Additional Episodes Research Articles

Recurring Rare Liver Tumor Presenting With Hypoglycemia

Question: A 55-year-old woman presented to the hospital with drowsiness, lethargy, and several months of abdominal pain and weight loss. Bloodwork performed in the emergency department detected a very low blood glucose level (2-3 mmol/L), but was otherwise unremarkable, except for mildly elevated liver enzymes. There was no history of insulin or antihyperglycemic use. CT of the abdomen and pelvis with intravenous contrast detected a large (15.3 15.5 15.4 cm) mass arising within the left hepatic lobe, which demonstrated hypervascularity on arterial phase imaging (Figure A), heterogeneity on the venous and delayed phases (Figure B, C), and mild biliary duct dilatation owing to mass effect (Figure D, white arrow). No other intra-abdominal or pelvic mass lesions, nor evidence of metastases, were detected. The patient experienced multiple additional episodes of hypoglycemia controlled with glucose tablets until she underwent a left extended hepatectomy. Pathology showed a tumor composed of small cells individually separated by thin bands of collagen fibers, with positive staining for CD34 and bcl-2 protein (Figure E, bottom). The patient’s presenting symptoms resolved entirely after the tumor resection, with normal periodic follow-up CT imaging, until she presented to the hospital again 5 years later with confusion, lethargy, and similar symptoms to the initial presentation. A right upper quadrant mass was palpable 10-12 cm below the costal margin. Blood glucose measured 1.6 mmol/L and liver enzymes were normal with the exception of mildly elevated g-glutamyl transpeptidase. CT imaging of the abdomen and pelvis demonstrated a large (11 17 15 cm), well-defined mass lesion adjacent to the resection site with imaging features similar to the previously detected mass lesion—markedly heterogeneous parenchyma. MRI of the liver demonstrated a mass lesion with heterogeneous low-to-isointense signal intensity on T1-weighted imaging (Figure F) and heterogeneous hyperintensity on T2-weighted imaging (Figure G), restricted diffusion on diffusion-weighted imaging, and heterogeneous progressive enhancement on postcontrast dynamic acquisition sequences without evidence of retention of hepatocyte-specific gadolinium. The patient underwent a hepatectomy involving segments V-VIII. Her presenting symptoms again resolved following surgery and she was discharged with a plan for clinical and radiological follow-up.

Does hydroxyurea prevent pulmonary complications of sickle cell disease?

A 27-year-old man with sickle cell disease (HbSS) presents to the sickle cell clinic for follow-up after a screening echocardiogram revealed an increased tricuspid regurgitant velocity of 2.7 m/s. He has a history of 2 painful crises per year and has been hospitalized 3 times over the past 10 years for management of painful crises. He had one episode of acute chest syndrome at age 15 that was treated with an RBC exchange transfusion, supplemental oxygen, and intravenous antibiotics; he did not require mechanical ventilation. He has not had additional episodes of acute chest syndrome and does not have a history of stroke, retinopathy, or leg ulcers. The patient has never been treated with hydroxyurea. He wants to know whether hydroxyurea will prevent future pulmonary complications related to sickle cell disease.

The cost-effectiveness of OM-85 in managing respiratory tract infections in China

Objectives:To demonstrate the health economic impact of OM-85, a bacterial lysates based immunostimulant, for its approved indications in China.Methods:A cost-effectiveness decision tree model was constructed comparing OM-85 with the best supportive care/placebo therapy for managing the acute exacerbation of chronic bronchitis and rhinosinusitis in the Chinese population. Clinical efficacy and adverse events (AE) data were included in the model based on a thorough literature review. All localized direct treatment costs, including drug cost, AE costs, and medical treatment costs for underlining diseases were included from a Chinese third party payer perspective. A Key Opinion Leaders (KOL) survey was conducted with 20 senior physicians specialized in respiratory, ENT, allergy, and immunology fields from tertiary hospitals in Beijing, Shanghai, Guangzhou, Hangzhou, Shenyang, and Wuhan to validate the local treatment costs. Incremental cost-effectiveness ratio (ICER) was calculated based on the above efficacy and cost information.Results:OM-85 is a cost-effective therapy when compared with placebo (standard care). OM-85 can treat/prevent one additional full episode exacerbation of chronic bronchitis and one additional full episode exacerbation of rhinosinusitis with only additional costs of RMB 653 and RMB 1182.84, respectively. In comparison, each acute exacerbation of chronic bronchitis will cost RMB 4510.10, and each acute exacerbation of rhinosinuisitis will cost RMB 1807.21 in a Chinese clinical management setting. One-way sensitivity analyses were performed and the ICER result was demonstrated to be consistent.>Conclusions:OM 85 reduces acute exacerbations among patients with chronic bronchitis and chronic rhinosinusitis when compared with Placebo (standard care). From a Chinese payer perspective, OM 85 is a cost-effective therapy in the clinical management of both chronic bronchitis and rhinosinusitis in the adult population.

Allegories of War: Paul de Man’s Moby-Dick Translation

Allegories of War:Paul de Man’s Moby-Dick Translation Michael Boyden This article deals with a Flemish translation of Moby-Dick, published in Antwerp in 1945, which has been attributed to the deconstructive critic Paul de Man in the Belgian phase of his career. The article’s objective is twofold. First, it qualifies the well-intentioned but one-sided claim on the part of de Man scholars that the Moby-Dick translation constitutes a resolute turning point in de Man’s ideological trajectory. Second, in doing so, it draws out some of the aporias of allegorical readings of the postwar period, which adopt a redemptive framework geared towards the American nation. My main claim is that, contrary to American liberal critics, de Man did not approach Moby-Dick in terms of a larger struggle against totalitarian closure, but rather responded to the theme of antimodernism and Melville’s complex relation to imperialism. This interpretation is inferred from the modifications to the novel’s situation of address, the amplification of martial imagery, and paratextual insertions by the translator. Rather than arguing for or against a specific reading of Moby-Dick, the article’s larger aim is to highlight the displacements inherent in any allegorical interpretation of the novel. In a still dominant but by no means uncontested reading of Moby-Dick, the book’s larger theme is framed in terms of a struggle between the ideological closure embodied by the “monomaniac mind” of Ahab and Ishmael’s democratic alternative. The orphaned Ishmael has the last word, which for Charles Feidelson, F. O. Matthiessen, Richard Chase, R. W. B. Lewis, Leslie Fiedler, and others, indicated that the book displayed a characteristically American, “melodramatic” quality (Chase 157). At least since the end of the Cold War, this allegorical understanding of the novel has increasingly come under fire from the so-called “New Americanists,” notably Donald Pease, who in an influential essay links the “essentialized opposition” between Ishmael and Ahab to a discourse of exceptionalism inherent in American Studies (137).1 Similarly, WaiChee Dimock has stressed how Melville’s dream of freedom and democracy in Moby-Dick “is haunted always by its obverse” (138). Dimock sets her interpretation off from a long line of Melville scholarship that in her view posits [End Page 21] Ishmael as a central “redemptive figure” in the book (236n52). Although such revisionist interpretations have done their work in exposing some ideological presuppositions of liberal criticism in the Cold War era, their field of vision remains national. Despite the desire to go beyond the narrowly “national telos” of earlier critics, Pease constructs C. L. R. James’s Marines, Renegades and Castaways, which the Trinidadian critic completed while in custody at Ellis Island, as “an additional episode within Melville’s masterwork” that somehow serves to complete Melville’s “interrupted intention” (156). However radical in purpose, such exegetical gestures remain tied to utopian visions—representing Melville’s “actual” intention—of an alternative, more democratic America.2 My aim in this article is to approach Melville’s “cultural declaration,” as John Bryant has called it (70), from a slightly wider orbit by way of a relatively unknown Flemish translation of Moby-Dick, published in 1945, which has been attributed to the deconstructive critic Paul de Man in his early, Belgian career. The translation raises important questions about de Man’s ideological leanings during the war. But the case may equally illuminate the ideological constraints governing interpretations of Melville’s classic by forcing us to come to terms with Moby-Dick’s appeal in ideological contexts ostensibly diametrically opposed to American conceptions of democracy. When the de Man “affair” broke out in the late 1980s, well-intentioned friends and colleagues referred to the Moby-Dick translation, which de Man completed at the end of the war after he had ceased writing for the collaborationist press, as evidence of his moral right-mindedness.3 Thus, in an oft-quoted essay reprinted in her book Testimony, Shoshana Felman argued that the Melville translation signals an “absolute break” in the young de Man’s ideological orientation (134). Offering a forthrightly allegorical reading, Felman suggests that the Moby-Dick translation was for de Man a way of...

Massive GI Bleeding Due to Jejunal Diverticulosis: A Rare Diagnostic Dilemma Highlighting the Importance of Endoscopic Timing and Multidisciplinary Care

SymbolIntroduction: Jejunal diverticula form as a result of increased intraluminal pressure at the weakest points of the jejunum, usually near the site of entry of blood vessels into the bowel wall, leading to herniation of mucosa/submucosa through the muscle layer. Patients present with melena and obscure GI bleeding. Once the diagnosis is established, the treatment of choice is surgical resection of the jejunal segment and primary anastomosis. A 77-year-old man presented to an outside institution with 3 days of shortness of breath and melena. Hemoglobin was 7.6 g/dL on admission. Transfused 3 units of pRBC and incremented to 9.2 g/dL, but fell to 7.2 g/dL the following day. EGD was normal. Colonoscopy with TI intubation showed pan-colonic diverticulosis without active bleeding. Melena continued and small bowel enteroscopy performed showing diverticula in the duodenum and proximal jejunum without any blood or clots. Melena continued and an abdominal CT angiography was performed. No bleeding seen. Patient transferred to our institution and capsule endoscopy was performed. Findings suggested a jejunal source of bleeding and a double balloon-assisted enteroscopy was performed. Surgical consultation obtained and stated that since multiple diverticula were found in the duodenum/jejunum but no active bleeding was seen, any surgical intervention in this area would be technically difficult and a targeted resection could not be performed; UGI series with small bowel follow-through performed to assess number and extent of diverticula. Multiple diverticula noted in the second/third portions of the duodenum, proximal/mid-jejunal loops and distal ileum. On hospital day 7, the patient began to have maroon-stools. Taken for urgent enteroscopy with a cap-fitted pediatric colonoscope. Cap used to carefully examine small bowel mucosa and interrogate diverticula. Actively bleeding jejunal diverticula located but no targets for endoscopic treatment identified. Area tattooed and patient sent for surgical resection. Patient did well following surgical resection of jejunal segment. No additional episodes of melena/hematochezia occurred. He was discharged from the hospital and no further GI hemorrhage at 6 months of follow-up.In summary, massive gastrointestinal hemorrhage from jejunal diverticulosis is extremely rare and preoperative localization of the bleeding intestinal segment is challenging. This case illustrates the importance of endoscopic timing in reaching the appropriate diagnosis and the multidisciplinary approach used in its successful management. Urgent endoscopy at the time of active bleeding may be the key to establishing the diagnosis and allow for targeted surgical resection and definitive hemostasis.Symbol

The Use of Hemospray® in Refractory Post-Polypectomy Bleeding From a Large Antral Polyp

SymbolIntroduction: The management of refractory upper gastrointestinal bleeding (UGIB) despite exhaustive use of conventional techniques is a challenge. A novel technology that has recently emerged is Hemospray® (Cook Medical), which is licensed in Canada and Europe for the management of non-variceal upper gastrointestinal bleeding. We present a case of Hemospray® in the treatment of refractory UGIB after removal of a large antral polyp.SymbolCase Report: A 77-year-old man with a past medical history of systolic heart failure requiring a HeartMate II left ventricular assist device presented to our emergency room with one week of melena. Esophagogastroduodenoscopy (EGD) showed an actively oozing 2 cm sessile polyp in the antrum. Initial hemostasis was attempted using 7 mL of epinephrine (1:10,000) and the polyp was removed with hot snare polypectomy. The post-polypectomy site was treated with argon plasma coagulation (APC) and three hemostatic clips. At discharge, he had no further episodes of bleeding and both his aspirin and warfarin were held. After 35 days post-discharge, his warfarin was restarted. However, 10 days later he had two episodes of melena. His EGD showed the post-polypectomy site with active oozing and no visible vessel. This site was injected with 3ml of epinephrine (1:10,000) and a hemostatic clip was applied. Four days later, he developed an acute episode of melena. Repeat EGD demonstrated blood in the gastric antrum with previous clip still in place and a fresh clot with active oozing at the polypectomy site. Cauterization was performed and five hemostatic clips were placed to achieve hemostasis. He was eventually discharged after his hemoglobin stabilized and no further evidence of active bleeding. Fourteen days after discharge, he returned with weakness, hemoglobin drop and melena. Again, his EGD showed an adherent clot and active oozing at the polypectomy site. One Ovesco® “bear trap” clip was placed at the polypectomy site but there was continual oozing. He received numerous rounds of APC but the bleeding persisted. Given that he failed conventional endoscopic therapies and was not a candidate for interventional radiology treatment, Hemospray was attempted. After Hemospray® was applied to the polypectomy site, there was no further evidence of active bleeding or oozing. He was monitored for several days and eventually discharged with stable hemoglobin and no additional episodes of bleeding. Conclusion: This case highlights the novel application of Hemospray® and its effectiveness in achieving acute hemostasis in a patient with refractory post-polypectomy bleeding from a large antral polyp. To date, there have only been 15 cases of its use in the United States.

Augmenting saturated LTP by broadly spaced episodes of theta-burst stimulation in hippocampal area CA1 of adult rats and mice.

Hippocampal long-term potentiation (LTP) is a model system for studying cellular mechanisms of learning and memory. Recent interest in mechanisms underlying the advantage of spaced over massed learning has prompted investigation into the effects of distributed episodes of LTP induction. The amount of LTP induced in hippocampal area CA1 by one train (1T) of theta-burst stimulation (TBS) in young Sprague-Dawley rats was further enhanced by additional bouts of 1T given at 1-h intervals. However, in young Long-Evans (LE) rats, 1T did not initially saturate LTP. Instead, a stronger LTP induction paradigm using eight trains of TBS (8T) induced saturated LTP in hippocampal slices from both young and adult LE rats as well as adult mice. The saturated LTP induced by 8T could be augmented by another episode of 8T following an interval of at least 90 min. The success rate across animals and slices in augmenting LTP by an additional episode of 8T increased significantly with longer intervals between the first and last episodes, ranging from 0% at 30- and 60-min intervals to 13-66% at 90- to 180-min intervals to 90-100% at 240-min intervals. Augmentation above initially saturated LTP was blocked by the N-methyl-D-aspartate (NMDA) glutamate receptor antagonist D-2-amino-5-phosphonovaleric acid (D-APV). These findings suggest that the strength of induction and interval between episodes of TBS, as well as the strain and age of the animal, are important components in the augmentation of LTP.

The self-regulation of neurotransmitter release.

Retzius cells are large neurons in the ganglia of the leech (Lent, 1977), releasing 5-HT (Leake, 1986) and orchestrating the animal behavior (Carretta, 1988). The leech nervous system is relatively simple and its exploration allows correlating, in a quantitative manner, the chemical and electrical activity, at cellular level, with the animal behavior (Mazzoni et al., 2007). The recent work of Francisco De-Miguel, Citlali Trueta and colleagues has given important contributions on the understanding of 5-HT secretion at Retzius cells that occurs both at the site of synaptic targets and from the soma (De-Miguel and Trueta, 2005). The somatic 5-HT release is dependent on L-type calcium channel activation (Trueta et al., 2003) and on calcium-induced calcium release (Trueta et al., 2004). Retzius cells have 5-HT autoreceptors and the activation of these proteins is coupled to chloride channels producing synaptic autoinhibition (Cercos et al., 2009). In the article by Leon-Pinzon et al. (2014) recently published in Frontiers in Cellular Neuroscience, a significant progress on the understanding of the mechanisms induced by 5-HT autoreceptors is presented. Specifically, the authors report the very interesting finding that sustained 5-HT vesicular release is regulated by a positive feedback at the same Retzius cell. The soma of Retzius neurons releases serotonin from dense clusters of core vesicles without evidence of active zones. This type of secretion is similar to secretion by excitable endocrine cells. When 5-HT release is associated with high-frequency action potential firing, the initial 5-HT release mediated by calcium entry via voltage-gated calcium channels activates 5-HT autoreceptors. This activation leads to one or two additional episodes of intracellular calcium increase which amplify the release of 5-HT. In order to perform this study, the authors used an elegant experimental analysis combining electrophysiological recordings, fluorescence imaging of calcium and neurotransmitter activity and pharmacological tests. The physiological amplification mechanism reported in this paper allows Retzius cells operating in a two-state mode: a “weakly releasing” mode and a “strongly releasing” mode. Presumably, there will be a critical frequency that may vary from cell to cell switching from one mode to the other. This bi-stable behavior, which might be similar to what reported in another invertebrate neuron (Achenbach et al., 1997), plays an obviously important role in the computational properties of both Retzius cells and associated neuronal networks. But did we learn something that can be possibly extended to the mammalian nervous system? The leech nervous system represents a rich model for vertebrate systems from the points of view of both cellular neurobiology (Schmold and Syed, 2012) and of higher functions (Sahley, 1995). In serotonergic neurons in the raphe nuclei of the rodent brain, 5-HT is also released from the soma (Sarkar et al., 2012) and from the dendrites (Colgan et al., 2012). These phenomena have several common features with 5-HT somatic release at Retzius neurons. Thus, Leon-Pinzon et al. (2014) formulate the hypothesis that the mechanisms of self-regulation of 5-HT discovered in Retzius neurons may also operate in the mammalian nervous system, perhaps by activating receptors not only at the soma and at different time-scale.

Continuation-phase cognitive therapy and fluoxetine are effective in reducing the risk of relapse/recurrence in major depression after incomplete remission

Patients receiving a diagnosis of major depression have high risks of relapse and recurrence, increasing with every additional depressive episode.1 Therefore, the prevention of further depressive episodes in recurrent depression...

Printed quit-pack sent to surgical patients at time of waiting list placement improved perioperative quitting

This study aimed to measure the effects of sending a smoking cessation 'quit-pack' to all patients placed on the elective surgical waiting list. Questionnaire-based study before intervention (mid-2011, 177 patients) and after (2012/13, 170 patients) conducted on day of surgery. All were identified as adult smokers at time of waiting list placement at an outer metropolitan Melbourne public hospital. The intervention was a quit-pack consisting of educational brochure containing cessation advice and focused on perioperative risks of smoking, together with Quitline referral form and reply-paid envelope. The primary outcome measure was proportion of smokers who quit on waiting list for ≥1 month before surgery, considered a clinically meaningful duration to reduce surgical complications. An 8.6% improvement in waiting list smokers achieving the target ≥1 month abstinence at day of surgery (P = 0.03). The number needed to treat of 12 (95% confidence interval 6-240) meant 12 smokers receiving intervention would create one additional episode of clinically meaningful quitting on wait list. Smoking cessation outcomes before elective surgery are significantly improved by systematic application of a printed intervention delivered at time of wait list placement that encourages and supports perioperative quitting.

Financial Impact of Coagulase-Negative Staphylococcal (CoNS) Bacteremia at a Cancer Hospital

Objective: To determine the financial impact of Coagulase-Negative Staphylococcus (CoNS)- positive blood cultures. Design: Retrospective chart review. Setting: Tertiary care cancer hospital. Patients: All episodes of CoNS bacteremia during the first 6 months of 2001 were identified. Episodes from the intensive care unit, those never treated, and those treated with antibiotics before the culture was drawn or became positive were excluded. Chart review was performed in a random sample of patients to estimate the cost of each component of medical care attributable to the management of CoNS. Each patient-episode was retrospectively designated as infection or contaminant by an expert reviewer. Results: In the 6 month study period, 137 episodes of CoNS were treated. Medical records for 43 (39%) of 111 eligible patients were extracted. The average cost of managing the 43 CoNS episodes was $7,594. For the subset of 16 patients with increased length of stay (LOS) attributable to CoNS, the mean cost was $15,919, 77% due to hospital day charges. The 43 episodes were retrospectively designated either infection (n=31) or contaminant (n=12); attributable cost differed by assigned category. The mean cost for 31 patients with infection was $8,858. Six episodes, designated as contaminants by both primary team and expert review, had a mean cost of $1,881. Six additional episodes, treated as infection by the primary team but reassigned as contaminant on retrospective review, had a mean cost of $7,127. Applying the proportion of patients (6/43 or 14%) reclassified as contaminant to the annual number of treated blood cultures (2×137) would project to an annual savings of $201,237 ($7,127 minus $1,881 or $5,246/episode) at our hospital. Conclusion: In the management of CoNS bacteremia, unneeded treatment of contaminants as true infection costs up to $200,000 a year at our hospital. Infectious disease or antibiotic management program management may result in a reduction of this cost.

Hyperplastic Gastric Polyposis Complicated by a High-Grade Sarcomatoid Malignancy

1Departments of Medicine (Gastroenterology) and 2Pathology, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Hugh J Freeman, University of British Columbia Hospital, 2211 Wesbrook Mall, Vancouver, British Columbia V6T 1W5. Telephone 604-822-7216, e-mail hugfree@shaw.ca Received for publication January 24, 2014. Accepted February 7, 2014 CASE PRESENTATION A 70-year-old Asian-born woman experienced intermittent melena and iron-deficiency anemia that was treated with long-term omeprazole and iron supplements. Previous studies in other hospitals in 2009 and 2010 revealed multiple hyperplastic gastric polyps in the gastric antrum and body, but no dysplasia. There was no known family history of gastric neoplasia or previous Helicobacter pylori infection. In 2012, she experienced an additional episode of melena. Gastroscopic evaluation confirmed the presence of multiple small and large gastric polyps, typical of hyperplastic polyps (1) (Figures 1A and 1B), some with focal erosions but no dysplasia, along with a superimposed large ulcerating and polypoid lesion in the gastric body consistent with a high-grade malignancy (Figures 2A and 2B). Routine immunostaining of these biopsies to exclude stromal tumours as well as tumours of smooth muscle and neural origin with CD-117, actin and S-100 were negative. Subtotal gastrectomy showed an anaplastic spindle and epithelioid neoplasm consistent with an undifferentiated high-grade sarcomatoid malignancy (sarcoma versus sarcomatoid carcinoma), but not a gastrointestinal stromal tumour (GIST), localized to the stomach without nodal or distant metastases. Extensive immunohistochemical staining for epithelial, neuroendocrine, hematopoietic and melanocyte differentiation on the resected gastric malignancy were negative. The following stains were all negative: CD117 and DOG1 for GIST; smooth muscle actin, desmin, caldesmon for leiomyosarcoma; S100, Melan A, HMB45 for malignant peripheral nerve sheath tumour, melanoma and PECOMA; CD31 and CD34 for angiosarcoma; synaptophysin, chromogranin and TTF1 for neuroendocrine differentiation; cytokeratins 7, 19, 20, Cam 5.2 and CDX-2 for epithelial differentiation; and CD45, CD20, CD3 and ALK1 for lymphoreticular origin.

CASE STUDY OF A PATIENT WITH HIV-AIDS AND VISCERAL LEISHMANIASIS CO-INFECTION IN MULTIPLE EPISODES

SUMMARYReport of a 45-year-old male farmer, a resident in the forest zone of Pernambuco, who was diagnosed with human immunodeficiency virus (HIV) in 1999 and treated using antiretroviral (ARV) drugs. In 2005, the first episode of visceral leishmaniasis (VL), as assessed by parasitological diagnosis of bone marrow aspirate, was recorded. When admitted to the hospital, the patient presented fever, hepatosplenomegaly, weight loss, and diarrhea. Since then, six additional episodes of VL occurred, with a frequency rate of one per year (2005-2012, except in 2008). In 2011, the patient presented a disseminated skin lesion caused by the amastigotes of Leishmania, as identified by histopathological assessment of skin biopsy samples. In 2005, he was treated with N-methyl-glucamine-antimony and amphotericin B deoxycholate. However, since 2006 because of a reported toxicity, the drug of choice was liposomal amphotericin B. As recommended by the Ministry of Health, this report emphasizes the need for HIV patients living in VL endemic areas to include this parasitosis in their follow-up protocol, particularly after the first infection of VL.

Supportive monitoring and disease management through the internet: An internet-delivered intervention strategy for recurrent depression

Major depression is a highly prevalent, disabling disorder associated with loss of quality of life and large economic burden for the society. Depressive disorders often follow a chronic or recurrent course. The risk of relapses increases with each additional episode. The internet-deliverable intervention strategy SUMMIT (SUpportive Monitoring and Disease Management over the InTernet) for patients with recurrent depression has been developed with the main objectives to prolong symptom-free phases and to shorten symptom-loaden phases. This paper describes the study design of a six-sites, three-arm, randomized clinical trial intended to evaluate the efficacy of this novel strategy compared to treatment as usual (TAU). Two hundred thirty six patients who had been treated for their (at least) third depressive episode in one of the six participating psychiatric centers were randomized into one of three groups: 1) TAU plus a twelve-month SUMMIT program participation with personal support or 2) TAU plus a twelve-month SUMMIT program participation without personal support, or 3) TAU alone. Primary outcome of this study is defined as the number of “well weeks” over 24months after index treatment assessed by blind evaluators based on the Longitudinal Interval Follow-Up Evaluation. If efficacious, the low monetary and nonmonetary expenditures of this automated, yet individualized intervention may open new avenues for providing an acceptable, convenient, and affordable long-term disease management strategy to people with a chronic mental condition such as recurrent depression.

Bipolar disorders in DSM-5: strengths, problems and perspectives.

The diagnostic classification of mood disorders by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) had two major shortcomings: an underdiagnosis of bipolar disorders and a large proportion of treated patients had to be allocated to the vague NOS groups ‘not otherwise specified’. Several new subthreshold groups of depression, bipolar disorders and mixed states are now operationally defined in DSM-5. In addition, hypomanic and manic episodes occurring during antidepressant treatments are, under certain conditions, accepted as criteria for bipolar disorders. The diagnosis of bipolarity now requires, as entry criterion A, not only the presence of elated or irritable mood but also the association of these symptoms with increased energy/activity. This restriction will unfortunately change the diagnoses of some patients from DSM-IV bipolar I and II disorders to subdiagnostic bipolar syndromes. Nonetheless, overall, DSM-5 is a step in the right direction, specifying more subdiagnostic categories with an improved dimensional approach to severity. DSM-5 may also have an impact on patient selection for placebo-controlled drug trials with antidepressants.

Associations Between Human Leukocyte Antigen Class I Variants and the Mycobacterium tuberculosis Subtypes Causing Disease

The development of active tuberculosis disease has been shown to be multifactorial. Interactions between host and bacterial genotype may influence disease outcome, with some studies indicating the adaptation of M. tuberculosis strains to specific human populations. Here we investigate the role of the human leukocyte antigen (HLA) class I genes in this biological process. Three hundred patients with tuberculosis from South Africa were typed for their HLA class I alleles by direct sequencing. Mycobacterium tuberculosis genotype classification was done by IS6110 restriction fragment length polymorphism genotyping and spoligotyping. We showed that Beijing strain occurred more frequently in individuals with multiple disease episodes (P < .001) with the HLA-B27 allele lowering the odds of having an additional episode (odds ratio, 0.21; P = .006). Associations were also identified for specific HLA types and disease caused by the Beijing, LAM, LCC, and Quebec strains. HLA types were also associated with disease caused by strains from the Euro-American or East Asian lineages, and the frequencies of these alleles in their sympatric human populations identified potential coevolutionary events between host and pathogen. This is the first report of the association of human HLA types and M. tuberculosis strain genotype, highlighting that both host and pathogen genetics need to be taken into consideration when studying tuberculosis disease development.

The second study of infectious intestinal disease (IID2): increased rates of recurrent diarrhoea in individuals aged 65 years and above

BackgroundInfectious intestinal disease (IID) is a major health and economic burden in high-income countries. In the UK, there are an estimated 17 million IID cases annually, of which 6 million are caused by the 12 most common pathogens. Host factors that influence risk of IID are not well understood.MethodsWe analyzed data from the IID2 Study, a UK cohort that measured IID incidence, to investigate factors associated with recurrent IID. We calculated rates of IID by age group, sex, previous episodes experienced, and socioecomic indicators. We used Cox models to investigate factors associated with recurrent illness.ResultsThe rate of IID was five times higher among infants than those aged 65 years and above (hazard ratio, HR = 5.0, 95% CI: 3.1 – 8.0). However, the association between previous IID and a subsequent IID episode was stronger in the elderly. Among those aged 65 years and above, each additional IID episode increased the rate of subsequent IID three-fold (HR = 3.1, 95% CI: 2.5 – 3.7). Among infants, the corresponding increase was 1.7-fold (HR = 1.7, 95% CI: 1.3 – 2.3).ConclusionsElderly populations have a high propensity for recurrent IID. More detailed studies are needed to identify vulnerable subgroups and susceptibility factors, and inform adequate control policies among the elderly.

Datapoints: False Starts in Psychotherapy for Substance Use Disorders and PTSD in the VHA

A of the push toward evidencebased mental health treatment, there is interest in increasing the proportion of patients who engage in evidence-based psychotherapy. However, attrition is a common phenomenon, especially at the beginning of psychotherapy. Using Veterans Health Administration (VHA) data, we examined psychotherapy utilization patterns among patients diagnosed as having a substance use disorder or posttraumatic stress disorder (PTSD) in fiscal year (FY) 2008. Start of a psychotherapy treatment episode was defined as the first psychotherapy visit after 60 dayswith noVHApsychotherapy visits within VHA. Thus psychotherapy visits more than 60 days apart were viewed as separate treatment episodes. This is consistent with a widely used definition of a treatment episode for a substance use disorder (1). Among patients who initiated psychotherapy, we also examined attrition—defined as attending only one or two psychotherapy visits. In FY 2008, of the 380,231 patients with an inpatient or outpatient encounter that included a substance use disorder diagnosis, 210,168 (55%) had at least one outpatient psychotherapy episode start, and among those, 121,257 (58%) attended only one or two visits. Of the 442,359 patients with an inpatient or outpatient encounter in FY 2008 that included a PTSD diagnosis, 297,831 (67%) had at least one outpatient psychotherapy episode start, and, among those, 183,801 (62%) attended only one or two visits (Figure 1). Repeated attempts at psychotherapy engagement were not rare; 40% of those with a substance use disorder and 48% of those with PTSD who started one outpatient psychotherapy episode had at least one additional episode start in the same year. These observations may have significant clinical and measurement implications. Clinically, these results suggest that more needs to be done to encourage patients to initiate and engage in treatment. Although attrition from care is common, both clinicians and patients should be aware that a significant number of patients who initially disengage from care will later make attempts at reengagement. Efforts to reengage patients may improve engagement rates and mental health outcomes. Explaining these rates to patients may reduce discouragement and self-stigma among those having difficulty with adherence during attempts at treatment seeking.Moreover,many patients with PTSD or a substance use disorder may need more than one attempt at psychotherapy to be successful. Some widely used measures of treatment engagement examine only the first episode of care in a year (1). Our results suggest that this approach could underestimate the proportion of patients who engage in treatment during a year because it overlooks subsequent treatment episodes. Our results underscore the importance of the adage, “If at first you don’t succeed, try, try again.”

Examination of Treatment Episodes Among Women and Racial and Ethnic Minorities in Addiction Treatment

Women and racial and ethnic minorities face significant challenges to successfully completing substance abuse treatment. There is limited knowledge about factors that affect women and minorities' treatment careers over several treatment episodes. Survival Cox regression was used to model time and episodes to treatment completion. Using multiyear (2006–2009) data, the sample consisted of 52,799 clients from 276 treatment programs in Los Angeles County, California. Findings supported the role of homelessness and mental health status and their association with more episodes to complete treatment. Results also showed that the rate of completion was 41% lower among African Americans and 17% lower among Latinos compared to Whites. With each additional treatment episode, the rate of treatment completion increased by 73% for all groups. Compared to minorities, Whites and men were more likely to complete treatment throughout their treatment career trajectories. Implications for social work interventions to enhance treatment adherence and reduce disparities are discussed.

Laparoscopic reversal of Roux-en-Y gastric bypass: Technique and utility for treatment of endocrine complications

BackgroundThe anatomic and physiologic changes with Roux-en-Y gastric bypass (RYGB) may lead to uncommon but occasionally difficult to treat complications such as hyperinsulinemic hypoglycemia with neuroglycopenia and recalcitrant hypocalcemia associated to hypoparathyroidism. Medical management of these complications is challenging. Laparoscopic reversal of RYGB anatomy with restoration of pyloric function and duodenal continuity is a potential treatment. The objective of this study was to present the indications, surgical technique, and clinical outcomes of laparoscopic reversal of RYGB. MethodsProspective study of consecutive patients offered laparoscopic reversal of RYGB. ResultsFive patients with remote laparoscopic RYGB underwent laparoscopic reversal of RYGB to normal anatomy (n = 2) or modified sleeve gastrectomy (n = 3). Indications were medically refractory hyperinsulinemic hypoglycemia with neuroglycopenia (n = 3), recalcitrant hypocalcemia with hypoparathyroidism (n = 1), and both conditions simultaneously (n = 1). Before reversal, all patients had a gastrostomy tube placed in the excluded stomach to document improvement of symptoms. Laparoscopic reversal was accomplished successfully in all patients. Three postoperative complications occurred: bleeding that required transfusion, gallstone pancreatitis, and a superficial trocar site infection. Average length of stay was 3 days. At a mean follow-up of 12 months (range 3 to 22), no additional episodes of neuroglycopenia occurred, average number of hypoglycemic episodes per week decreased from 18.5±12.4 to 1.5±1.9 (P = .05), and hypocalcemia became responsive to oral replacement therapy in both patients. ConclusionsLaparoscopic reversal of RYGB to normal anatomy or modified sleeve gastrectomy is feasible and may be a therapeutic option for selected patients with medically refractory hyperinsulinemic hypoglycemia and/or recalcitrant hypocalcemia associated with hypoparathyroidism.