Journal of Life Sciences Volume 8 Number (3)
JLS
Journal of Life Sciences
Volume 8, Number 8, August 2014 (Serial Number 76)
Contents
Pathology and Laboratory Medicine
633 Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins for the Detection of
Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
Gustavo Henrique Pereira Dutra 640
Individual Care Pathways in the Context of Complex Therapeutic System—Therapeutic Model and Case Report
Kálmán Erdélyi 648
A Comparative Study on Feeding Practice and Nutrition Status among 6-23 Months Age Children
Taslima Khatun, Md Shahjahan Matabbar, Manika Rani Sarker, Asad-Ud-Daula and Asirul Hoque
Botany and Zoology
Effect of Salinity Stress and Mutagenic Sodium Azide on Callus Induction and Plant Regeneration of Borage (Borago officinalis) in Vitro
Al-Mohammed Maher H. S., El-Kaaby Ekhlas A. J., Al-Anny Jenan A. and Musa Abdul-kadhim J.
668 Effect of Fermentation on Nutrient and Anti-nutrient Composition of Millet (Pennisetum glaucum)
and Soyabean (Glycine max) Blend Flours
Anthony Ojokoh and Babatunde Bello 676 Toxic Effects of Seed Methanolic Extracts of Endemic Albizia Species (Fabaceae) from
Madagascar on Animals
Hanitra Ranjàna Randrianarivo, Anjarasoa Ravo Razafindrakoto, Holy Christiane Ratsimanohatra, Lovarintsoa Judicaël Randriamampianina, Clara Fredeline Rajemiarimoelisoa, Lolona Ramamonjisoa, David Ramanitrahasimbola, Danielle Aurore Doll Rakoto and Victor Louis Jeannoda
690 Distribution of Origanum vulgare L. and Population Dynamics During the Last Decade in
Armenia
Armine Abrahamyan, Arvids Barsevskis, Sara Crockett and Andreas Melikyan
Interdisciplinary Researches
Economic and Market Analysis of Swine Rearing and Pork Production in Ghana
Kwamina Ewur Banson, Josephine Nketsia-Tabiri, Kweku Anno and Emmanuel Kofi Dagbui 709
Challenges in Forensic DNA Profiling and Critical Issues in Interpretation of STR Profiles
Seah Lay Hong
716 Physico-chemical and Bacteriological Specification Groundwater of Tangier
Asmaa Fakih Lanjri, Asmae El Cadi, Anass Lalilti and Jamal Brigui
Aug. 2014, Vol. 8, No. 8, pp. 633-639
Journal of Life Sciences, ISSN 1934-7391, USA
DAVID PUBLISHING
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
Gustavo Henrique Pereira Dutra Aquário Municipal de Santos, Avenida Bartolomeu de Gusmão s n Ponta da Praia-Santos-SP, 11030-500, Brazil
Received: June 18, 2014 / Accepted: August 15, 2014 / Published: August 30, 2014.
Abstract: Hepatic lipidosis is a common lesion in chelonians and may be related with vitellogenesis, hyperparathyroidism, follicular stasis, fatty diets or lacking nutrients, sedentary life and obesity, bacterial toxins in liver and starvation. Clinical signs are unspecific. Routine biochemical tests don’t have specificity and it is better defined through biopsy. The objective was evaluated the biochemical hepatic profile of red footed tortoises (Chelonoidis carbonaria) with the histopathological findings of lipidosis by laparoscopic biopsy. Samples of blood were collected for biochemistry of thirty-six animals from two different groups, twenty animals from a zoo and sixteen from a breeder. The animals were submitted to liver biopsy by videolaparoscopy. Three fragments were collected, two of them were processed by histology and one went to electron microscopy. Nineteen tortoises from the zoo had lipidosis in laparoscopy and macrovesicular degeneration. Fifteen tortoises from the breeder had microvesicular degeneration. The diagnosis of steatosis was confirmed by electron microscopy. There was no statistical difference of aspartate aminotransferase levels between the two groups; however there was significant difference of triglycerides levels. The enzymatic activity of transaminases is not related to the histological grading of lipidosis in tortoises, however triglycerides levels are higher in animals with more severe gradation.
Key words: Biopsy, steatosis, liver, Chelonoidis, enzymes.
1. Introduction are two fundamental types of steatosis: macrovesicular and microvesicular [7-11].
The chelonian liver acts in the metabolism of lipids, Liver enzymes are known markers of hepatocellular glycogen and protein [1]. It is responsible by the damage and cholestasis, but are nonspecific in degradation of nucleotides for uric acid excretion, and indicating the causes of the pathological states and acts as the main storage of fat in the body. Its interpretation can be challenging due to presence of functions may change during events such as isoenzymes and different causes of induced activity. hibernation and reproduction in females, when More definitive diagnosis are often only reached on vitellogenesis and protein synthesis increase, and the biopsy [12-14], and in chelonians it is invasive, liver may be larger and with changes in color and through the inguinal fossa [15] often by texture [2]. Such variations are important differentials
videolaparoscopy.
for primary or secondary liver diseases. Clinical signs, hematological and biochemical Steatosis or hepatic lipidosis represents the variations are often nonspecific. Tests of biliary excessive and abnormal accumulation [3] of lipids function have not been validated in chelonians. (triglycerides) within the hepatocyte [4-6]. There Lipidosis indicators also include cholesterol and
triglycerides [16].
Corresponding author: Gustavo Henrique Pereira Dutra, DVM, research field: experimental and comparative pathology.
The objective of this work was to evaluate the E-mail: dutra@kingnet.com.br.
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
diagnostic value of hepatocellular damage and Laborlab® (Laborlab® Guarulhos, SP, Brazil) at 37 cholestasis enzymes activity, triglycerides, and basic
ºC.
serum protein profile for the diagnostic of hepatic Core biopsies (measuring two centimeters by two lipidosis in red footed tortoise (Chelonoidis
millimeters) of hepatic tissue were collected with a carbonaria, SPIX, 1824).
semi-automatic guillotine biopsy cutting needle (gauge 15) TEMNO® (Allegiance Healthcare
2. Materials and Methods
Corporation McGaw Park, USA), and images of the
A total of 36 red footed tortoises (Chelonoidis hepatic surface were taken using the laparoscopic carbonaria, SPIX, 1824) were assessed. Twenty
probe. After intubation and anesthesia with isoflurane animals (11 males and 9 females) were from
(Forane® Abbott, São Paulo, SP, Brasil), the animals “Fundação Parque Zoológico de São Paulo” (São
were placed in dorsal recumbence and a surgical Paulo Zoo) and sixteen (8 males and 8 females) were
access was opened through the right inguinal fossa, from a commercial breeder. The tortoises from the
through a small incision through which was Zoo had a protein-rich diet (ground beef, sardines and
introduced a five millimeters laparoscopic probe boiled egg) that was offered in alternate days, and
Olympus® (Olympus Optical Medical do Brasil-São daily, they were fed pumpkin, carrot, banana, apple
Paulo-SP Brazil), under halogen light. and papaya and dark greens. The tortoises from the
Two hepatic fragments from each animal were breeder were fed vegetables, greens and fruits daily.
submitted to histological processing for hematoxylin This experiment was approved by the Diretoria de
and eosin, Masson’s trichrome, and Periodic acid-shiff Ecossistemas do Instituto Brasileiro do Meio staining. A third fragment was fixed in glutaraldehyde Ambiente e dos Recursos Naturais Renováveis at 2% for ultrastructural study. The contrast of the (Environmental Brazilian Agency; license 30/2002,
ultra-thin slices of about 90 nm was given by uranyl process 02027.003103/02-49) and by the University of
acetate at 2% and lead citrate. The electro São Paulo, College of Veterinary Medicine, Internal
micrographs were obtained in electronic microscopy Animal Care and Use Committee. Before the studies
of transmission Philips EM-201C (Koninklijke Philips all the animals were fasted for 24 h in a temperature
Eletronics®, Amsterdam, Netherlands). controlled room (27 ºC to 32 ºC). The animals had an
The statistical analysis was done using Biostat for average weight of 3.6 kg.
Windows 2009® (Analystsoft® Inc, USA). The The chelonians were washed with povidine-iodine
Kolmogorov-Smirnov’s test was applied to verify that degerming with polyvidone iodine at 10% (Laborioide
the curve assumed a Gaussian distribution. A degermante®, Segmenta, Ribeirão Preto-SP, Brazil),
two-tailed t test was used for average comparison of sedated with ketamine hydrochloride (Dopalen®, 100
each biochemical evaluation and independent samples mg/mL, Vetbrands Jacarei-SP-Brazil) dosage of 60-80
were compared using the Mann-Whitney’s test. mg/kg intramuscularly. Five milliliters blood aliquots
3. Results
were then collected via jugular or coccygeal vein, and the serum was immediately cooled at 4 ºC.
The data regarding biochemical serum analysis of
The serum samples were analyzed in a animals from the Zoo are grouped in Table 1 and from semi-automatic biochemical analyzer with variable
the breeder in Table 2.
wavelength filter, Bio 2000 (Bioplus® São Paulo, SP, There was no need of pneumocoelom for Brazil) for AST, ALT, ALP, GGT activities; and
visualization of the coelomic cavity. After the biopsy, triglycerides, total proteins and albumin from there was a small bleeding in the liver surface that was
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins
for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
Table 1 Serum biochemical values of red footed tortoises of zoo, Sao Paulo, 2003.
(g/L) A/G Female
Gender AST ALT
Glob µkat/L
µkat/L
(mmol/L) µkat/L
µkat/L
(g/L)
(g/L)
1.5786 0.1424 0.2724 0.0145 0.2724 13.873 6.8087 11.334 0.3964 SEM 0.353 0.0318 0.0609 0.0033 0.0609 3.1022 1.5225 2.5345 0.0886 variance 2.4919 0.0203 0.0742 0.0002 0.0742 192.4711 46.3579 128.4711 0.1571
AST (Aspartate aminotransferase); ALT (Alanine aminotransferase); TG (triglycerides); GGT ( γ-glutamil transferase); ALP (Alkaline Phosphatase); TP (Total Protein); Alb (Albumin); Glob (Globulin) A/G (Albumin/Globulin Ratio); SD—standart deviation ( σ); SEM—standart error of mean.
Table 2 Serum biochemical values of red footed tortoises of breeder, Sao Paulo, 2003.
(g/L) A/G Male
Gender AST ALT
Glob µkat/L
µkat/L
(mmol/L) µkat/L
µkat/L
(g/L)
(g/L)
1.1599 0.5087 0 0 0 8.2138 4.0249 5.0794 0.3728 SEM 0.29 0.1272 0 0 0 2.0535 1.0062 1.2698 0.0932 variance 1.3455 0.2588 0
0 0 67.4667 16.2 25.8 0.139 AST (Aspartate aminotransferase); ALT (Alanine aminotransferase); TG (triglycerides); GGT ( γ-glutamil transferase); ALP (Alkaline Phosphatase); TP (Total Protein); Alb (Albumin); Glob (Globulin); A/G (Albumin/Globulin Ratio); SD—standart deviation ( σ); SEM—standart error of mean.
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
quickly solved by the natural hemostatic process. The access used for the biopsy by the inguinal fossa There was no death during the experimentation.
allowed clear observation and sampling of specimens, Tortoises from the breeder had laparoscopy images
according to previous works for videolaparoscopy in of hepatic lobes slightly rounded and of magenta color.
chelonians [15, 17, 18]. Contrary to the proposed by One animal had liver wine-colored, soft consistency,
Divers, Stahl and Camus, 2010 [19], even without the tapered edges, not easily pervious to the entry of the
use of pneumocoelom, there was quality on liver needle bevel (Figs. 1 and 2). The great majority of
visualization.
testudine from breeder evidenced severe microvesicular degeneration consistent with glycogen accumulation
or hydropic degeneration, with no associated inflammation or fibroplasia. In animal number 11 from breeder, was observed a preserved histological hepatic architecture, with healthy hepatocytes (Fig. 4), abundant amount of glycogen and none fibroplasia evident in the Masson´s trichrome.
The laparoscopic image of the 19 tortoises from São Paulo Zoo were consistent with fatty liver disease,
with rounded edges, brownish yellow color, unctuous
Fig. 1 Laparoscopic image of a normal liver of red footed
aspect of surface and friable (Fig. 3). The tortoise tortoise.
number 5 had a liver with preserved dimensions, magenta color and soft consistency. After the sampling, the samples were placed in test tubes and almost all of them floated in aqueous solution of formalin.
After microscopic review, 16 tortoises from the zoo had macrovesicular degeneration consistent with lipid accumulation, with eccentric nuclei, but with no inflammation or fibrosis. In tortoise number 5 from the zoo, a mild microvesicular degeneration was observed. In two animals from the zoo, steatosis was
observed throughout the cut length, with heterophilic Fig. 2 Normal left lobe liver biopsy of tortoise.
and mononuclear inflammation (Fig. 5), one of them with mild fibroplasia and the second with marked fibrosis and macrovesicular degeneration (Fig. 6). Ultrastructure evaluation of the all animals from the zoo had electrodense vacuoles typical of lipid droplets (Figs. 7 and 8).
4. Discussion
The open circuit (non-rebreathing) of anesthesia was enough in this study for tortoises up to 5.0 kg for
the technique of hepatic biopsy by coelomic access.
Fig. 3 Right lobe liver biopsy of red footed tortoise.
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins
for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
Fig. 7 Transmission electron micrograph showing Fig. 4 Normal histology of tortoise liver HE 400 ×. electrodense droplets of fat in the cytosol of hepatocyte. Osmium tetraoxide 6000 ×.
Fig. 5 Microvesicular steatohepatitis of red footed tortoise liver HE 400 ×.
Fig. 8 Transmission electron micrograph showing inflammatory cell in hepatic parenchyma of tortoise.
Osmium tetraoxide 6000 ×.
sensitivity for diagnosing chronic fibroblastic injury, where there are fewer hepatocytes, since they are replaced by connective tissue. Also, ALT activity was not statistically between the two groups (t = 1.4401 and p = 0.159; α = 0.05). These findings were similar to what other found for AST and ALT activities [2, 16, 20].
The ALP activity was very low ( x = 0.1675 µkat/L,
Fig. 6 Hepatic fibroplasias in tortoise liver showing
SD = 0.2724) in the animals from the zoo and was
collagen fibers (blue staining) and melanin pigment,
below the minimum detectable limit for the animals
common in reptile liver. Masson’s trichrome 400 ×.
from the breeder. These findings are different from There was no statistical difference on AST activity
what was previously found by others [2, 16, 20]. between the two groups (t = 1.2297 and P = 0.2273),
Despite the lack of analytical sensitivity, the two or between female and male (p = 0.8702 and t = 0.1657,
groups were statistically different (t = 1.4401 and p = tc = 2.1009), in disagreement with Christopher et al.
0.159; α = 0.05). No statistical difference was found (1999) [2]. Testing AST activity may have a low
on GGT activity between the two groups (t = 1.9193
Diagnostic Value of Hepatic Enzymes, Triglycerides and Serum Proteins for the Detection of Hepatic Lipidosis in Chelonoidis carbonaria in Captivity
p = 0.0634; α = 0.05), once more there was a lack of good biomarkers for hepatic lipidosis, or severe liver analytical sensitivity of the test, with low activity for
disease of other etiologies in tortoises. Prior works the zoo animals and readings bellow the detectable
showed that hypertriglyceridemia can also be seen limit for the breeder’s group. Although the steatosis
females with follicular stasis or in vitellogenesis had pathophysiology involves cytosolic and mitochondrial
higher levels of triglycerides [2, 21, 22]. In this work, damage [3-6], which often lead to enzymatic the differences on levels of triglycerides between extravasation or induction of production, the results of
males and females were seemingly random. the enzymatic activities only revealed that AST
The mild fibroplasia and heterophilic and activity was the enzyme with more analytical mononuclear inflammation observed in two animals sensitivity in tortoises, with low diagnostic specificity
from the zoo, appeared to be a progression to cirrhosis for hepatic steatosis gradation. Similarly, others also
[7-11, 23]. The presence of the Mallory’s hyaline found this in other tortoises [2, 16, 20]. corpuscle, one of the criteria suggested in Concentrations of TP were significantly different
classification of steatohepatitis, was not observed in between the two groups (t = 5.9916 and p < 0.0001; α
any of the samples collected from tortoises. The = 0.05) with TP levels from the zoo tortoises being
histopathological findings of microvesicular liver higher than from the breeder ones. These findings
degeneration and macrovesicular lipid accumulation, were likely due to the protein rich diet of the zoo
was also used as prognosticators by others [7-11, 20, tortoises. The TP differences were likely due to
25], as the microvesicular degeneration findings, albumin concentration that was significantly higher in
without associated inflammation or fibrosis is considered a mild pathogenic process, according with
the animals from the zoo (t = 3.7079 and P = 0.0007; α = 0.05). These differences also leaded to a gradation system previously proposed [7-11, 24, 25].
significantly higher albumin to globulin ratio in the The presence of lipid was confirmed by transmission electronic microscopy. Since no differences were
zoo’s tortoises (t = 2.0557 and P = 0.0476; α = 0.05). found between males and females in any of the tests,
These findings suggest that although there were vitellogenesis was considered an unlikely confounder,
macroscopic and microscopic findings consistent with and the nutrition was the probable etiology of the
steatosis in the animals from the zoo, there was no differences between groups [7, 26, 27].
apparent loss in hepatic production of albumin. This is unexpected since steatosis is knowingly a cause of
5. Conclusions
hepatic insufficiency that could lead to decreased Although there was no correlation between the albumin production [3, 12]. Albumin has a small role activity of hepatic transaminases measured in the in colloid osmotic pressure of chelonians, serum of red-footed tortoises and hepatic steatosis approximately 20%. Very little is known about the
caused by hypercaloric diet, the serum triglyceride transport capacity of albumin in chelonians, the major
levels appeared to be reliable markers of hepatic part of proteins are alpha-1 and alpha-2 globulins,
lipidosis or severe hepatic disease. transferrins, lipoproteins, fibrinogen, isoagglutinins
(globulins) and vitelline [1], which question the
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Journal of Life Sciences, ISSN 1934-7391, USA
DAVID PUBLISHING
Individual Care Pathways in the Context of Complex Therapeutic System—Therapeutic Model and Case Report
Kálmán Erdélyi Újpest Mentalhygienic Outpatient Center, 40-42 Nyár Street, Budapest 1041, Hungary
Received: July 16, 2014 / Accepted: August 12, 2014 / Published: August 30, 2014.
Abstract: A complex multifactorial therapeutic system was established and developed during the past three years. Here present the basic approach and the individualized therapeutic strategies of this therapeutic system by examples of specific case reports. The aim of the study is to point out to the real mission of our outpatient care, namely psycho-social reintegration that is achieved by a therapy with a unique pattern. Case reports: 1. A 59-year-old female patient suffering from psychosomatic muscular tension, which started two years ago. After a partially effective cognitive-behavioral therapy a severe traumatic event in the patient’s past in connection with the symptoms was revealed, then the trauma was processed via psychodynamic approach. 2. A 56-year-old female patient suffering from psychosomatic symptoms and depression went through a therapeutic healing process, which focused on the development and maturation of her personality (from a “child” to an “adult”). Conclusion: All the processes of the complex group-centered dynamic therapy proved more effective compared to the classic static relationship between the psychiatrist and the patient. The multifocal therapy is appreciated more and more in parallel to the experiences gained, making it easier to establish and strengthen the therapeutic alliance. The patients have positive feelings about the help given and the possibilities offered. The author’s therapeutic team is appreciated by the patients and they regard the author’s center as a peaceful location of their lives being under cover, where voluntarily and willingly they can participate in the individualized therapy with great success.
Key words: Complex multifactorial system, individualized therapy, psycho-social reintegration.
1. Introduction residual disability of mental disorders [1]. Leaving the classic static therapeutic model behind, a new system
It is considered that the fundamental tasks of the with dynamic approach, integrative therapeutic outpatient therapeutic work to reach a level of orientation has been developed. The multifactorial stabilization by building a bio-psycho-social unit that system has become more colorful in a way like this. create optimal conditions. The main aim is the All the specialists of the team, namely psychiatrists, psycho-social reintegration achieving optimal state psychologists, art therapist, social therapist and the level and returning patients to their productive lives in nursing staff have their own roles, tasks and the community. Prevention, acute, chronic care and responsibilities. The team members cooperate with therapy together with the stabilization of the each other placing the major problems, actualities of compensated state, that means relapse prevention, are the patients in the centre of interest. The author’s team the basic tasks. Prevention means to decrease the work is characterized by the following sentence: onset (incidence), the duration (prevalence) and the System inside the system. The process of the patient
care with professional cooperation makes it easier to Corresponding author: Kálmán Erdélyi, M. D., research fields: psychiatric rehabilitation, social reintegration through
direct the patients to the appropriate therapeutic way. complex therapeutic approach. E-mail: Providing continuity of care and integrated services is
erdelyikalman@yahoo.com.
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
essential. To maintain the social network is a methods in the author’s outpatient center. challenge, but can be successfully carried out by
Self-knowledge group is a closed, thematized and applying a systemic therapeutic structure. The directed group with the aim improving self-knowledge, complex, advanced special outpatient care allows a
recognizing psychic obstructions. Group with substantial proportion of the patients not to be
emphasis on activity is an open, non-thematized and removed from their home environments or workplaces
non-directed group practicing social relations, sharing and not giving up or losing their individual roles.
experiences via common creative works mostly for The population number of the district the author’s
schizophrenic patients. Free association group is an outpatient center functions is about 100,000. The
open, partially thematized and directed group with annual number of the attendance was 14,264 in 2013.
emotional involvement and sharing. Last but not least Different types of the individual psychotherapy, group
free creative work, namely Art Brut, an open, psychotherapy, art therapy and social therapy are used
non-thematized, non-directed group, creative work according to the basic problem and the current state of
with continuous conversation between the patients. the patient, with or without pharmacotherapy. The
Further joint purposes of art therapy are to reach and community-like service with different therapeutic
to keep in connection with the clients widely and also modalities has the capacity for 120-130 patients per
create a lively and extensive cooperation within the week. Therapeutic options over the classic treatment
team in order to have effective therapy. (control, pharmacotherapy) are presented in short.
In the last year 59 patients took part in art therapies held once a week, the whole number of the
2. Patients and Methods
attendances was 1,440. It should be noted that some of In the last three quarters of the year 172 patients
the patients are involved in more parallel art therapy (the number of the patient’s attendances was 1,304)
sessions.
participated in different psychotherapies, namely 74 In a six-month period of 2013, six different social patients (582 attendances) in individual-, 41 patients
group therapies (Game—with the aim to reach a more (393 attendances) in verbal group-, 37 patients (193
balanced way of life discovering the joy of playing attendances) in stress management group and mobilizing emotions; Psychoeducation; psychotherapy and 20 persons (136 attendances) in
Living—means a complex management of unhealthy autogenic training [2, 3]. Summary of the therapies
lifestyle and the purpose is to improve the patient’s performed by psychologists is presented in Table 1.
quality of life and to make more conscious decisions Art therapy [4, 5] means four groups and four
in everyday life, mostly for schizophrenic patients; Art
Table 1 Summary of the psychological therapeutic modalities. Individual therapy
Verbal „free-association”
Autogenic training
Stress management
group therapy
group therapy
Verbal elaboration and
Treatment of stress reframing of the client’s
Exploration of the internal
context of psychological and
12 steps structured excercises
induced physiological,
Content
emotional, cognitive problems
interpersonal problems
reactions
Reduction of physiological
Improvement of coping Purpose clients, individual goals
Fitting to the needs of the
Improvement of self-reflection symptoms, improvement of
and interpersonal relationships self-regulation and relaxation
Adults with mental
Adults with psychological and Adults suffering from anxiety
Adults suffering from
group
disorders
interpersonal problems
disorders
mental distress Closed, small group structured Educative, structured (5
Form
Two-participants situation Open verbal small group
in time (12 sessions) and method (relaxation practice)
sessions), small group
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
therapy—creative techniques which help the patients by a multicolored, branchy tree with broad trunk is to express their emotions; Literature; Literary shown (Fig. 1). group—lecture, talking, watching movies, discussion
3. Case Reports
of novels and poems with the aim to be able to establish social contacts with group experience and
Below the specific pattern of the unique therapeutic improve self-knowledge and motivation) were started
way is being demonstrated the specific pattern of the with 83 patients and they attended 602 times
unique therapeutic way through specific cases, altogether.
proving the advantages of this caring approach and Social skills therapy is very essential for the chronic
practice, such as: 1. The voluntary, active latching on schizophrenic patients [6]. Both art therapy, to the programs. 2. The connection of the patient into psychoeducation, group therapy and recreational the care system through the experience of subjective activities, like common organized programs (visit to
usefulness. 3. The sense of security of the staff and the the museum, weekend trips) are very important to help
patients based on the fact, that a patient maintains the the patients to be interested in each other and become
connection—by the needs of his condition: voluntarily able to contact each other step by step.
and actively with the outpatient center and the These above-mentioned therapeutic options ensure
therapeutic team.
the complexity of the system and thus give the real M.I., a 59-year-old single woman (Fig. 1 Patient #4) chance to put the individualized care pathway into
was admitted to the author’s outpatient center practice [7]. A tree diagram symbolizing both the
suffering from psychosomatic trapezius muscular
classic and the patient-specific individualized model tension, which started two years ago. Awaking at
Fig. 1 Individualized care pathways based on the classic model.
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
nights she usually found her hands firmly clenched. the symptoms was revealed, then the trauma was Formerly she had panic disorder effectively treated by
processed via psychodynamic approach. pharmacotherapy. At the beginning of the therapeutic
Having finished pharmacotherapy (SSRI and contact the author had a first impression, that she was
benzodiazepine) and psychotherapy held for one year,
a highly self-limited, inhibited lady, who had to make the client joined the “Group with Free Association” constant efforts to be appreciated by her actual milieu.
(art therapy) and participated in it regularly, once a Emotional stress was often associated with the
week for one year. She associated drawing with prolonged contraction of neck muscles. Symptoms
self-knowledge. At the beginning she was somewhat fluctuated over time and might have been most intense
disturbed and she put a question to herself: “I wonder during periods of stress.
who I am” (Fig. 2). Slowly she learned to express She was directed to the author’s psychologist,
herself, her own feelings through her drawings, art whose first therapeutic step was the cognitive therapy
works in front of the members of the group. She with the aim to attain relaxation practice and to
learned to accept herself. Pleasure and high-level improve coping skills. At the very beginning of the
expression characterized her creative activities. cognitive and behavior therapy it came to light that
The difficulties she experienced in the individual she had a car accident and had been suffering from the
therapeutic process were drawn including her hope for above-mentioned symptoms generated by that trauma.
a more pleasant future without any difficulties (Fig. 3). The therapist (the author’s psychologist) overcame the
The next group of art therapy she joined after a year patient’s denial of the traumatic event, encouraged her
was the “Self-knowledge Group” working with the to relax and removed her from the source of the stress,
aim to improve self-knowledge. It’s a closed,
thus took the necessary steps to reduce the mental thematized, directed group with limited number of stress instead of leaving the process to be converted
participants. In addition, due to the positive effects of into somatic symptoms. The patient couldn’t recall the
drawing she joined another group, the free creative details of the incident, that’s why hypnotherapy was
the second psychotherapic intervention. The patient in
a hypnotic trance could recall memories and could describe an event with an intensity similar to that when it occured and experienced a sense of relief as a result. Her symptoms suddenly renewed and the psychotherapy became less efficient.
At this point she recalled another trauma from her past. At the age of 14 she became a victim of sexual violance, she was raped. The patient and the therapist worked together, aiming to resolve the problem and the patient actively participated in the treatment. All those therapeutic techniques, like suggestion and reassurance were aimed at decreasing the client’s anxiety.
Summarizing the above-mentioned after a partially effective cognitive-behavioral therapy a severe
Fig. 2 Different faces of her identity. Searching for
traumatic event in the patient’s past in connection with
herself.
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
intense feeling of solitude, though a compensatory coping mechanism seems to emerge: she can observe herself now from an outside, self-reflective perspective, which is essential for grounding her inner emotional stability (Fig. 4).
Now her mental state is stable. She finished pharmacotherapy two years ago and she has been drug-free since then. She is able to formulate exactly what she really wants and what she can do.
B.T.P, a 52 years old female patient (Fig. 1 Patient #2) suffering from psychosomatic symptoms and depression became engaged in therapy. She has been visiting the author’s outpatient center since January 2010 suffering from the above mentioned symptoms and demotivation. She felt that she was useless and
that her family despised her for not having a job,
Fig. 3 That’s my way. Step by step to the balance.
though she had sacrificed herself for them. The group “Art Brut” for drawing occasionally. After two
therapeutic process focused on the development of her years it was the first time the client was able to talk
personality as a whole (holistic, dynamic approach) about the sexual violance she suffered from in front of
[8]. Her “obsessions”, such as painting, meant a lot to people.
her, she always had compulsively driven activities in The patient had a look at herself from the window
her life. Blue tones dominated the painting creating a of a ship cabin: she became able to observe herself,
depressive atmosphere, and a hysteric appearance of her actual state, and her psychic, emotional actions
the whole character, too. The emphasized silhouette of from an outside perspective. The picture reflects an
the lips radiated toughness, which attribution could be
Fig. 4 Outside perspective Exploring new ways of self-reflection.
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
generally observed in the patients’ behavior during group therapy sessions (Fig. 5). She refused to soften up her firmness as an organic attribution of her personality and fended off her negative emotions (traumas), though she became really engaded to the art therapy group. As the result of the multifocal therapy she showed significant improvement in her coping mechanisms, her conversive symptoms eventually vanished. At the end of the therapeutic process her psychosomatic symptoms escaped from the focus of her thoughts, so her emotional distress relieved. She had problems with handling conflicts, but eventually she showed a significant progress on that field, too. She went through a therapeutic healing process, which focused on the development and maturation of her personality from immaturity to adulthood (Figs. 6 and 7).
4. Results
Fig. 5 Self portrait in blue.
The individually customized complex therapeutic system with dynamic approach and integrative therapeutic orientation fits the real needs of the patients. The team succeeded both in stabilization of the psychological state, relapse prevention and the social field enhancing socialization, conversational skills. That means this complex model gave all the patients in the program more chances for social reintegration. The author’s community-like service with different therapeutic modalities proved to be
effective in returning patients to productive lives in
Fig. 6 “I used to be …”.
the community. The afore-mentioned personal experiences are confirmed by concrete data of the study as follows. The research focused on the efficiency of the complex therapeutic care of the different patient groups separated by the therapeutic modalities.
The number of the patients was 175. The objectives were 1.) Compare the different therapeutic modalities
and their efficiencies measured by quantitative
methods and 2.) Differentiate according to the
concrete psychiatric diagnosis, which means to realize
the changes measured in the different patient groups.
Fig. 7 “… then I’ve found myself”.
Individual Care Pathways in the Context of Complex Therapeutic System
—Therapeutic Model and Case Report
The psychological tests used in the study are system allows the authors’ team to plan the complex CISS–48 (coping); SCL–90-R (inventory of rehabilitation program for the patients, and to ensure, psychopathological symptoms); Zung (depression)
that the patients attend to the programs fitting to their and STAI (anxiety).
unique needs [9].
The results of the psychological tests according to According to the author’s basic therapeutic the therapeutic modalities up to the present are as
approach it’s the individual himself with his own follows.
problems, symptoms, past and present, who is in the (1) Classic static model (pharmacotherapy) versus
focus of the therapy. The therapeutic options are individual therapy with dynamic approach: The
offered within the framework of the author’s individual therapeutic way confirmed significant
multifocal system providing the psychological sense reverse tendencies in the grade of somatoform,
of security. The patients are informed in details and obsessive-compulsive, mood, anxiety symptoms and
can make decisions with the help of the therapeutic in interpersonal hypersensitivity, enmity, trait anxiety,
staff. During the therapy the patients proceed step by too.
step and parallel to the state improvement new (2) Classic static model versus group therapies
therapeutic sets at a higher level become available. (social-, art- and psychotherapy): The patients treated
All the process of the complex group-centered by the methods of the classic model stayed with the
dynamic therapy proved more effective, than the emotion-oriented coping, depression and paranoia
classic static one [10]. The therapeutic way—with its among these patients remained at higher levels
main stages—could be compared mostly to the significantly.
maturation and detachment of the frail child. During The results according to the psychiatric diagnosis
the care pathways the experiences of the patient have are as follows.
positive significance. The patient can participate in (1) The tendency of avoidance-oriented coping
creating and realizing the plan of the treatment as a decreased significantly in the group of schizophrenics.
partner. The patients have positive feelings about the (2) The tendency of emotion-oriented coping and
help given and the possibilities offered. The trait anxiety decreased significantly in the group of
multifocal therapy is appreciated more and more in patients with mood disorders.
parallel to the experiences gained, making it easier to The research program is going to be continued with
establish and strengthen the therapeutic alliance. The enlarged method and test batteries.
author’s team is appreciated by the patients feeling the
In the case reports the psychosomatic and author’s center a peaceful location of their lives being depressive symptoms have improved, furthermore the
under cover, where voluntarily and willingly they can functioning of the patients’ personalities has moved to
participate in the individualized therapy with great
a more mature direction. success. The leading thought of the author’s therapeutic system is as follows: “When someone
5. Conclusions
helps You, it is not a failure, it means that You are not In the author’s Mentalhygienic Outpatient Center
alone.”
built up a complex, multifactorial therapic care system,
Acknowledgments
which stands for helping the patients to create and to retain their physical-mental harmony, and to
The author offers very special thanks to Anna Pálos strenghten their social adaptability in order to help
art therapist and Tamás Nagy psychologist for their their social reintegration. This complex therapeutic
conscientious work and professional help. The author
Individual Care Pathways in the Context of Complex Therapeutic System
647
—Therapeutic Model and Case Report
thanks the two patients (case reports) for giving their The Guilford Press, A Division of Guilford Publications, 106-111.
consents to include their histories and drawings in this [6] Kaplan, I. H., and Sadock, B. 1994. Synopsis of
publication. Of equal importance are all the clients, Psychiatry. Baltimore: Williams & Wilkins, 483-485. who have taught me about the power and value of the
[7] Erdelyi, K. 2014. “Egyedi Gondozási Utak a Komplex complex therapy in personal growth, recovery, and
Ellátórendszer Keretében (Individual Care Pathways in the Complex Care).” Presented at the 8th National
well-being. Congress of the Association of the Hungarian
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Section B: The Sciences and Engineering 73 (3-B): 1839.
Aug. 2014, Vol. 8, No. 8, pp. 648-659
Journal of Life Sciences, ISSN 1934-7391, USA DAVID PUBLISHING
A Comparative Study on Feeding Practice and Nutrition Status among 6-23 Months Age Children
1 2 1 3 Taslima Khatun 1 , Md Shahjahan Matabbar , Manika Rani Sarker , Asad-Ud-Daula and Asirul Hoque
1. Faculty of Public Health, Department of Community Nutrition, Bangladesh University of Health Sciences (BUHS), Dhaka-1216,
Bangladesh 2. Nutrition expert, Urban Partnership and Poverty Reduction Project, UNDP, Bangladesh 3. Applied Nutrition and Food Technology, Islamic University, Kustia, Bangladesh
Received: June 12, 2014 / Accepted: August 20, 2014 / Published: August 30, 2014.
Abstract: To investigate the Infant and Young Child Feeding Practice and Nutrition status among 6-23 months age group children in nutrition intervention (national nutrition program) and non-intervention areas. Nutrition intervention has been proposed to reduce the risk of malnutrition. It was a comparative cross-sectional study. A total of 360 households, of which 180 were from the nutrition intervention area each with at least a child aged between 6-23 months were randomly selected. Statistical package for Social Scientists (SPSS/PC + ) was used for data entry and analysis. Nutritional status that is weight-for-age, height-for-age and weight-for-height were computed using anthro software. T-test, chi-square and Pearson’s correlation (p < 0.05) were administered to compare the two groups. There was a significant difference between the intervention and non intervention groups in relation to the incidence of initiation of breast feeding, prelacteal and exclusive breast feeding and complementary feeding (p < 0.05). The prevalence of wasting (p = 0.004), stunting (p = 0.015) and underweight (p = 0.003) was observed to be greater for non NNP area compared with the group of NNP area and association was found between those areas. In the study showed that the Infant and Young Child Feeding Practice and Nutritional status are better in nutrition intervention area.