A Psychological Profile of the Bariatric Patient with Implications for Treatment

Background: Psychological testing of the bariatric patient utilizing instruments such as the MMPI have not proven useful in predicting successful weight loss following bariatric surgery. This has led many physicians and professionals who treat bariatric patients to believe that psychological testing is of no value. This paper discusses three instruments and the psychological profile of the average bariatric patient that they provide, and how the profile may be of benefit to the bariatric patient and to professionals who treat them. Methods: The profile to be presented was obtained from the statistical analysis of the tests of 70 patients selected by random sample from a population of 695 patients. Results: Results suggest that the average bariatric patient is mentally healthy and free of any psychological disorders contraindicating surgery. Although mentally healthy, the results suggest that the average bariatric patient does have a number of attitudes, behaviors, and personality traits which may sabotage weight loss following surgery. Conclusions: The psychological profile obtained from the data provides valuable information toward the development of a comprehensive treatment program designed to improve these potentially sabotaging attitudes, behaviors, and personality traits, in order to facilitate successful weight loss following bariatric surgery.     

Self-reported involvement of family members in the care of adults with CF.

BACKGROUND: Few empirical studies have examined the role of family caregivers in the lives of adults with CF. METHODS: As part of the Project on Adult Care in CF (PAC-CF), an on-going prospective, longitudinal panel study of adults with CF, 119 family members and friends of adults with CF completed a mail survey in which they reported the frequency of help they provide for their family member with CF during routine care, hospitalization, and home IV treatment. RESULTS: The 119 caregivers were mainly spouses or unmarried partners (56%) and parents (29%). Fifteen percent of caregivers were children, friends, siblings or roommates. Family caregivers for adults with CF report assisting mainly with communication and social support during routine treatment, although one third provide some clinical care on a regular basis. Family caregivers report an increase in assistance during periods of acute illness, such as during a hospitalization and home IV treatment, especially with clinical care tasks. CONCLUSIONS: The depth of commitment required of families of children with CF has been well documented for decades. Our results suggest that the responsibilities of family members diminish only moderately as those with CF reach adulthood.     

Beyond Bariatric Surgery … Complications We Fail to Address

As we progress in the field of bariatric surgery, improving methods and fine tuning operative procedures, we witness many benefits. Fewer complications, shorter hospital stays, and more evidence of successful weight loss consistently appear in the statistics that have been accumulated through years of research. The information provided, continues to verify that surgery is the most viable treatment for morbid obesity. There is minimal literature, however, that addresses the emotional issues faced by the patients who have undergone bariatric procedures. Postoperatively we may find at intervals of 3 months, 6 months and even 1 or more years, a patient struggling to deal with their identity. The resolution or improvements of various medical anomalies, may seem insignificant as the patient now begins to focus on emotional and physical changes. Their bodies' new shape may create distressing personal concerns. Family members may also struggle with these psychological and physical changes. The surgery has forced the patient to deal with the loss of a love that is not easily replaced, the love of food. These, all too frequently, are the actual postoperative complications of surgery. Although we must continue to monitor physiological complications, co-morbidity changes, and weight loss, most importantly, we must also understand our responsibility to address the patients' emotional well-being. While indicating our concerns for the psychological as well as physiological recovery, the patient may then realize a healthier transition into life beyond bariatric surgery.     

家属对晚期肿瘤患者实施预立医疗照护计划态度的质性研究

目的 了解家属对晚期肿瘤患者实施预立医疗照护计划的态度,为姑息照护领域相关医疗决策的制定提供依据.方法 对17名晚期肿瘤患者家属进行深度访谈,采用现象学分析法分析资料.结果 家属对预立医疗照护计划的态度提炼出4个主题:如患者主动提出,自己愿意支持;预立医疗照护计划本意较好,但不忍患者面对;预立医疗照护计划本身存在一定缺陷,效果令人质疑;目前实施有难度,将来有望推广.家属对晚期肿瘤患者终末治疗的选择提炼出2个主题:不忍患者受苦,选择放弃抢救;进退两难,抢救为无奈之举.结论 晚期肿瘤患者家属在认可预立医疗照护计划的同时存在很多顾虑,知晓抢救的无效性但因外在压力和良心不安选择抢救;医护人员应做好家属健康教育,并协助家属与患者、家属与家属之间进行坦诚沟通,以推广预立医疗照护计划的理念.     

Past, Present, and Future of Obesity Surgery

Background: At the meeting 1 year ago, Mary Lou Walen asked the author to provide a brief luncheon talk about the past, present, and future of obesity surgery for the Allied Health Sciences members who meet in conjunction with the annual meeting of the American Society for Bariatric Surgery. This led the author to examine the surgical treatment of severe obesity as it relates to our times and society. Edward O. Wilson has recommended that bariatric surgeons enlarge their view of the work they are engaged in, to include a more universal perspective. From this review, the following talk was presented.     

What Do Patients, Families and Society Expect From The Bariatric Surgeon?

The expectations of patients, their families and society of the bariatric surgeon are often unrealistic, but for different reasons. The morbidly obese patient often expects ‘everything’ from bariatric surgery. The patient's family is frequently ambivalent. Society, on the other hand, tends to unrealistically regard the morbidly obese as billboards advertising them as willful deviants whose problems can all be resolved by ‘just pushing away from the table’. This invalid stereotype has prompted some to incorrectly regard bariatric surgery as an undeserved reward for individuals who will not control their own behavior. The undeserved intentional deviant status of the morbidly obese causes members of society to harass, mock or otherwise mistreat this subpopulation. Society's harmful, destructive and unjust weight harassment ‘fat-ism’ has made the morbidly obese modern day moral equivalents of lepers. We conclude that society must be persuaded to accept weight harassment as ‘politically incorrect’, subject to the same consequences as any other form of bigotry. Once society regards the morbidly obese as victims, not perpetrators, of their nonsurgically curable disease, bariatric surgery results should become held to similar standards as surgery for carcinoma, cardiovascular and other diseases. Until then, the morbidly obese remain the last true bastion of prejudice.     

Positive Psychological Impact of Bariatric Surgery

Background Psychological impact of bariatric surgery has been described mostly in terms of reduction of psychopathology. This exploratory study examines the impact of bariatric surgery in terms of positive psychological growth and development. Methods 57 patients who underwent LAGB were recruited to this study; 31 patients (54.4%) completed a questionnaire battery 1 year or more following surgery. Positive impact was assessed using the posttraumatic growth questionnaire. Mental and physical health were assessed using the SF-36. Family support was assessed using the perceived family support questionnaire and weight loss measure was assessed using measured weight differences prior to and 1 year after surgery. Results Positive impact was apparent in all dimensions including greater appreciation of life, increased sense of personal strength and improvement in relating to others. Positive impact appears to be independent of physical and mental health as well as of family social support. Conclusion Positive impact of bariatric surgery is a substantial outcome and should be examined further. Positive impact of bariatric surgery should be taken into account as a therapeutic tool in positive oriented psychological interventions following bariatric surgery.     

Can a Bariatric Surgery Program Succeed Without Close Patient Proximity? The Experience in a Military Medical Centre

Many centers advocate close patient follow-up and a multidisciplinary approach as necessary ingredients for the success of a bariatric surgery program. The military medical environment is not suitable for these conditions. Many patients are referred from great distances to the large regional medical centers, thereby preventing such close follow-up and the ability to create active support groups. A review of the 4-year experience with bariatric surgery at a major military medical center was conducted to determine if the program could be successful, considering that 60% of its patients came from out of state. Hospital records of all 92 patients and the bariatric registry were reviewed. A comprehensive survey to update weight data and assess patient satisfaction was sent to the first 72 patients to undergo surgery. There were no deaths and a perioperative complication rate of 18%. By 1 year after surgery, 67% of patients lost greater than 50% of their excess weight (mean = 56.6%). Sixtyeight percent of patients responded to the survey; 87% felt they were better off and satisfied with their quality of life since surgery, and 75% reported improved energy levels. If given a chance to rethink their decision, 86% of responders would choose surgery again. A total of 91% were satisfied with their follow-up. Patient proximity to the medical center did not influence weight loss or patient satisfaction. These results suggest that a bariatric surgery program can succeed in a medical environment such as the military where patients are likely to live at great distances from the hospital.     

Informed consent issues in the conduct of bariatric surgery

BACKGROUND: The goals of this article are to set forth the principles involved in obtaining informed consent in the context of bariatric surgery and to change the widely held perception that proper informed consent is an empty paper exercise. The ever-expanding use of bariatric procedures is associated with a profusion of data regarding the risks, benefits, and expected outcomes. It is now possible for physicians who perform bariatric surgery to know the reported data on the morbidity, mortality, and rehospitalization rates. Communicating this information to prospective patients is necessary for the process of informed consent. METHODS: A literature review of the work done in the areas of informed consent as it relates to bariatric procedures was performed to provide state-of-the-art information of this important topic. RESULTS: Ethically, the concept of informed consent arises from the deep-rooted American respect for the independence of one's right to decide what is or is not done to one's body. Legally, the physician has two duties: to obtain consent and to provide information to allow the consent to be informed. The elements required for proper disclosure and consent have been codified by a variety of professional organizations. CONCLUSION: Done properly, informed consent allows patients to have a more realistic expectation of the outcome and could also allow more effective participation in their own care. We conclude with possible directions for additional research, improvement of the consent process, and the inclusion of new technologies as they arise.     

Obesity disease burden and surgical risk

BACKGROUND: The rapid national expansion in bariatric surgical procedures has been accompanied by recent reports of significant complication rates. This has resulted in increased public scrutiny of bariatric surgery outcomes, restrictions on patient eligibility criteria by payors, and credentialing requirements for providers. This focus on outcomes has resulted in interest in bariatric risk analysis. METHODS: During an 8-year period, 1210 patients were evaluated for bariatric surgery. Clinical information was recorded prospectively. Co-morbid medical conditions were analyzed according to proven surgical risk factors: age, body mass index (BMI), and male gender. RESULTS: The prevalence of many co-morbid conditions and the total number of co-morbid conditions correlate highly with increasing age, increasing BMI, and male gender. CONCLUSION: The established surgical risk factors, age, BMI, and male gender, are markers for a sicker patient population, as evidenced by a greater obesity disease burden.     

ICU患者转出时家属内心体验的质性研究

目的探讨ICU患者转出时家属的内心体验,为制定干预措施提供依据。方法采用目的抽样法选取即将转出ICU患者的直系家属12名,进行个人面对面半结构式深度访谈,运用Colaizzi现象学研究法对访谈内容进行整理分析。结果提炼出4个主题:转出期望与应激压力并存,因意识到患者依然危重而焦虑,感知到治疗环境及护理模式的转变,照顾能力自我效能感水平低。结论患者转出ICU时,家属有较大的心理压力,与治疗环境改变、照护知识缺乏有关。ICU医护人员应提高对家属的关注度,及时给予评估并干预,以维持家属对患者的良好照护能力。     

The Medical Malpractice Risk Associated with Bariatric Surgery

Background: Bariatric surgery has been classified as high risk by the medical malpractice industry, but it is unclear what data support this classification. When a small group of physicians is separated from their peers and asked to support their malpractice claims, their premiums will often rise unfairly in relation to the outcome of the claims. This report outlines the results of a survey sent to the members of the American Society for Bariatric Surgery (ASBS) asking for information on malpractice claims. Methods: Surveys were mailed to the 285 ASBS members requesting which bariatric operations were performed, how many procedures were completed each year, details of any suits filed against the member including final outcome, and information on whether the members also performed gastric surgery for ulcer disease. Results: Surveys were returned by 165 members (58%) from surgeons in 33 states and Washington, D.C. Malpractice claims had been made after 107 bariatric procedures and three ulcer procedures with the risk of a suit being filed for a bariatric procedure being approximately 1.6/1,000 cases. The average monetary award was $88,667. Of the suits that resulted in a jury trial, 14% agreed with the plaintiff. Over half the cases that had been resolved were either dropped or dismissed before trial. Conclusions: The incidence of suit being brought against ASBS members performing bariatric procedures is low. Once filed, most cases do not reach a jury trial. Settlements are usually under $100,000. These data suggest that this group of bariatric surgeons do not represent a disproportionately large risk pool for medical malpractice insurance companies.     

Perforation of an Adjustable Gastric Banding Connecting Tube into distal Transverse Colon with Intra-luminal Migration

Laparoscopic adjustable gastric banding (LAGB) is one of the most common bariatric procedures performed in Europe and Australia. Major post-operative complications are limited but once they occur, prompt diagnosis and treatment are mandatory. LAGB complications are related either to the port and the connecting tube, such as infection or tubing disconnection and migration, or to the band, such as slippage, pouch dilatation, or intra-gastric migration. We report a case of intra-colonic migration of the connecting tube occurring 4 years after gastric banding placement in a patient otherwise asymptomatic.     

Persons with AIDS and their support persons: stress and life satisfaction

The purpose of this study was to investigate the role of historical family functioning, family stress, coping, perceived impact of acquired immune deficiency syndrome (AIDS), and health stress upon the life satisfaction of persons with AIDS (PWAs) and their support persons. Utilizing Family Stress Theory, a survey research design was employed involving 114 PWAs and 114 support persons. Historical family functioning was indirectly related to life satisfaction as mediated by family coping. Current family stress was indirectly related to life satisfaction as mediated by perception of stress. Female support persons experienced greater perceptions of caregiver stress. Family and health‐care professionals need to be aware of the importance of family stress and coping as they influence the health stress and life satisfaction of PWAs and their support persons. Copyright © 2009 John Wiley & Sons, Ltd.     

Primary care provider management of patients with obesity at an integrated health network: A survey of practices,views, and knowledge

Background

Obesity is a serious health problem that affects a wide range of patients and disease processes.

How do family practitioners perceive surgery for the morbidly obese?

BACKGROUND: Little is known about the level of knowledge and comfort with bariatric surgery among family practice physicians. METHODS: Surveys were sent to all family practitioners in Connecticut querying the practice type and knowledge of bariatric surgery. The results were analyzed for the prevalence of opinion. RESULTS: Of 620 surveys sent out, 129 (21%) were completed. Of the 129 respondents, 73% were men, aged 31-79 years, and 92% were board certified, with an average of 19 years' experience. The average body mass index of respondents was 26 kg/m2 (range 16-40). Only 4% of respondents had a body mass index >30 kg/m2. Physicians reported a patient obesity rate of 43%. Of the 129 respondents, 88% believed obesity was difficult to control with diet and exercise alone. Only 6% thought obesity was best controlled surgically. Also, 85% of respondents had referred a patient for gastric bypass, although only 57% were comfortable explaining the procedure. The most common reason for refusal to refer was fear of complications and death. Additionally, 55% correctly listed a body mass index of 40 kg/m2 as qualifying for bariatric surgery without comorbidities; 48% identified the mortality rate of surgery as <1%, with 4% of respondents reporting >10%; and 84% were familiar with gastric bypass, 66% with LapBand, 33% with vertical banded gastroplasty, and 5% with duodenal switch. The respondents believed that nausea was the most common side effect, followed by anemia and fatigue. Finally, 53% believed bowel obstruction was common. CONCLUSIONS: The results of our study have shown that misconceptions about bariatric surgery exist in the family practice community despite the increasing frequency of these procedures. Educational programs need to be designed to assist family practitioners in treating and referring obese patients.     

Issues and concerns of family members of burn patients: A scoping review

IntroductionThe issues and concerns that emerge in the families of burn patients have received minimal attention.ObjectiveTo map out what is known about the challenges facing the family members of burn patients.MethodsThe review followed the PRISMA Extension guidelines for scoping reviews and the review approach by Arksey and O’Malley to synthesize the available evidence. Twenty-six (26) papers from various database searches were identified and included in the review. The citation retrieval and retention methods are reported in a PRISMA statement.ResultsAlthough most of the studies included parents (n = 21), the evidence suggests that the shared concerns of family members include taking on new roles, and psychosocial and financial issues. Uniquely, parents had to endure blame, shame and guilt; partners/spouses were faced with difficulties in re-establishing an emotional connection with the patient; siblings simultaneously expressed jealousy and feelings of being outsiders; and children with a burn parent had to deal with feelings of exclusion from the care delivery process. Aside from these individuals, friends, neighbours and in-laws may also assume a caregiving role, with grandparents playing a supporting role. Family members are unprepared for their roles, as they are forced into them suddenly. Although distress may occur among family members, its determinants, severity, pattern and recovery process remain unclear.ConclusionA burn is a family injury that creates the need for family-centred care. Future studies need to explore the nature of psychological distress, family members’ recovery pathways, and how family members can prepare for their roles in the period after discharge.     

特重度烧伤患者家属心理需求的调查

目的：调查特重度烧伤患者家属的心理需求，为临床医患沟通提供有力的参考依据。方法：50名特重度烧伤患者家属于患者进入病房24～36小时后接受危重患者家属需求量表（critical care family needs inventory，CCFNX）的调查。结果：患者家属需求的重要程度由高到低依次为病情保证、获取信息、接近患者、获得支持和自身舒适。结论：特重度烧伤患者家属心理需求与ICU患者家属家庭需求的调查研究结果基本一致，这要求医护人员在救治患者的同时要注重患者家属的心理需求，避免家属的压力情境变成危机情境，促进医患和谐。     

The Post-surgical Treatment of the Bariatric Patient: Helping the Patient Succeed

Background: A psychological profile of the average bariatric patient demonstrates psychopathology that may contribute to patient noncompliance with post-surgical treatment guidelines. Methods and results: Patient psychopathology is analysed with regard to noncompliance and its contribution to poor surgical outcome. The interpersonal process approach is reviewed as a psychotherapeutic framework that provides interventions to patient psychopathology. Conclusions: Treatment of patient psychopathology with the interpersonal process approach encourages postsurgical compliance and helps patients succeed.     

Family system outcome following acquired brain injury: clinical and research perspectives

Objectives : To investigate family system outcome following acquired brain injury (ABI) using the Family Assessment Measure-III (FAM-III).

Research design : Clients and families referred to the Family Support Service completed the FAM-III, a measure of family system functioning.

Methods and procedures : Forty-three persons and 92 family members completed the FAM-III as part of intake. FAM-III scores were calculated and compared within the family, between subscales, and with established norms.

Results : FAM-III scores of the family member sample were significantly elevated compared to individuals with ABI and compared to the norm across all seven domains of family functioning. No significant relationship was found between family member relationship status or time post-injury and overall FAM-III scores.

Conclusions : Family members identified distressed family functioning across all domains compared to survivors and compared to population norms. The FAM-III provides clinical utility in assessing family system functioning and shows promise as a family system outcome measure.