The Patient Factor

Long-term results of bariatric surgery are reviewed. The weight criteria for patient acceptance for bariatric surgery and their variation are presented graphically and discussed. Factors affecting patient selection in an attempt to improve outcome results in the small group of patients who currently achieve less weight loss than anticipated are defined. An attempt is made to define pre-operative criteria for selection of pure restrictive versus combined restrictive and malabsorptive procedures. Aspects of motivation, co-morbidity, age and pre-operative weight are discussed and the position statement of the ASBS in regard to laparoscopic bariatric surgery is defined.     

Psychiatric Co-Morbidity and Substance Use Disorders: Treatment in Parallel Systems or in One Integrated System?

Psychiatric co-morbidity among substance users refers to the simultaneous presence of at least another psychiatric disorder in a person diagnosed with a substance use disorder. Co-morbid patients represent a substantial number of people in treatment and present greater disorder severity from both the clinical and social perspectives than those people diagnosed with only one type of disorder. We present an overview of the current state of the art concerning the choice of site of treatment, the kind of intervention, the length of such treatment, and future goals, aiming to establish a more effective intervention, and finally so as to further improve clinical outcomes.     

The co-existence of depression,anxiety and post-traumatic stress symptoms in the perinatal period: A systematic review

Objectiveto identify and appraise the current international evidence regarding the presence and prevalence of the co-existence of depression, anxiety and post-traumatic stress symptoms in the antenatal and post partum period.Methodsusing a list of keywords, Medline, CINHAL, Cochrane Library, EMBASE, PsychINFO, Web of Science and the Index of Theses and Conference Proceedings (Jan 1960 – Jan 2015) were systematically searched. Experts in the field were contacted to locate papers that were in progress or in press. Reference lists from relevant review articles were searched. Inclusion criteria included full papers published in English reporting concurrent depression, anxiety and post-traumatic stress symptoms in pregnant and post partum women. A validated data extraction review tool was used.Findings3424 citations were identified. Three studies met the full inclusion criteria. All reported findings in the postnatal period. No antenatal studies were identified. The prevalence of triple co-morbidity was relatively low ranging from 2% to 3%.Conclusions and implications for practicetriple co-morbidity does occur, although the prevalence appears to be low. Due to the presentation of complex symptoms, women with triple co-morbidity are likely to be difficult to identify, diagnose and treat. Clinical staff should be aware of the potential of complex symptomatology.     

Comparison of the Impact of “Fast Decline” in Residual Renal Function and “Initial Anuria” on Long-Term Outcomes in CAPD Patients

♦ Background: Residual renal function (RRF) is pivotal to long-term outcomes, while rapid RRF decline (RRFD) is associated with mortality risk for continuous ambulatory peritoneal dialysis (CAPD) patients. This study was conducted to compare the impact of “initial anuria” and rapid RRFD on the long-term prognosis of CAPD patients.♦ Method: According to the timing of anuria and the slope of RRFD, a total of 255 incident CAPD patients were divided into 3 groups. For the “anuria” group, anuria was detected from CAPD initiation and persisted for > 6 months (n = 27). Based on the median of the RRFD slope, the other 228 non-anuric patients were divided into a “slow decliner” group (n = 114), and a “rapid decliner” group (n = 114). The maximal observation period was 120 months.♦ Results: Logistic regression tests indicated that the “anuria” group was associated with previous hemodialysis > 3 months (odds ratio [OR]: 8.52, 95% confidence interval [CI]: 3.12 – 23.28), and female (OR: 0.29, 95% CI: 0.09 – 0.90), while the “fast decliner” group with higher Davies co-morbidity scores (DCS) (OR: 1.52; 95% CI: 1.08 – 2.14), body mass index (BMI) (OR: 1.12; 95% CI: 1.04 – 1.21), and male (OR: 1.12; 95% CI: 1.04 – 1.21). After adjusting for DCS, the “fast decliner” group (hazard ratio [HR]: 0.37; 95% CI: 0.17 – 0.80) showed a better outcome than that of the “anuria” group (reference = 1). Both baseline RRF (β = -0.24; p < 0.001) and DCS (β = -3.76; p < 0.001) showed inverse linear correlations to the slope of RRFD. From the Cox proportional analyses, higher baseline RRF (HR: 0.92; 95% CI: 0.88 –.97) and higher slope of RRFD (slower decline in RRF) (HR: 0.90; 95% CI: 0.85 – 0.96) were independent factors for less mortality risk in patients with DCS = 0. However, only a higher slope of RRFD (HR: 0.97; 95% CI: 0.94 – 0.99) was significant for better survival in CAPD patients with DCS > 0.♦ Conclusion: Compared to the baseline RRF, CAPD patients with co-morbidities that rapidly deteriorate RRFD are more crucially associated with long-term mortality risk.     

Transcranial magnetic stimulation： potential treatment for co-occurring alcohol,traumatic brain injury and posttraumatic stress disorders

Alcohol use disorder （AUD）, mild traumatic brain injury （mTBI）, and posttraumatic stress disorder （PTSD） commonly co-occur （AUD ＋ mTBI ＋ PTSD）. These conditions have overlapping symptoms which are, in part, reflective of overlapping neuropathology. These conditions become problematic because their co-occurrence can exacerbate symptoms. Therefore, treatments must be developed that are inclusive to all three conditions. Repetitive transcranial magnetic stimulation （rTMS） is non-invasive and may be an ideal treatment for co-occurring AUD ＋ mTBI ＋ PTSD. There is accumulating evidence on rTMS as a treatment for people with AUD, mTBI, and PTSD each alone. However, there are no published studies to date on rTMS as a treatment for co-occurring AUD ＋ mTBI ＋ PTSD. This review article advances the knowledge base for rTMS as a treatment for AUD ＋ mTBI ＋ PTSD. This review provides background information about these co-occurring conditions as well as rTMS. The existing literature on rTMS as a treatment for people with AUD, TBI, and PTSD each alone is reviewed. Finally, neurobiological findings in support of a theoretical model are discussed to inform TMS as a treatment for co-occurring AUD ＋ mTBI ＋ PTSD. The peer-reviewed literature was identified by targeted literature searches using PubMed and supplemented by cross-referencing the bibliographies of relevant review articles. The existing evidence on rTMS as a treatment for these conditions in isolation, coupled with the overlapping neuropathology and symptomology of these conditions, suggests that rTMS may be well suited for the treatment of these conditions together.     

An association between length of stay and co-morbidity in chronic airflow limitation.

OBJECTIVE: To examine factors which impact on the length of stay and readmission for patients with chronic airflow limitation at a South Australian hospital from December 1996 until March 1998. DESIGN: Discharges from Flinders Medical Centre for patients aged > or = 18 years, where chronic airflow limitation was an active problem, and including a subset with a primary diagnosis of chronic airflow limitation, were identified, retrospectively, by the center's Clinical Coding Service from the hospital's in-patient separation database. SETTING: Flinders Medical Centre, Adelaide, South Australia. OUTCOME MEASURES: Length of stay; number of co-morbidities; readmission within 28 days. RESULTS: Five-hundred and twenty discharges (male:female, 258:262) with a primary diagnosis of chronic airflow limitation (ANDRG-3 177, chronic obstructive airways disease) were identified. Readmission within 28 days was related to the number of co-morbidities and to age. A relationship between length of stay and the number of co-morbidities was identified. A mean length of stay of 6.39 days was found for patients with less than five co-morbidities, 5.36 at their first admission to Flinders Medical Centre and 3.25 at their first admission to Flinders Medical Centre with no co-morbidities. These mean lengths of stay fall below overseas data previously published and are consistent with Kong's estimate of an ideal mean length of stay of 3.2 days when a clinical management guideline is used in low-risk chronic airflow limitation patients. CONCLUSIONS: Length of stay and readmission to hospital within 28 days of patients with a primary diagnosis of chronic airflow limitation is at least partly related to the number of co-morbidities and to age. The study has highlighted the difficulty of relying on changes to aggregate data as outcome measures for these patients.     

Chronic daily headache in childhood and adolescence: clinical aspects and a 4-year follow-up

Chronic daily headache (CDH) represents a challenge in clinical practice and the scientific field. CDH with onset in children and adolescents represent a matchless opportunity to understand mechanisms involved in adult CDH. The aim of this study was to evaluate the diagnosis, prognosis and psychiatric co-morbidity of CDH with young onset in the young. Fifty-nine CDH patients has been followed from 1997 to 2001 in our department. Headache and psychiatric diagnoses were made on the basis of the international system of classification (International Headache Society, 1988; DSM-IV). Chi2 test and multinomial logistic regressions were applied to analyse factors predicting outcome. The current diagnostic system allows a diagnosis in 80% of CDH patients, even if age-related characteristics have been evidenced. Psychiatric disorders are notable in CDH (about 64% of patients) and predict (mainly anxiety) a poorer outcome. Surprisingly, analgesic overuse is not involved in the chronicization process. Diagnosis of CDH needs further study. Psychiatric disorders predict a worse outcome and greater account should be taken of them in treatment planning.     

Psychiatric disorders in Danish children aged 5–7 years: A general population study of prevalence and risk factors from the Copenhagen Child Cohort (CCC 2000)

Background: Knowledge about the presentation of psychopathology in preschool age and associated risk factors is fundamental to preventive intervention before schooling. Aims: To investigate the full spectrum of psychiatric diagnoses in general population children at the period of transition from preschool to school. Methods: A sample of 1585 children from the Copenhagen Child Cohort, CCC2000 aged 5–7 years was assessed using the Development and Well-Being Assessment (DAWBA) with diagnostic classification by experienced clinicians. Perinatal, sociodemographic and socio-economic data was obtained from Danish national registries. Results: The prevalence of any ICD-10 psychiatric disorder was 5.7% (95%CI: 4.4–7.1). Pervasive developmental disorders (PDD) were found in 1.3% (95%CI: 0.8–1.8) and behavioural and hyperkinetic disorders were found in 1.5% (95%CI: 0.9–2.1) and 1.0% (95%CI: 0.4–1.6), respectively. Emotional disorders were found in 2.9% (95%CI: 1.9–40). More boys were diagnosed with PDD, behavioural disorders and tics. No gender differences were found in hyperactivity disorders (HD) and emotional disorders. Co-morbidity was frequent, in particular between HD and PDD, but also between HD and emotional disorder and behavioural disorder. Teenage mothers, single parents and low household income the first two years after the child’s birth were associated with a three-to fourfold increased risk of psychiatric disorder in the child at age 5–7 years. Conclusion: The study results point to two “windows of opportunity” for prevention. In the earliest postnatal years, prevention should target families at socio-economic risk; and in the years before schooling, intervention should focus on children with symptoms of PDD, HD, and behavioural disorders.     

Depression or anxiety and all-cause mortality in adults with atrial fibrillation – A cohort study in Swedish primary care

Objective Our aim was to study depression and anxiety in atrial fibrillation (AF) patients as risk factors for all-cause mortality in a primary care setting.

Methods The study population included adults (n?=?12?283) of 45 years and older diagnosed with AF in 75 primary care centres in Sweden. The association between depression or anxiety and all-cause mortality was explored using Cox regression analysis, with hazard ratios (HRs) and 95% confidence intervals (95% CIs). Analyses were conducted in men and women, adjusted for age, educational level, marital status, neighborhood socio-economic status (SES), change of neighborhood status and anxiety or depression, respectively, and cardiovascular co-morbidities. As a secondary analysis, background factors and their association with depression or anxiety were explored.

Results The risk of all-cause mortality was higher among men with depression compared to their counterparts without depression even after full adjustment (HR?=?1.28, 95% CI 1.08–1.53). For anxiety among men and anxiety or depression among women with AF, no associations were found. Cerebrovascular disease was more common among depressed AF patients.

Conclusions Increased awareness of the higher mortality among men with AF and subsequent depression is called for. We suggest a tight follow-up and treatment of both ailments in clinical practice.     

Hepatitis C progressing to hepatocellular carcinoma: the HCV dialysis patient in dilemma

Summary.  Approximately 3.2 million people in the United States have chronic hepatitis C virus (HCV) infection; the primary cause for adult liver transplantation and a significant burden on healthcare resources. The role of HCV and other risk factors in development of HCC in patients with chronic kidney disease is not well defined. We studied predictors of hepatocellular carcinoma (HCC) in dialysis patients with chronic HCV by analyzing factors associated with its development. Data were extracted from the United States Renal Database System (USRDS) using ICD-9 codes. Variables included were gender, race, duration on dialysis and co-morbidities (alcohol abuse, drug abuse, HIV, hepatitis B, diabetes and/or presence of cirrhosis). Among the 32 806 HCV infected subjects, 262 cases had HCC. HCC was 12 times more likely in subjects with cirrhosis ( P  < 0.001), three times more likely in subjects with alcohol abuse ( P  <   0.001), and 1.3 times more likely in subjects with diabetes ( P  = 0.04). Asians were three times more likely ( P  < 0.001) to have HCC. Females were less likely to have HCC compared to males ( P  = 0.002). The likelihood of having HCC increased with age ( P  =0.001). This population-based study demonstrates that among subjects with HCV on dialysis, those with cirrhosis, Asian race and history of alcohol abuse are at highest risk for development of HCC. Furthermore, these findings indicate links between HCV and HCC which are valuable in case management for identifying; monitoring, and managing dialysis patients with HCC.