Chronic Medical Disorders Research Articles

A Review of Psoriasis, Therapies, and Suicide.

Many chronic medical disorders are associated with psychiatric morbidity. Yet the psychological burden of these disorders often goes unnoticed. In dermatology, psoriasis has a higher association with psychiatric illness, including depression and suicide risk, compared with many other conditions. Studies suggest that effective treatment of psoriasis results in the improvement of psychiatric morbidity, particularly depression and anxiety. New biologic treatments for psoriasis may offer help beyond clearing of the skin in these patients and may lead to a reduction of psychiatric morbidity. Although concerns have been raised regarding the potential link between interleukin-17R blockade in the treatment of psoriasis and suicide, current literature provides no evidence to support this association.

A Call to Action: A Blueprint for Academic Health Sciences in the Era of Mass Incarceration

Over 100 million Americans have criminal records, and the U.S. incarcerates seven times more citizens than most developed countries. The burden of incarceration disproportionately affects people of color and ethnic minorities, and those living in poverty. While 95% of incarcerated people return to society, recidivism rates are high with nearly 75% arrested again within five years of release. Criminal records impede access to employment and other social services such as shelter and health care. Justice-involved people have higher rates of substance, mental health, and some chronic medical disorders than the general population; furthermore, the incarcerated population is rapidly aging. Only a minority of academic health science centers are engaged in health services research, workforce training, or correctional health care. This commentary provides rationale and a blueprint for engagement of academic health science institutions to harness their capabilities to tackle one of the country's most vexing public health crises.

Healthcare Use in Individuals with Obesity and Chronic Hypoxemia Treated for Sleep Disordered Breathing.

To determine if treatment of obstructive sleep apnea (OSA) and obesity hypoventilation syndrome (OHS) among patients with chronic hypoxemia is associated with reduced healthcare utilization. We performed a retrospective cohort study of 129 obese, hypoxemic patients who underwent polysomnography and were prescribed positive airway pressure (PAP) therapy. During a 2-year follow-up period we examined the associations between adherence to PAP therapy and rates of hospitalization, emergency room (ER) visits, and outpatient visits. Severe OSA and OHS were common, as were hypertension, cardiovascular, and pulmonary disease. Forty-nine percent of patients were adherent with PAP therapy. Compared to patients who were not adherent to PAP therapy, adherent patients had significantly lower rates of all-cause hospitalization (incident rate ratio [IRR]:0.55, 95% CI 0.33, 0.93) after adjustment for age, sex and hospitalisation rates prior to treatment. Adjustment for additional comorbidities attenuated this association (IRR: 0.61, 95% CI 0.35, 1.06). Adherence with PAP therapy was associated with lower odds of frequent hospitalization (odds ratio 0.23, 95% CI 0.07, 0.73). There were no significant differences in the rates of ER or outpatient visits between adherent and non-adherent patients. Adherence with PAP treatment in patients with chronic hypoxemia and chronic medical disorders is associated with reduced rates of hospitalization, which has significant benefit both for patients and the healthcare system.

Should Expanded Weight Loss Counseling Include Sleep Counseling and Simple Clinical Tools for Patient Assessment?

Sleep restriction is associated with weight gain and chronic medical disorders. We randomized 40 women with body mass indices between 25 and 49 kg/m2 into 2 counseling groups: dietary advice with exercise and dietary advice with exercise and sleep counseling. We measured blood pressure, gait speed, and the Get Up and Go test. The mean age was 43.0 ± 10.4 years; the mean body mass index was 33.4 ± 4.3 kg/m2. Twenty-seven subjects completed 6 visits. There was no difference between the 2 intervention groups in weight loss. Mean blood pressures were within normal limits. Gait speeds increased and Get Up and Go times decreased in the women who completed 6 months of counseling. These tools provide quick assessments of health and physical performance and provide dietitians with additional outcome measurements.

Perceived caregiver stress in Alzheimer's disease and mild cognitive impairment: A case control study.

Objectives:Cross sectional studies have reported a tremendous amount of stress in caregivers of patients with Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI). The present study aimed at evaluating the perceived stress in caregivers of patients with AD and MCI compared to controls.Materials and Methods:Caregivers of patients diagnosed with Alzheimer's disease/Mild Cognitive Impairment were recruited at the Memory Clinic of Neurology Department of a Tertiary Care Hospital in Northern India. The controls included caregivers of patients with chronic medical and psychiatric disorders. Caregivers were interviewed using Perceived Stress Scale (PSS) and the patients were assessed using The Blessed Activity of Daily Living (ADL), Mini Mental State Examination (MMSE) and Clinical Dementia Rating scale. The perceived stress of caregivers was compared amongst both groups and correlated with the severity of illness and activities of daily living of the patients.Results:Caregivers of a total of 31 patients of AD/MCI (Males = 24, Females = 7), and 30 controls (Males = 18, Females = 12) were interviewed. PSS Score was 23.29 ± 7.17 in cases and 7.5 ± 3.12 in controls. ADL Score was 7.97±5.53 in cases and 0.00 in controls. There was a significant difference between the PSS and ADL scores between those with AD and controls (P < 0.0001). Caregivers of patients with MCI had lower PSS scores compared to AD caregivers but significantly higher scores compared to caregivers of other chronic disorders. Similarly, correlation between Perceived Stress and ADL was significant (P < 0.001).Conclusions:Present study shows that caregivers of patients with AD/MCI have a high perceived stress compared to caregivers of patients with other chronic illness.

Comparative Evaluation of Antioxidative Properties and Effects of Aqueous Extracts of Cola Nitida and Vitex Doniana on Fe2+ - Generated Oxidative Stress in Rat Testes in Vitro

Male sexual dysfunction (MSD) might be produced by multifactorial determinants which include psychological disorders, androgen deficiencies, chronic medical conditions, vascular insufficiency, penile disease, pelvic surgery, neurological disorders, drugs, life style, aging and systemic diseases. This study sought to assess the antioxidant properties of the water-extractable component of the leaves of Black plum (Vitex doniana) and bark of Kola nut (Cola nitida),evaluate their effect on pro-oxidant generated lipid peroxidation in rat’s testes; and examine the effect on arginase which is among the major enzymes associated with Erectile dysfunction. The results of the total phenol, total flavonoid of aqueous extracts of Cola nitida and Vitex doniana revealed that Cola nitida (10.64 mgGAE/g) had significantly (P<0.05) more total phenol content than Vitex doniana (4.68 mgGAE/g). The result also revealed that Vitex doniana (2.1 mgQE/g) had significantly (P<0.05) higher total flavonoid content than Cola nitida (1.3 mgQE/g). Also, Vitex doniana (20.24 mgAEE/g) had significantly (p<0.05) higher reducing property than Cola nitida (17.43 mgAEE/g). The results of the 2, 2’-azino-bis (3-ethylbenthiazoline-6-sulphonic acid (ABTS*) radical mopping up capacity of the water extractable component of Vitex doniana and Cola nitida also showed that the extracts are able to scavenge ABTS* radicals, however, Vitex doniana (1.8 Mmol TEAC/100g) had significantly (P<0.05) higher ABTS* mopping up capability than Cola nitida (1.2 Mmol TEAC/100g). Furthermore, the DPPH* result revealed that Cola nitida and Vitex doniana extracts scavenged DPPH* radicals in a concentration-dependent pattern. However, Vitex doniana (IC50 = 1.28mg/ml) had a significantly (P<0.05) higher DPPH* mopping up capability than Cola nitida (IC50 = 0.83 mg/ml). Both extracts were able to inhibit FeSO4-generated lipid peroxidation at a dose-dependent manner; however, Vitex doniana (IC50 = 1.07 mg/ml) had a higher inhibitory action of Fe2+ induced lipid peroxidation than Cola nitida (IC50 = 1.01 mg/ml). Vitex doniana (IC50 = 0.38mg/ml) has the higher arginase inhibitory activity than Cola nitida (IC50 = 0.34mg/ml). High phenolic content and strong antioxidant properties could be part of the mechanisms through which the water extractable phytochemicals of Cola nitida (bark) and Vitex doniana (leaves) exhibits its preventive measure of erectile function. However, Vitex doniana displayed a stronger effect on Male reproductive function than Cola nitida.

Perceived caregiver stress in Alzheimer's disease and mild cognitive impairment: A case control study.

Objectives: Cross sectional studies have reported a tremendous amount of stress in caregivers of patients with Alzheimer's disease (AD) and Mild Cognitive Impairment (MCI). The present study aimed at evaluating the perceived stress in caregivers of patients with AD and MCI compared to controls. Materials and Methods: Caregivers of patients diagnosed with Alzheimer's disease/Mild Cognitive Impairment were recruited at the Memory Clinic of Neurology Department of a Tertiary Care Hospital in Northern India. The controls included caregivers of patients with chronic medical and psychiatric disorders. Caregivers were interviewed using Perceived Stress Scale (PSS) and the patients were assessed using The Blessed Activity of Daily Living (ADL), Mini Mental State Examination (MMSE) and Clinical Dementia Rating scale. The perceived stress of caregivers was compared amongst both groups and correlated with the severity of illness and activities of daily living of the patients. Results: Caregivers of a total of 31 patients of AD/MCI (Males = 24, Females = 7), and 30 controls (Males = 18, Females = 12) were interviewed. PSS Score was 23.29 ± 7.17 in cases and 7.5 ± 3.12 in controls. ADL Score was 7.97±5.53 in cases and 0.00 in controls. There was a significant difference between the PSS and ADL scores between those with AD and controls (P < 0.0001). Caregivers of patients with MCI had lower PSS scores compared to AD caregivers but significantly higher scores compared to caregivers of other chronic disorders. Similarly, correlation between Perceived Stress and ADL was significant (P < 0.001). Conclusions: Present study shows that caregivers of patients with AD/MCI have a high perceived stress compared to caregivers of patients with other chronic illness.

Colloidion Baby: A Rare Clinical Entity.

Colloidion baby is a rare clinical entity. Herein the neonate is born with a shiny, yellowish parchment like transparent membrane stretched over the skin. It was Hallopeau and Watelet in 1892, who first used this term and since then literature has a record of nearly 270 colloidian babies [1]. Eventually, these children will develop signs of one of the several types of ichthyosis, giving the skin ‘fish scales’ appearance [2]. We herein report one such case owing to its rarity. A primi gravida presented at 32 weeks of gestation according to her last menstrual period with complaint of leaking per vaginum for two days prior to presentation. There was no personal or family history of diabetes, any exposure to teratogenic drug, no history of any chronic medical disorders. Mother was diagnosed as pregnancy induced hypertension but was not on any treatment. Her present pregnancy was followed in a local hospital with regular follow-up with ultrasonography examination done one week prior to delivery showing oligohydramnios (decreased amniotic fluid index=4). There was no comment on any congenital malformations. On admission patient was haemodynamically stable. On abdominal examination, fundal height corresponded to 32 weeks of gestation with breech presentation with normal fetal heart rate pattern. On per vaginal examination cervix was closed and not effaced with high breech with clear dribbling liquid. She was started on intravenous antibiotics and betamethasone was given. Caessarean section was planned after 48 hours and a 1900 grams female baby was born with following morphological features [Table/Fig-1]. [Table/Fig-1]: Appearance of baby on day 1 of life. Thick shield like taut skin all over body with cracked pinkish areas in between, scanty hair, malformed ears, everted eyelids with exposed swollen conjunctiva, slit like nostril, open mouth, flexed limbs with malformed palms, oedematous feet were present. Baby did not need active resuscitation and was shifted to neonatal intensive care unit. Dermatological opinion was taken and a diagnosis of Harlequin ichthyosis was made. Baby was managed with intravenous fluids, intravenous antibiotics and topical emollients. Baby remained haemodynamically stable with cracks in the skin increasing [Table/Fig-2]. Baby was taken to home against medical advice on fifth day of life and lost to follow-up. [Table/Fig-2]: Appearance of baby on day 4 of life. Approximately 75% of collodion baby develops a type of autosomal recessive congenital ichthyosis, either lamellar ichthyosis or congenital ichthyosiform erythrodema) [3]. The third type of autosomal recessive congenital ichthyosis, Harlequin ichthyosis, is the most rare and severe form. Other rare causes of colloidion baby include-Epidermolytic hyperkeratosis (bullous congenital ichthyosiform erythroderma), Gaucher’s disease and Sjogren-Larsson syndrome. Although, the colloidian membrane develops due to an epidermal cornification disorder, keratinocyte protein and lipid metabolism defects resulting from autosomal recessive genetic mutations have also been notified as important cofactors [4]. Transglutaminase 1 gene mutation localized on the 14q11 have been implicated in congenital autosomal recessive ichthyosis [5]. Owing to impairment of the skin barrier function, collodion babies prone for a number of complications like hypernatremic dehydration, hypothermia, skin infections, fissures, conjunctivitis, sepsis, dehydration and constrictive bands of the extremities resulting in vascular compromise and oedema [1,2]. They require proper fluid and electrolyte balance, emollients and lubricants for hydrating the membrane. Suitable eye care and pain control should be carried out for the collodion babies with ectropion. Prophylactic antibiotics should be used to prevent sepsis. In the present scenario, owing to intensive care, the survival of neonates has increased. Humidified incubators and water dressings followed by emollient agents are important aspects in its management.

Treat-to-target in lupus: what does the future hold?

Implementing a ‘treat-to-target’ (T2T) strategy that aims to improve disease outcomes through achievement of prespecified treatment goals has proven efficacy in chronic medical disorders. An international task force has recommended that treatment in systemic lupus erythematosus patients should aim at prevention of organ damage accrual by achieving the lowest possible disease activity, preventing flares, minimizing glucocorticoid exposure and treating co-morbidities. Notwithstanding the above, application of T2T in routine care remains challenging due to systemic lupus erythematosus complexity, limitations of available activity and damage indices and paucity of validated treatment targets. For the future, we anticipate that accumulating data from clinical studies, together with advances in biomarkers research, will help to resolve these issues and engage the T2T strategy in daily practice.

The Puerto Rico Healthcare Crisis.

The Commonwealth of Puerto Rico is an organized nonincorporated territory of the United States with a population of more than 3.5 million U.S. citizens. The island has been the focus of much recent attention due to the recent default on its debt (estimated at more than $70 billion), high poverty rates, and increasing unemployment. Less attention, however, has been given to the island's healthcare system, which many believe is on the verge of collapsing. Healthcare makes up 20% of the Puerto Rican economy, and this crisis affects reimbursement rates for physicians while promoting the disintegration of the island's healthcare infrastructure. A major contributor relates to a disparity in federal funding provided to support the island's healthcare system when compared with that provided to the states in the mainland and Hawaii. Puerto Rico receives less federal funding for healthcare than the other 50 states and the District of Columbia even though it pays its share of social security and Medicare taxes. To make matters worse, the U.S. Center for Medicaid and Medicare Services is planning soon to implement another 11% cut in Medical Advantage reimbursements. This disparity in support for healthcare is considered responsible for ∼$25 billion of Puerto Rico's total debt. The impact of these events on the health of Puerto Ricans in the island cannot be entirely predicted, but the loss of healthcare providers and diminished access to care are a certainty, and quality care will suffer, leading to serious implications for those with chronic medical disorders including respiratory disease.

Patterns and Predictors of Dropout from Mental Health Treatment in an Asian Population

Studies examining mental health treatment dropout have primarily focused on Western populations and less so on Asian samples. The current study explored the prevalence and correlates of mental health treatment dropout across the various healthcare sectors in Singapore. Data was utilised from the Singapore Mental Health Study (SMHS), a cross-sectional epidemiological survey conducted among an adult population (n = 6616) aged 18 years and above. Statistical analyses were done on a subsample of respondents (n = 55) who had sought treatment from the various treatment providers (i.e. mental health, medical, social services and religious healers) in the past 12 months. The World Mental Health (WMH) Composite International Diagnostic Interview version 3.0 (CIDI 3.0) was used to determine diagnoses of mental disorders, chronic medical disorders and service utilisation. Of those who had received treatment, 37.6% had ended treatment prematurely, 23.2% had completed treatment and 39.2% were still in treatment. The religious and spiritual sector (83.1%) had the highest dropout, followed by the general medical sector (34.6%), mental health services sector (33.9%) and the social services sector (30%). Marital status emerged as the only sociodemographic factor that significantly predicted treatment dropout-with those who were married being significantly less likely to drop out than those who were single. The overall dropout rate across the various healthcare sectors was comparable to past studies. While the small sample size limits the generalisability of findings, the current study provides useful insight into treatment dropout in an Asian population.

Study protocol of the DUCATI-study: a randomized controlled trial investigating the optimal common channel length in laparoscopic gastric bypass for morbid obese patients.

BackgroundMorbid obesity has become one of the most frequent chronic medical disorders in Western countries, affecting 1.5-2 % of the Dutch population. Currently, the laparoscopic Roux-Y gastric bypass is considered to be the most effective bariatric treatment option for morbid obesity as it results in adequate weight loss and a significant decrease in comorbidity. Although this technique has been applied for years, the optimal lengths of the three bowel limbs (alimentary limb, biliopancreatic limb, and common channel) in order to achieve maximal percentage excess weight loss with minimal side effects (i.e. malabsorption symptoms), are unknown. As ‘normal’ sized gastric bypasses achieve an average of 60 − 80 % excess weight loss after one year, one could hypothesize that afferent limb lengths should be longer in order to reduce the common channel length, thereby improving outcome in terms of excess weight loss.The aim of the current study is to investigate the effect of the length of the common channel in gastric bypass surgery for morbid obesity. In this randomized controlled trial the very long Roux limb gastric bypass will be compared to the standard gastric bypass, in order to conclude which option is the optimal therapeutic strategy in the morbidly obese patient.Methods/designIn this multicentre trial patients will be randomized either to a very long Roux limb gastric bypass with a fixed common channel length of 100 cm, or to a standard gastric bypass with a variable common channel length.The primary objective is to evaluate whether the very long Roux limb gastric bypass is superior in terms of percentage excess weight loss after one year follow-up compared to the standard gastric bypass.Secondary endpoints are quality-of-life, cure /improvement of obesity related comorbidity, complications, malnutrition, re-admission rate, and re-operation rate.DiscussionWe hypothesize that our proposed distal LRYGB will provide for improved results concerning % EWL with an acceptable rate of (metabolic) complications.Our main point of interest is to determine if the distal LRYGB is a superior alternative to standard LRYGB in terms of percentage excess weight loss and to put more focus on the role of the common channel. Therefore we will perform this randomized controlled trial comparing both techniques, with % EWL as a primary outcome.Trial registrationCCMO registration number: NL43951.101.13 and Netherlands Trial Registry number: NTR4466.

Coherent long‐term treatment approaches–superior in the treatment of opioid dependence

Evans et al. have published an impressive registry-based study from California, including more than 32 000 individuals and 76 000 observation years 1. The aim of the study was to investigate if two commonly used treatments, detoxification and methadone maintenance treatment (MMT), provided differential effects on all-cause and cause-specific mortality among opioid-dependent people. Both treatments, detoxification and MMT, reduced mortality following treatment admission: MMT more so than detoxification treatment alone. The combination of first in-patient detoxification, thereafter directly entering MMT in a (probably planned) sequence produced the best overall results in terms of mortality reductions. Contemporary understanding is that opioid dependence is to be perceived and treated most often from the perspective of chronic medical disorders, thus well-designed provision of treatment would be the ideal and logical response 2-4. In that context, treatment needs to be designed and combined as a long-term and coherent effort in a continuum of care. This is in contrast to shorter-term interventions that aim at ‘total cure’ at the end of a specified treatment episode, as would be the model practised in acute care medicine. Few would argue today that short-term detoxification is an adequate stand-alone treatment, due to the high risk of relapse combined with loss of opioid tolerance 5. Nevertheless, as part of a planned series of interventions, detoxification may have an important role in the treatment of opioid dependence, as shown by Evans et al. [1]. As untreated opioid dependence is a disorder with a very high risk of premature mortality, a main goal is to recruit opioid-dependent people into adequate treatment 6. Hence, treatment providers need to offer evidence-based services that attract opioid-dependent people. A higher risk of mortality was observed among those who had more severe disorder and who had been untreated for the longest periods 1. More ‘aggressive’ engagement of opioid-dependent people into treatment sooner after onset of drug use is recommended. Current evidence points towards opioid maintenance treatment (OMT) as the preferred treatment for opioid dependence 7-9. OMT reduces the risk of overdose and overall mortality while people are in treatment 10, 11, and is ideally a long-term approach. However, OMT is provided in a range of ways globally, and the search is still on to settle how this treatment is to be offered in the most appropriate fashion. As has been shown in the Evans et al. [1] paper, OMT should preferably be provided in a long-term/life-long perspective, to ensure long-term risk reduction, ideally with a detoxification prior to OMT. In California, and for many other treatment providers across the world, it should be seen as a challenge that only a minority (11% in California) of those entering treatment for opioid dependence actually received the combination and sequence of treatments (detoxification followed by OMT) that provided the best outcome in terms of mortality reduction. In contrast, most of the observation time was spent outside treatment, and when treatment was provided the most common mode of treatment was short-term stand-alone detoxification (25%), which offers a horrendously increased risk of mortality immediately following treatment cessation. In addition to finding the right combinations and sequence of treatments the contents of treatments also vary and are indeed of importance. It has been shown that there is a dose–response relationship with positive outcomes such as long-term retention in OMT with increasing amounts of psychosocial services included 12. OMT with an emphasis on integrated psychosocial interventions is key to supporting patients in their recovery process. From Norway, we have reported previously from a national OMT system which performs treatment initiations via specialist treatment centres 10. The results from that setting showed very low rates of mortality during the first 2 weeks of OMT 13, 14. This was in contrast to predominantly primary care and general practitioner-initiated OMT reported previously from the United Kingdom, as well as the current findings from California, which show an elevated risk of overdose mortality during the first weeks of OMT 15. OMT initiation is a challenging medical procedure, and if not managed by skilled and experienced personnel with knowledge of addiction medicine it may be a hazardous undertaking. Ongoing polydrug use along with OMT initiation provides a serious risk for death. We need to investigate further how the sequences of different interventions are best combined to meet the needs of people with chronic disorders, rather than delivery of treatment as stand-alone efforts. Particularly at ‘treatment completion’ or, rather, transitions from one treatment phase to another, we need to emphasize the ideals of long-term continuum of care. Additionally, a range of different treatments are probably required to meet the needs of the heterogeneous opioid-using population. Evaluating treatment outcomes using registries and cohorts from real-life treatment settings will become increasingly important when combinations of interventions are to be evaluated for chronic conditions from a long-term perspective. None.

Telemedicine screening for eye disease.

Telemedicine is increasinglyused fordiseasemonitoringandmanagement of chronic medical and mental disorders, but also has screening and diagnostic applications such as teleradiology and teledermatology. Indeed, “therapy at a distance” will complement office-based care in the 21st century. Another screening application is teleophthalmology, in which digital photography with telemedicine links has proven cost-effective for retinal disorders, including diabetic retinopathy and retinopathy of prematurity.1,2 Ina recent study in JAMAOphthalmology, Chasanetal3 complementedpriorcost-effectivenessanalysesof teleretinal screeningprogramsbyexaminingboth theaccuracyofdiabetic teleretinal screening as well as the subsequent eye care use and resources required in such a program. Regarding accuracy, screening tests that have good sensitivity and specificity are likely to bemore cost-effective. Regarding resource use, implementation of screening generates more referrals, testing, and procedures. The cost-effectiveness of any screening program is therefore contingent on reasonable test accuracy coupledwith a sufficient supply of resources tomeet the increased demand. Chasan et al3 conducted the study in community-based clinics ofasingleVeteransAffairs (VA)medical center.Of 1935patientswho underwent diabetic retinal screening, 465 (24%) had an abnormal finding on the retinal photograph and were referred to the VA eye clinic, of whom 326 were seen by an eye specialist and had a confirmatorydiagnosis.Themostcommonreasonsfor referralwerenonmacular diabetic retinopathy (43.2%), nerve-related disease (30.8%), lensormediaopacity (19.1%), age-relatedmacular degeneration (12.9%), and diabetic macular edema (5.6%). The percentageof agreementbetween retinal screeningand theophthalmicexamination for all diagnoseswas 90.4%,with a sensitivity of 73.6%. Sensitivity may have been somewhat inflated for 2 reasons. First, onlypatientswithabnormal retinalphotographswere referred, thus greatly increasing the number of cases with disease and minimizing thenumberof caseswithoutdisease. This verificationbias (also known as “workup bias” or “referral bias”) is a type of measurementbias inwhich the resultsof adiagnostic test affectwhether the gold standard procedure is used to verify the test result. Second, it is not clear that the clinician performing the ophthalmic examinaJAMAOPHTHALMOLOGY

Is Aerobic Physical Activity a Viable Management Strategy for ADHD?

For the past couple decades, the recommended evidence-based treatments for attention-deficit/hyperactivity disorder (ADHD) have remained largely consistent: medication, behavior therapy, and their combination (American Academy of Pediatrics’ Subcommittee on ADHD, Steering Committee on Quality Improvement and Management, 2011; MTA Cooperative Group, 1999). Although important new pharmaceutical preparations have emerged, as well as variations on behavioral intervention strategies, the basic approach to treating the disorder has remained largely the same. Yet, medication is considered unpalatable or unworkable (e.g., due to side effects) for some families (Halperin & Healey, 2011) and behavior therapy is considered cumbersome to others (Benner-Davis & Heaton, 2007). Further, with both treatments, as well as their combination, symptoms generally return upon treatment cessation (Jensen et al., 2007). In the past decade, our understanding of the life course of the disorder has advanced, making clear that in a majority of cases, impairment associated with ADHD persists into adulthood (Barkley, Fischer, Smallish, & Fletcher, 2002; Biederman, Petty, Clarke, Lomedico, & Faraone, 2011; Hinshaw et al., 2012). Given the chronic nature of ADHD, sustainable lifestyle changes should be explored that enable a proactive, chronic approach to its treatment, much like the approach taken to manage chronic medical disorders (Hoza et al., 2014) such as heart disease. One relatively unexplored approach to managing ADHD symptoms over the long term is the use of chronic aerobic physical activity (PA). To our knowledge, only one large-scale randomized clinical trial has applied aerobic PA to management of ADHD symptoms and impairments in young children (Hoza, et al., 2014), and we are unaware of any well-controlled randomized trials applying aerobic PA to older children or adolescents with ADHD. A handful of smaller sample studies, however, are present in the literature. Although forms of PA and methods of measuring outcomes vary widely across these extant studies, the emerging message from this small body of work is that PA may be a promising strategy for managing ADHD symptoms and impairments both in the short and long term (see Berwid & Halperin, 2012, and Halperin, Berwid, & O’Neill, 2014, for reviews).

The Impact of Cognitive, Social and Physical Limitations on Income in Community Dwelling Adults With Chronic Medical and Mental Disorders.

Introduction:As much as 45% of the US population has at least one chronic condition while 21% have multiple chronic diseases. The study examined the impact of cognitive, social and physical limitations on the personal income of U.S. adults with seven chronic diseases.Methods:A cross-sectional analysis of 19,357 US adults with seven chronic diseases (diabetes, hypertension, heart disease, stroke, depression, emphysema and joint disease) from the 2006 Medical Expenditure Panel Survey (MEPS) was performed. The effect of seven chronic diseases and their associated cognitive, social, and physical limitations on personal income was assessed using a two-stage Heckman model.Results:Depression emerged as the only chronic disease that was independently associated with a significant $1,914 decrease in personal income (95% CI -$2,938--$890). Social and cognitive limitations resulted in $1,944 (95% CI -$3,378--$511) and $3,039 (95% CI -$4,418-$1,659) decreases in personal incomes respectively while physical limitations did not result in a statistically significant reduction. Being Non-Hispanic Black, Hispanic, Other Race, female, never married, married, less than a bachelor’s degree, publicly insured, uninsured, or having a health status less than very good were also associated with significant reductions in personal income.Conclusions:The findings of this study suggest a need to determine the specific limitations associated with common chronic diseases and identify appropriate compensatory strategies to reduce their impact on income.

Nonadherence with antipsychotic medication in schizophrenia: challenges and management strategies.

Nonadherence with medication occurs in all chronic medical disorders. It is a particular challenge in schizophrenia due to the illness’s association with social isolation, stigma, and comorbid substance misuse, plus the effect of symptom domains on adherence, including positive and negative symptoms, lack of insight, depression, and cognitive impairment. Nonadherence lies on a spectrum, is often covert, and is underestimated by clinicians, but affects more than one third of patients with schizophrenia per annum. It increases the risk of relapse, rehospitalization, and self-harm, increases inpatient costs, and lowers quality of life. It results from multiple patient, clinician, illness, medication, and service factors, but a useful distinction is between intentional and unintentional nonadherence. There is no gold standard approach to the measurement of adherence as all methods have pros and cons. Interventions to improve adherence include psychoeducation and other psychosocial interventions, antipsychotic long-acting injections, electronic reminders, service-based interventions, and financial incentives. These overlap, all have some evidence of effectiveness, and the intervention adopted should be tailored to the individual. Psychosocial interventions that utilize combined approaches seem more effective than unidimensional approaches. There is increasing interest in electronic reminders and monitoring systems to enhance adherence, eg, Short Message Service text messaging and real-time medication monitoring linked to smart pill containers or an electronic ingestible event marker. Financial incentives to enhance antipsychotic adherence raise ethical issues, and their place in practice remains unclear. Simple pragmatic strategies to improve medication adherence include shared decision-making, regular assessment of adherence, simplification of the medication regimen, ensuring that treatment is effective and that side effects are managed, and promoting a positive therapeutic alliance and good communication between the clinician and patient. These elements remain essential for all patients, not least for the small minority where vulnerability and risk issue dictate that compulsory treatment is necessary to ensure adherence.

Air Travel and Pneumothorax

The number of medical emergencies onboard aircraft is increasing as commercial air traffic increases and the general population ages, becomes more mobile, and includes individuals with serious medical conditions. Travelers with respiratory diseases are at particular risk for in-flight events because exposure to lower atmospheric pressure in a pressurized cabin at cruising altitude may result in not only hypoxemia but also pneumothorax due to gas expansion within enclosed pulmonary parenchymal spaces based on Boyle's law. Risks of pneumothorax during air travel pertain particularly to those patients with cystic lung diseases, recent pneumothorax or thoracic surgery, and chronic pneumothorax. Currently available guidelines are admittedly based on sparse data and include recommendations to delay air travel for 1 to 3 weeks after thoracic surgery or resolution of the pneumothorax. One of these guidelines declares existing pneumothorax to be an absolute contraindication to air travel although there are reports of uneventful air travel for those with chronic stable pneumothorax. In this article, we review the available data regarding pneumothorax and air travel that consist mostly of case reports and retrospective surveys. There is clearly a need for additional data that will inform decisions regarding air travel for patients at risk for pneumothorax, including those with recent thoracic surgery and transthoracic needle biopsy.

Prevalence of mental disorders in the general population referring to a medical educational center in Rasht, Iran

Received: June 2015, Accepted: August 2015 Background: Mental disorders in patients with chronic medical disorders are associated with, performance degradation, poor quality of life, lack of cooperation with treatment and inappropriate use of medical services, and increased costs. The objective of this study was to determine the prevalence of mental disorders in the general population referring to an educational medical hospital in Rasht, Iran, in 2013. Materials and Methods: In this cross-sectional study, 1725 patients who referred to a medical educational center in Rasht were selected using convenience sampling method. Data were collected through clinical interviews and using inpatients' psychological condition analysis form. Data were analyzed using descriptive and inferential statistics. Results: Results showed that the prevalence of mental disorders in this population was 48.6%. The statistical test results showed age (P < 0.0001), marital status (P < 0.0001), occupation, history of substance abuse (P < 0.0001), psychiatric history (P < 0.0001), and a history of suicide attempt (P < 0.001) had significant relationships with presence of mental disorders. Conclusions: Given the high prevalence of mental disorders in this community, it is recommended that consultation and therapeutic services be provided in health centers for patients' health.

Effect of vinpocetine (cognitol™) on cognitive performances of a nigerian population.

Background:Chronic medical disorders are often complicated by cognitive impairments, making medical intervention that can alleviate cognitive disturbances desirable. Vinpocetine enhances cerebral utilization of oxygen and glucose and consequently improves cerebral functions including memory.Aim:This study assessed the efficacy of vinpocetine (Cognitol™) in improving memory and concentration in cognitively impaired patients.Subjects and Methods:A prospective analytical study of 56 cognitively impaired patients compared with age, sex and level of education matched 56 controls. Cognitive performance was assessed with the Short Blessed Test, which was pilot-tested. Baseline cognitive performances of the patients and controls were obtained and thereafter cognitive performances of the patients were assessed at 6 and 12 weeks after administration of vinpocetine at a dose of 5 mg twice-a-day. Comparative analysis of their performances at baseline was done using the Student t-test, while the improvement in patients’ performances and effect of disease variables on cognitive performances were analyzed with one-way analysis of variance and likelihood ratio analysis respectively.Results:The mean (standard deviation) [SD] ages of the cognitively impaired patients (56/112) and controls (56/112) were 49.5 (18.9) and 53.8 (15.8) years respectively (P = 0.19; 95% confidence interval [CI]: 2.2-10.8). The pilot study yielded an optimal cut-off error score of 6 with a sensitivity of 71.4%, specificity of 96.4% and accuracy of 83.9%. Patients performed significantly worse than the controls (P < 0.001; 95% CI 6.7-11.4). There were significant improvements in memory and concentration with vinpocetine therapy (P < 0.05). The clinical variables of the patients had no effect on the trend of cognitive performances.Conclusions:Vinpocetine was effective in improving memory and concentration of patients with epilepsy and dementia although the efficacy was minimal in demented patients.