Pneumothorax as a Complication of Apnea Testing for Brain Death

Background

Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurological determination of death. It may result in hemodynamic instability or even cardiac arrest, compromising ability to declare brain death (BD) and viability of organs for transplantation. We report three cases of pneumothorax with apnea testing (PAT) and review the available literature of this phenomenon.

Methods

Series of three cases supplemented with a systematic review of literature (including discussion of apnea testing in major brain death guidelines).

Results

Two patients were diagnosed with PAT due to immediate hemodynamic compromise, while the third was diagnosed many hours after BD. An additional nine cases of PAT were found in the literature. Information regarding oxygen cannula diameter was available for nine patients (range 2.3–5.3 mm), and flow rate was available for ten patients (mean 11 L/min). Pneumothorax was treated to resolution in the majority of patients (n = 8), although only six completed apnea testing following diagnosis/treatment of pneumothorax and only three patients became organ donors afterward. Review of major BD guidelines showed that although use of low oxygen flow rate (usually ≤ 6 L/min) during apnea testing is suggested, the risk of PAT was explicitly mentioned in just one.

Conclusion

Development of PAT may adversely affect the process of BD determination and could limit the opportunity for organ donation. Each institution should have preventive measures in place.

     

Medical Comorbidities in Bipolar Disorder

Purpose of Review

Bipolar disorder (BD) medical comorbidity presents significant clinical and public health concerns with serious impact on health. The aim of this article is to present an updated narrative review of original research articles (case control, longitudinal cohort, and cross-sectional studies) and meta-analyses published in English language journals from January 2013 to May 2017 focusing on general medical comorbidity in BD, including the added risks of iatrogenic factors relevant to the treatment of BD.

Recent Findings

We found numerous patterns of association between BD and various medical disorders involving multiple organ systems. One pattern indicated reciprocal increase in the rate of each comorbid condition, such as an increased rate of BD in asthma or migraine, and likewise an increase in the rate of asthma or migraine in patients with BD. A second pattern was a predominantly unidirectional increase in the rate of BD in patients with certain medical disorders, such as multiple sclerosis or cerebellar diseases. A third pattern was a predominantly unidirectional increased rate of medical disorders in patients with BD. One study suggested the potential involvement of genetic mechanisms for the association between BD and migraine. Most of the studies had cross-sectional or retrospective designs, and many relied on analysis of large administrative databases inviting multiple potential biases.

Summary

Our review highlights the association between BD and a variety of medical disorders. Further research is needed to elucidate the potential underlying etiopathological mechanisms that contribute to observed comorbidities. The results of this review also emphasize the need for comprehensive screening for medical disorders in BD and for adoption of an integrated model of care to address these complex comorbidities.

     

Primary Posterior Fossa Lesions and Preserved Supratentorial Cerebral Blood Flow: Implications for Brain Death Determination

Background

Patients with primary posterior fossa catastrophic lesions may clinically meet brain death criteria, but may retain supratentorial brain function or blood flow. These patients could be declared brain-dead in the United Kingdom (UK), but not in the United States of America (USA). We report the outcome of adult patients with primary posterior fossa lesions without concurrent major supratentorial injury.

Methods

Henry Ford Hospital database was reviewed over a period of 88 months in order to identify all adult patients with isolated brainstem or posterior fossa lesions. We excluded patients with concurrent significant supratentorial pathology potentially confounding the clinical brain death examination. One more patient from a different hospital meeting these criteria was also included.

Results

Three patients out of 161 met inclusion criteria (1.9% of all brain deaths during this period). With the addition of a fourth patient from another hospital, 4 patients were analyzed. All four patients had catastrophic brainstem and cerebellar injuries meeting the clinical criteria of brain death with positive apnea test in the UK. All had preserved supratentorial blood flow, which after a period of 2 h to 6 days disappeared on repeat testing, allowing declaration of brain death by US criteria in all four. One patient became an organ donor.

Conclusions

Patients with primary posterior fossa catastrophic lesions, who clinically seem to be brain-dead, evolve from retaining to losing supratentorial blood flow. If absent cerebral blood flow is used as an additional criterion for the declaration of death by neurological criteria, these patients are not different than those who become brain death due to supratentorial lesions.

     

Hypochondriac concerns and correlates of personality styles and affective states in bipolar I and II disorders

Background

Hypochondriac concerns are associated with the treatment-difficulty of bipolar disorder, which might be due to the personality styles and affective states.

Methods

We invited outpatients with bipolar I disorder (BD I, n?=?87), bipolar II disorder (BD II, n?=?92) and healthy volunteers (n?=?129) to undergo the Illness Attitude Scales and Parker Personality Measure tests, and measurements of concurrent affective states.

Results

Compared to healthy volunteers, BD I and BD II patients scored significantly higher on mania, hypomania and depression. BD I and BD II patients also scored significantly higher on Symptom Effect and Treatment Seeking, and BD II patients scored higher on Patho-thanatophobia and Hypochondriacal Belief. BD II in addition scored higher on Patho-thanatophobia than BD I did. In controls, the Dependent style predicted Patho-thanatophobia and Symptom Effect, Schizoid with Hypochondriacal Belief; in BD I, Narcissistic (?) with Hypochondriacal Belief, Histrionic with Patho-thanatophobia and Hypochondriacal Belief, depression with Hypochondriacal Belief, and hypomania with Symptom Effect and Hypochondriacal Belief; in BD II, depression with Symptom Effect and Hypochondriacal Belief, mania with Symptom Effect.

Conclusions

Bipolar disorder, especially BD II, is associated with greater hypochondriac concerns, which relates to personality disorder functioning styles and concurrent affective states.

     

Gender difference in QTc prolongation of people with mental disorders

Background

We examined gender difference in QTc interval distribution and its related factors in people with mental disorders.

Methods

We retrospectively reviewed medical charts of patients discharged from a university psychiatric unit between November 1997 and December 2000. Subjects were 328 patients (145 males and 183 females) taking psychotropics at their admission. We examined patient characteristics, medical history, diagnosis, and medication before admission.

Results

Mean QTc interval was 0.408 (SD = 0.036). QTc intervals in females were significantly longer than those in males. QTc of females without comorbidity was significantly longer than that of males.

Conclusion

The influence of gender difference on QTc prolongation in people with mental disorders merits further research.

     

Variability of activity patterns across mood disorders and time of day

Background

Few actigraphy studies in mood disorders have simultaneously included unipolar (UP) and bipolar (BD) depression or BD mixed states as a separate subgroup from mania. This study compared objectively measured activity in UP, BD depression, mania and mixed states and examined if patterns differed according to time of day and/or diagnostic group.

Methods

Eighty -eight acutely admitted inpatients with mood disorders (52 UP; 18 mania; 12 BD depression; 6 mixed states) underwent 24 hours of actigraphy monitoring. Non-parametric analyses were used to compare median activity level over 24 h (counts per minute), two time series (64-min periods of continuous motor activity) in the morning and evening, and variability in activity across and within groups.

Results

There was no between-group difference in 24-h median level of activity, but significant differences emerged between BD depression compared to mania in the active morning period, and between UP and mania and mixed states in the active evening period. Within-group analyses revealed that UP cases showed several significant changes between morning and evening activity, with fewer changes in the BD groups.

Conclusions

Mean activity over 24 hours has limited utility in differentiating UP and BD. In contrast, analysis of non-linear variability measures of activity at different times of day could help objectively distinguish between mood disorder subgroups.

Trial registration

ClinicalTrials.gov Identifier: NCT01415323, first registration July 6, 2011.

     

Deutschlandweite Evaluation der ärztlichen Weiterbildung in der klinischen Neurologie

Background

Currently, no data are available, which reflect the situation of medical doctors specializing in neurology in German hospitals. In order to secure the high standard of neurological patient care it is essential to evaluate the working conditions and the specialty training in neurology.

Objective

This nationwide survey was conducted throughout Germany with the aim to address problems and to give suggestions for improvements in neurological training curricula.

Material and methods

The survey was online from February to May 2017 and 953 neurologists undergoing further training participated.

Results

More than half of the young neurologists were satisfied with their medical training. One of the main problems that complicates clinical training is the workload. In addition, organizational obstacles within the clinic, such as poor structure of education or a lack of mentors, lead to dissatisfaction among participants. The size or type of the department, as well as the prevailing service system, exert only a minor influence on the quality of specialist training, although there were differences especially in the self-assessment of the participants in connection with the type of department (university hospital versus public or private hospital).

Conclusion

Specialist training in neurology can be improved by simple arrangements, e.?g., the introduction of a binding rotation scheme, internal mentoring and structured feedback. In addition, it will be necessary to relieve medical staff of administrative duties in order to create time for training and the learning of competencies.

     

A Review of Environmental Influences on Food Choices

Background

Diet-related environmental and policy interventions are being advocated at a population level because individual change is more likely to be facilitated and sustained if the environment within which choices are made supports healthful food options.

Purpose

This study aims to review research that examines factors having an influence on food choices in social environments, physical environments, and macroenvironments.

Methods

A snowball strategy was used to identify relevant peer-reviewed studies and reviews, with a focus on research completed in the US and published within the past 10 years.

Results

Research has identified a number of environmental factors associated with dietary intake; however, the majority of completed studies have methodological limitations which limit their credibility to guide interventions and policy changes.

Conclusions

Future research will need to emphasize multilevel investigations, examine how associations vary across population subgroups, develop a standard set of measures for assessing food environments and policies, and improve dietary assessment methodology.

     

Changing Family Food and Eating Practices: The Family Food Decision-Making System

Background

Food decision-making processes interact with family and community environments to shape families’ thinking (i.e., their constructed reality) about food, eating, health, and well-being as discussed by Gillespie and Gillespie (J Fam Consum Sci 99(2):22–28 2007).

Purpose

To understand the processes and impetuses for changing family food and eating routines and policies and to develop a framework for the family food decision-making system (FFDS).

Methods

Interviews and observations with parents and change agents were used to generate grounded theory in the form of propositions which provided the basis for the FFDS framework.

Results

The propositions elucidate the processes of and influences on family food decision-making systems. The framework illustrates the family food decision-making system and processes of changing family food and eating routines and policies.

Conclusion

The FDMS framework begins to address the complexity of food decision-making to guide intervention planning and further research.

     

Barriers to HIV Medication Adherence as a Function of Regimen Simplification

Background

Barriers to HIV medication adherence may differ by levels of dosing schedules.

Purpose

The current study examined adherence barriers associated with medication regimen complexity and simplification.

Methods

A total of 755 people living with HIV currently taking anti-retroviral therapy were recruited from community services in Atlanta, Georgia. Participants completed audio-computer-assisted self-interviews that assessed demographic and behavioral characteristics, provided their HIV viral load obtained from their health care provider, and completed unannounced phone-based pill counts to monitor medication adherence over 1 month.

Results

Participants taking a single-tablet regimen (STR) were more likely to be adherent than those taking multi-tablets in a single-dose regimen (single-dose MTR) and those taking multi-tablets in a multi-dose regimen (multi-dose MTR), with no difference between the latter two. Regarding barriers to adherence, individuals taking STR were least likely to report scheduling issues and confusion as reasons for missing doses, but they were equally likely to report multiple lifestyle and logistical barriers to adherence.

Conclusions

Adherence interventions may need tailoring to address barriers that are specific to dosing regimens.

     

Mental and Addictive Disorders and Medical Comorbidities

Purpose of Review

Mental and addictive disorders commonly co-occur with medical comorbidities, resulting in poor health and functioning, and premature mortality. This review provides an overview of the intertwined causal pathways and shared risk factors that lead to comorbidity. Additionally, this review examines the strategies to prevent the onset of and to effectively manage chronic medical conditions among people with mental and addictive disorders.

Recent Findings

Recent research provides further evidence for the shared genetic and biological, behavioral, and environmental risk factors for comorbidity. Additionally, there is evidence of effective approaches for screening, self-management, and treatment of medical conditions among people with mental disorders. There are promising health system models of integrated care, but additional research is needed to fully establish their effectiveness.

Summary

A combination of public health and clinical approaches are needed to better understand and address comorbidity between mental and addictive disorders and chronic medical conditions.

     

Sex Differences in the Treatment of Sexual Dysfunction

Purpose of Review

Sex differences in the treatment of sexual dysfunction are partly due to neurobiological differences, as well as, the central and peripheral physiological effects of hormones and neurotransmitter actions on reproductive systems in men and women. Differences in epidemiology of complaints and diagnostic considerations, variance in medical comorbidities, and interference from related medications also contribute to the need for different strategies for treatments of sexual dysfunction according to gender.

Recent Findings

Flibanserin and ospemifene are new medication treatment options that may help some women with symptoms of sexual dysfunction.

Summary

Various therapies are available to address sexual dysfunction and sex differences are relevant to consider, in terms of diagnosis, effectiveness of treatments, and side effect profiles that may help determine indication, safety, and outcomes for specific treatments.

     

Aesthetic Amenities and Safety Hazards Associated with Walking and Bicycling for Transportation in New York City

Background

One strategy to address health problems related to insufficient physical activity is to examine modifiable neighborhood characteristics associated with active transportation.

Purpose

The aim of this study is to evaluate whether neighborhoods with more aesthetic amenities (sidewalk cafés, street trees, and clean sidewalks) and fewer safety hazards (pedestrian-auto fatalities and homicides) are associated with active transportation.

Methods

The 2003 Community Health Survey in New York City, which asked about active transportation (walking or bicycling >10 blocks) in the past 30 days, was linked to ZIP-code population census and built environment characteristics. Adjusted associations were estimated for dichotomous (any active transportation versus none) and continuous (trip frequency) active transportation outcomes.

Results

Among 8,034 adults, those living near sidewalk cafés were 10 % more likely to report active transportation (p?=?0.01). Homicide rate was associated with less frequent active transportation among those reporting any active transportation (p?=?0.002).

Conclusions

Investments in aesthetic amenities or homicide prevention may help to promote active transportation.

     

Gender Differences in Self-Report Physical Activity and Park and Recreation Facility Use Among Latinos in Wake County,North Carolina

Background

Lack of physical activity (PA) may be a cause of Latinos’ health problems. Latinas may be especially at risk, and public parks and recreation services may be a logical place to address PA deficiencies.

Purpose

The objectives of our study were to investigate Latino gender differences related to (1) self-reported work/household and leisure-time PA, (2) perceptions about PA and parks/recreation services, (3) parks/recreation services behaviors, (4) and preferences for activities/programming.

Methods

This is a cross-sectional survey completed by 457 Latinos.

Results

Significant gender differences were found for work/household PA but not for leisure-time PA. Use of parks and recreation services were similar between genders, but Latinos stayed significantly longer per visit. Latinos and Latinas significantly differed on park activities and preferences for recreational services.

Conclusions

Even though parks/recreation services are viewed as viable options for Latinos’ PA, the study identified gender differences that inform health promotion interventions to be more effective in targeting Latinos.

     

Shared Decision-Making: a Systematic Review Focusing on Mood Disorders

Purpose of Review

This study aims to provide a review of the randomized controlled studies evaluating the effects of shared decision-making (SDM) intervention in comparison to care as usual in patients with mood disorders.

Recent Findings

Of the 14 randomized controlled studies identified, only three 6-month studies evaluated the interest of SDM interventions using decision aids in depressed patients. All of them showed that the intervention effectively improved patient satisfaction and engagement in the decision-making process. Only one study in patients with bipolar disorder (BD) showed improvement of depressive symptoms, functioning, and quality of life. Other included studies were collaborative care interventions using a SDM approach in patients with depression in specific populations depending on age, gender, income, and physical comorbidities. All of them showed significant improvement in depression outcomes or medication adherence.

Summary

SDM interventions using decision aids and collaborative care showed evidence of improvements in the management of depression. Stronger evidence of SDM interest in BD is needed.

     

Beyond Distance: Children’s School Travel Mode Choice

Background

Long distance is a leading environmental barrier to walking to school and requires long-term, multilevel interventions. Meanwhile, childhood obesity remains highly prevalent, calling for more immediate solutions.

Purpose

The purpose of this study was to examine attitudinal and environmental correlates of walking to the elementary school, controlling for distance.

Methods

Using parental survey data, 601 child pairs with matched home locations and different school travel modes (walking vs. private automobile) were examined, using conditional logistic regressions.

Results

Despite the same/similar objectively measured distance and home location, perceptions of distance, sidewalk and traffic conditions, park presence, and convenience of walking differed between walkers and automobile users. Parental attitudes and children’s preferences were associated with the odds of walking. Safety concerns (traffic danger, stranger danger, and getting lost) were higher among drivers, but only significant in bivariate analyses.

Conclusions

To promote walking to school, route/street improvements appear promising, but parallel educational and promotional efforts may be needed to address perceptual and attitudinal barriers.

     

Perceptions of Neighborhood Park Quality: Associations with Physical Activity and Body Mass Index

Background

Parks are important resources for physical activity (PA), yet few studies have examined how perceptions of park characteristics relate to PA and health.

Purpose

This study investigated associations between perceptions of neighborhood park quality and overall moderate-to-vigorous PA (MVPA), park-based PA, and body mass index (BMI).

Methods

Data were collected via questionnaire from 893 households in Kansas City, Missouri.

Results

The newly developed neighborhood park quality scale demonstrated good test–retest and internal reliability. Residents’ perceptions of neighborhood park quality were related to PA and health outcomes. Perceiving parks as a benefit was positively related to overall MVPA and park-based PA and negatively related to BMI. Perceptions of well-used parks were positively related to BMI, while perceived cleanliness was negatively related to park-based PA.

Conclusions

Better measuring and understanding how perceptions of local parks are associated with PA and health can improve appreciation of how parks facilitate active living.

     

Mindfulness Meditation for Chronic Pain: Systematic Review and Meta-analysis

Background

Chronic pain patients increasingly seek treatment through mindfulness meditation.

Purpose

This study aims to synthesize evidence on efficacy and safety of mindfulness meditation interventions for the treatment of chronic pain in adults.

Method

We conducted a systematic review on randomized controlled trials (RCTs) with meta-analyses using the Hartung-Knapp-Sidik-Jonkman method for random-effects models. Quality of evidence was assessed using the GRADE approach. Outcomes included pain, depression, quality of life, and analgesic use.

Results

Thirty-eight RCTs met inclusion criteria; seven reported on safety. We found low-quality evidence that mindfulness meditation is associated with a small decrease in pain compared with all types of controls in 30 RCTs. Statistically significant effects were also found for depression symptoms and quality of life.

Conclusions

While mindfulness meditation improves pain and depression symptoms and quality of life, additional well-designed, rigorous, and large-scale RCTs are needed to decisively provide estimates of the efficacy of mindfulness meditation for chronic pain.

     

Anterior Temporal Lobectomy for Refractory Status Epilepticus in Herpes Simplex Encephalitis

Background

Herpes simplex virus (HSV) is a common cause of viral encephalitis that can lead to refractory seizures. The primary treatment of HSV encephalitis is with acyclovir; however, surgery sometimes plays a role in obtaining tissue diagnosis or decompression in cases with severe mass effect. We report a unique case in which anterior temporal lobectomy was successfully used to treat refractory status epilepticus in HSV encephalitis.

Methods

Case report and review of the literature.

Results

We report a case of a 60-year-old man with HSV encephalitis, who presented with seizures originating from the right temporal lobe refractory to maximal medical management. Right anterior temporal lobectomy was performed for the purpose of treatment of refractory status epilepticus and obtaining tissue diagnosis, with ultimate resolution of seizures and excellent functional outcome.

Conclusions

We suggest that anterior temporal lobectomy should be considered in cases of HSV encephalitis with refractory status epilepticus with clear unilateral origin.

     

Die ambulante Betreuung von Patienten mit somatisch nicht erklärten Beschwerden

Background

The aim of this study was to compare the approach of general practitioners (GP) and outpatient specialists for psychiatry, neurology or psychosomatic medicine to patients with somatically unexplained complaints.

Methods

Qualitative interviews were conducted with general practitioners in Berlin and with outpatient specialists. Interviews were analyzed by qualitative content analysis.

Results

Both GPs and specialists rarely used structured diagnostic instruments. Guidelines are seen and used with reservation throughout the different specialties. Similar to the GPs, most of the specialists surveyed in this study had reservations against the necessity of a precise coding according to the International Classification of Diseases (ICD).

Conclusion

In outpatient care the concern for the individual patient is the connecting element between different medical specialties. This results in a differential diagnostic and therapeutic approach that is not automatically in line with guidelines. The development of common concepts in ambulatory care might help to meet the demands of this complex group of patients with somatically unexplained complaints.