Obesity,neoliberalism and epidemic psychology: critical commentary and alternative approaches to public health

Obesity and neoliberalism are two concepts that generate plenty of concern and debate, arguably leading to more heat than light when terms like ‘epidemic’ are thrown into the fray. Drawing from critical weight studies, this paper offers critical commentary on the recent designation of obesity as a ‘neoliberal epidemic’ that can be attributed to energy-dense foods and a toxic mode of political economic organization. After delineating neoliberalism and the use of this concept in health studies, discussion turns towards contrasting invocations in the ‘fat field’ before seeking to navigate a course through this terrain. In addition to contributing to critical weight studies and the obesity debate, this commentary engages discussions on the perils of invoking neoliberalism in public health critique. In conclusion, we move from critique to hope with reference to epistemologies derived from alternative health practices, notably frameworks incorporating Indigenous knowledge(s).     

Optimizing Health for Complex Adults in Primary Care: Current Challenges and a Way Forward

As the population ages, the quantity and complexity of comorbidities only increases in the primary care setting. Health systems strive to improve quality of care and enhance cost savings, but current administrative and payment systems do not easily support the implementation of existing evidence and best practices for multimorbid adults in most primary care offices. This perspectives piece sets forth a research agenda in the area of implementation science at the intersection of geriatrics and general internal medicine. We challenge academic medical centers, medical societies, journals, and funders to actively value and support investigation in this area as much as traditional research pathways.     

Antidepressant use and risk of central nervous system metastasis

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, were found to increase central nervous system (CNS) metastasis in mice. Our study investigated in humans whether antidepressants, and specifically SSRIs, increased the relative odds of CNS metastasis. We identified 189 cases of CNS metastasis amongst breast cancer, melanoma, and non-Hodgkin lymphoma subjects who were diagnosed with CNS metastasis or infiltration between January 1, 2005 and September 30, 2013 and 756 controls (patients without CNS metastasis or infiltration). Using logistic regression, we estimated the relative odds of CNS metastasis associated with antidepressant use adjusting for relevant covariates. The prevalence of antidepressants was 28.6?% in cases and 27.5?% in controls, whereas SSRIs were used in 16.9?% of cases and 17.3?% of controls. Among all patients, antidepressants were not associated with CNS metastasis or infiltration. No consistent patterns of association were observed in the analyses of other cancer subsets or exposure measures, with the possible exception of an increased risk of CNS metastasis associated with ‘any SSRI use’ among breast cancer patients (OR?=?1.73, 95?% CI?=?0.75, 4.04). We did not observe clear patterns of association, which may be due in part to the small sample size in many of our analyses.     

Community-Based Accompaniment and Psychosocial Health Outcomes in HIV-Infected Adults in Rwanda: A Prospective Study

We examined whether the addition of community-based accompaniment to Rwanda’s national model for antiretroviral treatment (ART) was associated with greater improvements in patients’ psychosocial health outcomes during the first year of therapy. We enrolled 610 HIV-infected adults with CD4 cell counts under 350 cells/μL initiating ART in one of two programs. Both programs provided ART and required patients to identify a treatment buddy per national protocols. Patients in one program additionally received nutritional and socioeconomic supplements, and daily home-visits by a community health worker (“accompagnateur”) who provided social support and directly-observed ingestion of medication. The addition of community-based accompaniment was associated with an additional 44.3 % reduction in prevalence of depression, more than twice the gains in perceived physical and mental health quality of life, and increased perceived social support in the first year of treatment. Community-based accompaniment may represent an important intervention in HIV-infected populations with prevalent mental health morbidity.     

Supraventricular tachyarrhythmias after hematopoietic stem cell transplantation: incidence, risk factors and outcomes

Recent studies suggest that cancer patients may be at increased risk for supraventricular tachyarrhythmias (SVTA). We have observed clinically significant SVTA in patients undergoing hematopoietic stem cell transplantation occurring at a median of 6 days post transplant, manifesting as atrial fibrillation/flutter or regular narrow-complex tachycardia and persisting for a median of 3 days (range, 0-8). All patients received aggressive medical therapy and/or electrical cardioversion to restore sinus rhythm and to re-establish hemodynamic stability. Non-Hodgkin's lymphoma (NHL) was the most common diagnosis (53%), and a case control analysis in those patients demonstrated that SVTA occurred in 12% of patients and was associated with older age and pre-existing cardiac conditions. In conclusion, patients undergoing HSCT are at moderate risk for developing SVTA, particularly older patients with a diagnosis of NHL. These arrhythmias are clinically significant, and are a marker for increased mortality and prolonged hospital stay. Additional studies are needed to identify high-risk patients who may benefit from prophylactic anti-arrhythmic therapy.     

Intravenous gammaglobulin treatment of chronic idiopathic thrombocytopenic purpura

High-dose intravenous gammaglobulin (IVIgG) was given to 12 children and adults with chronic idiopathic thrombocytopenic purpura (ITP) to avoid splenectomy or because they either failed to respond to or required maintenance with high doses of steroids and/or immunosuppressives. The average platelet count increase to initial therapy was 239,500/microliters (range 23,000-790,000). A concomitant IgG Fc receptor blockade, measured by IgG-sensitized 51Cr-labeled autologous erythrocytes, was seen in 11 of 11 patients tested, both splenectomized and not splenectomized, lasting 3-4 wk. Six or more months after treatment, 2 children are in remission, 2 children and 2 adults are stable requiring no therapy with platelet counts of approximately 50,000 and 30,000, respectively, 3 children require maintenance IVIgG therapy at 2-10-wk intervals, and 1 child and 2 adults have become refractory to further IVIgG. Splenectomy was not performed in 4 children. Two adults were able to discontinue daily prednisone. The 3 patients who became unresponsive to Swiss Red Cross gamma-globulin (IgSRK) therapy did so in conjunction with a markedly elevated platelet-associated IgG and IgM. Serum IgM increased an average of 103 mg/dl after the IVIgG infusions. No significant side effects were seen.