Dialectical behavior therapy in the Asia‐Pacific Rim region

Background: Borderline personality disorder (BPD) contributes to suicide‐related morbidity and mortality and requires more intensive psychotherapeutic resources due to its high mental health service usage. Accessibility to an evidence‐based treatment program is a cornerstone to support patients with BPD and part of broader suicide prevention efforts as well as improving their quality of life. Aims: In this article, the authors aim to discuss and review available dialectical behavior therapy (DBT) and DBT‐informed services of selected countries in the Asia‐Pacific Rim, namely Singapore, Malaysia, and Mexico. Materials & Methods: We contacted providers of different services and gathered information on the process of setting up the service and adapting the treatment, in addition to reviewing the available literature published in the countries. Results: To date, there have been a pair of DBT‐informed services in Singapore, four in Malaysia, and several in Mexico with a few of them offering standard DBT. Different efforts have been put in place to increase the accessibility to training and also the number of DBT practitioners. Discussion: Important considerations during the process of setting up new services include the use of domestic examples and local language that are contextually appropriate for the local community. Selected challenges faced in common include shortage of workforce, affordability of training programs, and the need for language adaptation with or without translation. Conclusion: Further long‐term evaluation of locally adapted DBT‐informed mental health services will help to elucidate the effectiveness and efficacy of the program which will potentially serve as a guide for other resource‐scarce regions.     

Predictors of failure of Helicobacter pylori eradication and predictors of ulcer recurrence: a randomized controlled trial

OBJECTIVE: In light of evidence that Helicobacter pylori treatment fails 5% to 20% of the time, the objective of this study was to determine predictors of unsuccessful H. pylori eradication and of duodenal ulcer recurrence. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: Gastroenterology services of 2 general hospitals in Montreal, Que. PATIENTS: All patients (aged 16 to 90) with an endoscopically proven duodenal ulcer within the previous year and H. pylori infection detected on antral biopsy were asked to participate; 85 were included. INTERVENTIONS: Patients were randomized in double-blind fashion to 1 of 2 eradication therapies, consisting of metronidazole, bismuth subcitrate and either amoxicillin or placebo. Endoscopy was performed at follow-up every 3 months for 12 months. OUTCOME MEASURES: Demographic data, characteristics of patients and disease, previous history and family history of ulcer disease, compliance at day 10 and day 28 of therapy; in vitro metronidazole resistance of H. pylori; eradication of H. pylori (determined by endoscopic biopsy 3 months after therapy); and ulcer recurrence within 12 months after therapy. RESULTS: Metronidazole resistance (odds ratio [OR] 0.11, 95% confidence interval [CI] 0.017 to 0.69) was the only independent predictor of eradication. Compliance (as defined in the study), density of organisms on culture, as well as several other factors examined, were not significant predictors. Treatment group, although a significant factor on univariate analysis, was not an independent predictor on multivariate analysis, as there were relatively good eradication rates (82% and 97% among compliant patients) in both groups. With regard to ulcer recurrence, 3 independent predictors were identified: failed H. pylori eradication (OR 86.5, 95% CI 4.2 to 1769), unemployment (OR 13.2, 95% CI 1.8 to 95) and a family history of ulcer disease (OR 12.2, 95% CI 1.2 to 128). CONCLUSIONS: The best predictor of ulcer recurrence is failure of H. pylori eradication, which, in turn, depends on metronidazole resistance. Hence, treatments containing metronidazole should be avoided in populations with high rates of metronidazole resistance. A family history of ulcer disease and unemployment were also predictors of ulcer recurrence, which suggests a potential role for treatment of contacts.     

Breast tomosynthesis in clinical practice: initial results

The purpose of this study was to assess the potential value of tomosynthesis in women with an abnormal screening mammogram or with clinical symptoms. Mammography and tomosynthesis investigations of 513 woman with an abnormal screening mammogram or with clinical symptoms were prospectively classified according to the ACR BI-RADS criteria. Sensitivity and specificity of both techniques for the detection of cancer were calculated. In 112 newly detected cancers, tomosynthesis and mammography were each false-negative in 8 cases (7%). In the false-negative mammography cases, the tumor was detected with ultrasound (n?=?4), MRI (n?=?2), by recall after breast tomosynthesis interpretation (n?=?1), and after prophylactic mastectomy (n?=?1). Combining the results of mammography and tomosynthesis detected 109 cancers. Therefore in three patients, both mammography and tomosynthesis missed the carcinoma. The sensitivity of both techniques for the detection of breast cancer was 92.9%, and the specificity of mammography and tomosynthesis was 86.1 and 84.4%, respectively. Tomosynthesis can be used as an additional technique to mammography in patients referred with an abnormal screening mammogram or with clinical symptoms. Additional lesions detected by tomosynthesis, however, are also likely to be detected by other techniques used in the clinical work-up of these patients.     

Intragastric Balloon as Bridging Therapy Prior to Bariatric Surgery for Patients with Severe Obesity (BMI ≥ 50 kg/m2): a Systematic Review and Meta-analysis

Bariatric surgery for patients with severe obesity (body mass index (BMI) ≥ 50kg/m²) is technically challenging. Intragastric balloon (IGB) has been proposed for weight loss before bariatric surgery to reduce surgical risks but its efficacy remains unclear. We conducted a systematic review and meta-analysis of the effectiveness of IGB as bridging therapy and assess potential complications. Amongst 2419 citations, 13 studies were included. IGB resulted in a BMI reduction of 6.60 kg/m² (MD=6.60, 95% CI: 5.06–8.15; I²=72%). The total post-procedural complication rate was 8.13% (95% CI: 4.04–13.17%), with majority being balloon intolerance. Overall, IGB is effective as a bridging therapy with adequate procedural safety profile, but further study is needed to evaluate the risk reduction for bariatric surgery and long-term weight-loss outcomes.

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The impact of clinical protocols in the management of severe sepsis: a prospective cohort study

This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.