allele, compared to 60.5% of those who had comorbid substance abuse. Forty-eight controls and 102 gamblers completed a shorter version of the Pathological Gambling Score. Of the 45 controls with a score of zero, 17.8% carried the D2A1 allele. Of the 99 gamblers with a score of 5 or more, 52.5% carried the D2A1 allele (chi 2 = 15.36, p = 0.00009). These results suggest that genetic variants at the DRD2 gene play a role in pathological gambling, and support the concept that variants of this gene are a risk factor for impulsive and addictive behaviours.

We retrospectively evaluated the results of laparoscopic cholecystectomy in patients infected with the human immunodeficiency virus (HIV) with and without acquired immunodeficiency syndrome (AIDS). One thousand one hundred twenty-seven consecutive patients underwent laparoscopic cholecystectomy by our surgical group. Eighteen of these patients were known to be infected with the HIV virus; 6 were asymptomatic and 12 had AIDS. We reviewed the medical records of all HIV-positive individuals with regard to morbidity, mortality, and postoperative outcome following laparoscopic cholecystectomy. In the six HIV-patients without AIDS, five (83%) had improvement of symptoms postoperatively. There was one minor complication (17%). In contrast, only one of the 12 patients with AIDS had postoperative improvement of symptoms and eight (66%) had complications after surgery. There were four deaths (33%) within 30 days of surgery in this group. Only a small percentage of AIDS patients benefit from laparoscopic cholecystectomy. There is a significantly morbidity and mortality following this procedure in this group. Strategies to improve outcome are presented.

Objective: To evaluate treatments for common bile duct stones (CBDS)., Design: Retrospective review of authors' case series., Setting: Large private metropolitan teaching hospital., Patients: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography., Interventions: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10)., Main Outcome Measures: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization., Results: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death., Conclusions: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.

One thousand seventy-one consecutive laparoscopic cholecystectomies were performed. Routine cholangiography was employed with a 99% success rate. One hundred thirty patients were found to have common duct stones (CBDS). In 48 (37%) patients they were unsuspected. One hundred eleven patients underwent attempted trans-cystic-duct extraction techniques (TCD-CBDE). One hundred three (93%) were successful. The following techniques were employed: 101--biliary endoscopy, 23--ampullary balloon dilation, 2--fluoroscopic basket retrieval. The average operative time was 136 min. The average postsurgical stay was 3.7 days. There were 19 (17%) complications--6 (5%) major. There were 4 retained stones (2 intentional) and 1 death. Patients over 65 years of age had more complications and patients with unsuspected CBDS under 65 years of age had the fewest. TCD-CBDE is a safe, effective way to extract common duct calculi. Endoscopy and basket stone retrieval was the primary technique employed.

Six hundred sixty-nine German hospitals participated in a survey on the use of intraoperative cholangiography (IOC) in its relationship to common bile duct injuries. Of these, 174 surgical departments are presently practicing IOC, 30 routinely. Only 16 injuries to the bile duct occurred in the 6,328 patients who underwent surgery in those 30 units. Approximately 80% of these injuries were discovered during surgery because of IOC and were treated immediately. A significant difference was found between these rates and those reported by units that performed IOC selectively. Only 58% of bile duct injuries were discovered at the time of surgery in units performing selective cholangiography. In addition, it appears that IOC helps to avoid bile duct injuries; the 30 units that performed routine IOC were defined as "learners," as they had performed fewer LCs, and yet they had a significant lower bile duct injury rate than "experienced" centers that did not perform IOC routinely.

A psychodynamic approach emphasizes the meaning and consequences of one's behavior. After a brief review of the literature, the authors present the first of a two-part model for psychodynamic psychotherapy with pathological gamblers. In this first phase, the immediate goal is abstinence, and five strategies for obtaining it are discussed. These consist of 1.) breaking through the denial 2.) confronting omnipotent defenses 3.) interrupting the chasing cycle 4.) identifying reasons for gambling, and 5.) motivating the patient to become an active participant in treatment. An argument is made for integrating a traditional psychodynamic approach with an addictions model.

Traditionally, in psychodynamic forms of treatment, the patient's relationship with the therapist is central to eliciting and exploring the patient's characteristic ways of thinking, feeling and behaving. Research has increasingly demonstrated the significance of the therapeutic relationship to the treatment outcome. Since little has been written about the therapist-patient relationship in the treatment of pathological gambling, we shall describe what we have found to be some of the common and problematic transference and countertransference reactions and interactions. Both positive and negative transferences and countertransferences will be discussed not only as obstacles to successful therapy, but as tools for understanding patients' conflicts, defenses and reasons for gambling.

Objective: Pathological self-mutilation--the deliberate alteration or destruction of body tissue without conscious suicidal intent--was examined both as a symptom of mental disorders and as a distinct syndrome., Methods: Data from more than 250 articles and books were reviewed, as well as data obtained by the authors from their extensive clinical experience in treating self-mutilating patients., Results and Conclusions: The diverse behaviors that constitute pathological self-mutilation can be categorized into three basic types: major--infrequent acts that result in significant tissue damage, usually associated with psychoses and acute intoxications; stereotypic--fixed, rhythmic behavior seemingly devoid of symbolism, commonly associated with mental retardation; and superficial or moderate--behavior such as skin cutting, burning, and scratching associated with a variety of mental disorders. The authors propose that a syndrome of repetitive superficial or moderate self-mutilation should be regarded as an axis I impulse disorder. In most cases, the syndrome coexists with character pathology.

Patients comparable in disease, therapy and serum bilirubin concentration were either treated with mezlocillin intravenously or not at all. The bile of each patient was collected either from a T-drainage or from a percutaneously placed drainage into the bile ducts. The concentrations of GGT and AP, which were liberated by destroyed liver cells, and of bilirubin and mezlocillin, which were secreted actively, were analysed. Those patients who had normal serum bilirubin concentrations had a significantly higher biliary bilirubin excretion than those with high serum bilirubin level. The maximum excretion was after 4 hours. While the biliary concentration of bilirubin decreased, the concentration of secreted mezlocillin increased. Due to destroyed liver cells those patients with pathologically elevated blood bilirubin levels had a 50-fold lower mezlocillin excretion than those with normal blood values.

Over the past three decades, gambling has been the nation's fastest growing industry. Although there is now some leveling off, states are still turning to legalized gambling to address financial problems without having to raise taxes. In addition, there is new technology that produces more rapidly addicting games. States are accepting some responsibility and, as of this writing, 12 of them have funded some programs in public education, research, training, and treatment. Although there are only a half dozen inpatient programs and very few qualified counselors and therapists, we can anticipate the development of clinics, residential programs, halfway houses, and alternative sentencing programs. The National Council on Problem Gambling has developed guidelines for the certification of gambling counselors. In addition to the training of mental health professionals, workshops are needed for attorneys, judges, probation and parole officers, and prison administrators. Initially, the task of assessing and diagnosing the pathological gambler was left to a small number of experts. Starting with DSM-IV, there will be clear and reliable criteria available to the professional community. These criteria, which are the product of thorough testing, should easily discriminate the pathological gambler from other types of gamblers. Most of what we have learned about pathological gambling has come in the last 5 years. A major impetus for research has been the Journal of Gambling Studies, which began publication in 1985. A review of the nature and course of the disorder, including the studies of criminal behavior, leads one to conclude that the majority of pathological gamblers (at least 70% to 80%) commit offenses late in the disorder and that these offenses are strictly gambling related. This is a population which is essentially nonviolent and which turns to property crimes out of desperation over gambling losses and their sequelae. The minority (in one study 14%) of gamblers with antisocial personality disorder--the group for whom treatment would be least likely to be effective--can be recognized easily both by the pattern of offenses and by diagnostic criteria for antisocial personality. Once this group is excluded, treatment for the others, in combination with restitution, community service, and some form of monitoring, would seem beneficial both for the individual and for society. Once they have stopped gambling, pathological gamblers are frequently hard-working people, whose mathematical skills and intelligence, high energy, and need to excel make them extremely valuable at their jobs. The alternative, imprisonment, may very well reinforce the disorder.(ABSTRACT TRUNCATED AT 400 WORDS)

This is a review of the literature on pathological gambling prepared for the work group on disorders of impulse control, not elsewhere classified of the American Psychiatric Association. It introduces the new DSM-IV criteria as well as outlines the phases of the career of the pathological gambler. Research discussed includes that on pathological gambling and psychiatric disorders, substance abuse, family issues, children, finances, and crime. Psychoanalytic, personality, behavioral, sociological, psychologically based addiction theories, and physiological research are also summarized. Finally, treatment outcome studies are outlined.

Pathological self-mutilation appears as a non-specific symptom as well as a specific syndrome. Since psychotic persons may commit horrifying acts, such as enucleation of an eye or amputation of a body part, identification of high risk patients is crucial. Stereotypical self-mutilation, such as head banging and biting off of fingertips, is associated with mental retardation and with the syndromes of Lesch-Nyhan, deLange, and Tourette. This type of self-mutilation is the focus of biological research or endorphins and on dopamine receptors. Skin cutting and burning, the most common type of self-mutilation, is often associated with personality disorders, post-traumatic stress disorder, and multiple personality disorder. When cutting and burning become established as responses to disturbing psychological symptoms on environmental events, a specific Axis I impulse disorder known as Repetitive Self Mutilation may be diagnosed. Patients with this newly identified syndrome may alternate their direct acts of self-mutilation with eating disorders and episodic alcoholism.

There is a kind of transitional phenomenon found among certain borderline patients which is quite distinct from Winnicott's transitional object. These are patients who are preoccupied with maintaining proper physical distance from their objects, in order to regulate anxieties about isolation on the one hand, and identity-annihilating closeness on the other. Since they believe the activity of looking to be intrusive and devouring, hence dangerous, transparent screens are interposed between self and other, and serve as protective barriers. These screens function intrapsychically as well, to split off or hide those aspects of the self felt to be unacceptable. The analyst may witness the failure of the screen in several ways: it may create too great a distance, isolating the individual and keeping him from life; it may become contaminated by projections and turn into a persecutor, or trap the individual, a state of intolerable claustrophobia; most dramatically, it may suddenly shatter. The latter is associated with psychosis and death, and its appearance may be a harbinger of suicide.