Significant Medical Comorbidities Research Articles

Enhanced Cognitive Behavior Therapy: A Single Treatment for All Eating Disorders

Eating disorders (EDs), including anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified (ED-NOS), are serious illnesses with a high burden of disease and significant psychiatric and medical comorbidity. Anorexia has the highest mortality rate of any psychiatric disorder, and bulimia and EDNOS are also associated with medical instability (Crow et al., 2009). Because approximately half of the individuals presenting with EDs fail to meet the strict criteria of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association [APA], 2000) for anorexia or bulimia, the most common ED diagnosis in clinical settings is EDNOS. It is highly likely that professional counselors will encounter EDs in their practice, even in clients presenting with other problems. Studies have found that up to 15% of women will suffer from a diagnosable ED in their lifetime (Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006). Moreover, although it has traditionally been believed that only one in 10 ED cases occurs in a male, a recent community study of over 10,000 teenagers, ages 13 to 18, found equal numbers of males and females with anorexia (Swanson, Crow, Le Grange, Swendsen, & Merikangas, 2011). It is likely that male ED cases often go undetected or undiagnosed, making accurate estimation of prevalence difficult. Anorexia tends to develop in adolescence, with peaks in onset at ages 14 and 18, whereas bulimia tends to develop in later adolescence or early adulthood (Hudson, Hiripi, Pope, & Kessler, 2007). However, EDs can also present in children and develop or persist into late adulthood. Indeed, EDs tend to persist in a majority of cases, although their form may vary over time (Wade et al., 2006). Approximately 50% of individuals with anorexia will go on to experience bulimia or EDNOS, and individuals with bulimia may also shift to EDNOS over time (Steinhausen, 2009). In terms of prognosis, approximately 50% of individuals with anorexia and bulimia may be expected to recover, 20%-30% will present with persistent subclinical symptoms, 20%-25% will have a chronic disorder, and up to 10% may die as a result of the disorder (Steinhausen, 2009). Medical complications in EDs are wide ranging and have an effect on major organs of the body, particularly the skeletal, gastrointestinal, cardiovascular, and endocrine systems (Kaplan & Noble, 2007). Individuals with EDs can experience severe medical problems and may require one or multiple hospital admissions. In addition, they frequently present with psychiatric comorbidities, including depression (45%-86%; O'Brien & Vincent, 2003), anxiety disorders such as social anxiety and obsessive compulsive disorder (64%; Kaye et al., 2004), and personality disorders (58%; Rosenvinge, Martinussen, & Ostensen, 2000). Because medical and psychiatric comorbidities are common when working with EDs, treatment guidelines recommend the regular monitoring of clients' mental and physical status (APA, 2006; National Institute for Clinical Excellence [NICE], 2004). Several risk factors for developing an ED have been identified. Gender and sociocultural factors, such as the media and Western culture, clearly play a role. Repeated exposure to fashion magazines (which often use technology to modify images) has been found to predict increases in ED symptoms among adolescent girls valuing a thin ideal (Stice, Spangler, & Agras, 2001). In a comprehensive review, Jacobi, Hayward, de Zwaan, Kraemer, and Agras (2004) concluded that low self-esteem and elevated weight and shape concern substantially increase the risk of an ED. Early childhood feeding and gastrointestinal problems, such as pica, indigestion, and picky eating, can also elevate risk. Adverse life experiences, such as sexual abuse or loss of a first-degree relative, are risk factors for developing a psychiatric disorder and may predispose some individuals to an ED (Jacobi et al. …

OS074. Brachial artery flow-mediated dilatation as a predictor of pre-eclampsia in the first trimester of pregnancy

Increased vascular reactivity secondary to endothelial injury has been reported to be involved in the pathogenesis of pre-eclampsia (PE). However, whether these observations of vascular activity are the result or the cause of PE is still not fully understood. Some studies have shown that pregnant women who subsequently suffer from PE have an impaired flow-mediated dilatation in the brachial artery at the beginning of the second half of pregnancy. However this parameter has not been tested as a first trimester predictor of PE. To investigate the role of maternal brachial artery reactivity during the first trimester of pregnancy (11-14 weeks) for the prediction of PE. Prospective study with singleton pregnancies examined at 11-14 weeks of gestation, presenting consecutively for antenatal care in a tertiary Brazilian hospital. Maternal endothelial dysfunction was assessed by flow-mediated dilatation (FMD) of the brachial artery. FMD was assessed in 550 pregnant women by the same examiner. Obstetric and perinatal outcomes were available in 506 patients (92%). A total of 19 cases were excluded, because 6 miscarried, 12 presented isolated fetal growth restriction (FGR) and 1 was considered an "outlier" because of a significant inflammatory medical co-morbidity. The main outcome was PE based on the ISSHP classification, and we considered early-onset PE when delivery occurred before 34 weeks and late-onset PE when delivery occurred after 34 weeks. In a total of 487 patients, 31 cases developed PE (6.3%), with 9 cases (1.8%) of early-PE and 22 cases (4.5%) of late-PE. The mean gestational age of the study was 12 weeks (range 11-14 weeks).The diameter of the brachial artery at rest was similar between control and PE groups (2.83mm and 2.93mm; p = 0.60) and the resistance and pulsatility index measurements also showed no significant differences among these groups. The mean FMD was 7.4 ± 8.2% in the control group and 7.3 ± 8.2% in the PE group. Logistic regression analysis determined that FDM was not a predictor of PE (OR=0.99, CI 95% 0.94-1.04; p=0.90). Dividing the cases of PE in early and late-onset, it was also observed that the mean diameter of the brachial artery at rest was similar among these groups, and that after the shear stress test the diameter was not significantly different in patients who developed early-PE. Maternal brachial artery reactivity assessed by FMD in the first trimester of pregnancy is not a predictor of PE.

Does Significant Medical Comorbidity Negate the Benefit of Up-front Cytoreduction in Advanced Ovarian Cancer?

The objective of the study was to determine if initial surgery (IS) or initial chemotherapy (IC) affects rates of optimal surgery and survival in a population with significant medical comorbidities. Data of all patients with stage III-IV ovarian, peritoneal, and fallopian tube cancers diagnosed from 1995 to 2008 were reviewed. Clinical and pathologic data were abstracted. There were 551 cases for review: 255 (46.3%) received IS, and 296 (53.7%) received IC. Patients who received IC had higher stage (P < 0.001), higher-grade cancers (P < 0.001), higher mean CA-125 (P = 0.015), higher rates of diabetes (P = 0.006), hypertension (P = 0.008), and presurgical embolism (P < 0.022) and were older (P = 0.043). There was no difference with respect to body mass index, albumin, extent of surgery, or intensive care use. Rates of optimal cytoreduction were higher with IC compared with IS (72.7% vs 56.1%, P < 0.001). IS was associated with more blood loss (P = 0.005) and higher rates of postsurgical venous thrombosis (P < 0.001). Optimal cytoreduction predicted survival in both groups. Among optimal patients, IS improved median survival: progression-free survival of 14 months (IS) versus 12 months (IC), P = 0.004; overall survival of 58 months (IS) versus 34 months (IC), P = 0.002. Factors influencing this difference were receipt of IC and history of diabetes; both predictors of mortality: hazard ratios, 1.9 (95% confidence interval, 1.3-2.8; P < 0.001) and 1.8 (95% confidence interval, 1.02-3.1; P = 0.042), respectively. The achievement of optimal cytoreduction continues to be a significant predictor of survival, regardless of treatment approach. Patients selected for IS and in whom optimal cytoreduction was achieved had improvements in both progression-free survival and overall survival. However, the differences could not be explained by surgical effort alone as diabetes was independently associated with mortality.

Carotid Artery Surgery: High-Risk Patients or High-Risk Centers?

Carotid angioplasty and stenting has been proposed as an alternative to carotid endarterectomy (CEA) in patients deemed as at high risk for this surgical procedure. To date, definitely accepted criteria to identify "high-risk" patients for CEA do not exist. Our objective was to assess the relevance of numerous supposed high-risk factors in our experience, as well as their possible effect on our early postoperative results. A retrospective review of 1,033 consecutive CEAs performed during a 5.6-year period at a single institution was conducted (Vascular Surgery Department, St. Etienne University Hospital, France). Early results in terms of mortality and neurologic events were recorded. Univariate and multivariate analyses for early risk of stroke, myocardial infarction, and death were performed, considering the influence of age, sex, comorbidities, clinical symptoms, and anatomic features. The cumulative 30-day stroke and death rate was 1.2%. A total of 10 strokes occurred and resulted in three deaths. The postoperative stroke risk was significantly higher in the subgroup of patients treated for symptomatic carotid artery disease: 2,6% (P = 0,004). Univariate analysis and logistic regression did not show statistical significance for 30-day results in any of the considered variables. Patients with significant medical comorbidities, contralateral carotid occlusion, and high carotid lesions can undergo surgery without increased complications. Those parameters should not be used as exclusion criteria for CEA.

1593 CLINICAL MANAGEMENT OF MUSCLE INVASIVE MICROPAPILLARY BLADDER CANCER

You have accessJournal of UrologyBladder Cancer: Invasive II1 Apr 20121593 CLINICAL MANAGEMENT OF MUSCLE INVASIVE MICROPAPILLARY BLADDER CANCER Joshua Meeks, Jennifer Taylor, Harry Herr, S. Machele Donat, Bernard Bochner, and Guido Dalbagni Joshua MeeksJoshua Meeks New York, NY More articles by this author , Jennifer TaylorJennifer Taylor New York, NY More articles by this author , Harry HerrHarry Herr New York, NY More articles by this author , S. Machele DonatS. Machele Donat New York, NY More articles by this author , Bernard BochnerBernard Bochner New York, NY More articles by this author , and Guido DalbagniGuido Dalbagni New York, NY More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.1366AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES High grade urothelial carcinoma may have divergent histologic variants, among the most aggressive is micropapillary (MP) type. So aggressive, that some advocate early cystectomy for muscle invasive (MI) MP forgoing the potential benefits of neoadjuvant chemotherapy. Our goal was to determine the response of MI MP bladder cancer to neoadjuvant chemotherapy. METHODS Eighty-two patients were treated at Memorial Sloan-Kettering Cancer Center with MI bladder cancer with MP histology and were clinical stage T2 or greater. After exclusion for metastatic disease at presentation, MP first identified at radical cystectomy, and patients with significant medical comorbidities unfit for surgery, 49 patients were identified with MP diagnosed at TUR. MP histology was diagnosed at time of first presentation with T2 disease in 39 (80%) while 10 (20%) were initially diagnosed as T1 and later progressed to MI. RESULTS Of the 49 patients with MI MP, 88% were male, 72% were smokers, 90% were Caucasian with a median age of 73. MP was associated with CIS in 44% and vascular invasion was present in 30% of TURs. Neoadjuvant chemotherapy was initiated in 31 (62%) of patients. One patient had progression during neoadjuvant chemotherapy and was unable to undergo cystectomy. Radical cystectomy was performed in 43 (86%), while two were managed by TUR alone and two underwent partial cystectomy. Perineural invasion was present in 28%, CIS in 58%, lymphovascular invasion in 36%. Soft tissue margins were positive in 6%, urothelial margins in 4%. Final cystectomy pathology revealed 42% with <pT2 (pT0/T1/Tis), pT2 in 16%, pT3 in 40% and pT4 in 2%. Lymph nodes were positive in 34%. After cystectomy, 34% recurred and 34% died of bladder cancer. Overall, the rate of recurrence was no different after neoadjuvant chemotherapy (42% vs. 27%, p<0.3) and there was no difference in cancer-specific survival (39% vs 27%, p=0.3) or the rate of nodal metastasis (35% vs. 31%, p=0.2). Down-staging occurred in 48% of those that underwent neoadjuvant chemotherapy to pT0, pT1 or pTis with 27% that were pT0. If down-staging occurred, recurrence after cystectomy (21% vs. 48%, p<0.07), and cancer-specific mortality (24% vs. 77%, p<0.1) were improved. CONCLUSIONS Our retrospective data demonstrate that almost half of patients with MI MP do respond to neoadjuvant chemotherapy, with a downstaging rate similar to that reported in other studies. Progression on chemotherapy remains a risk and these patients may benefit from interim restaging. An opportunity is present for a trial comparing outcomes with or without neoadjuvant chemotherapy in this high-risk population. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e644-e645 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Meeks New York, NY More articles by this author Jennifer Taylor New York, NY More articles by this author Harry Herr New York, NY More articles by this author S. Machele Donat New York, NY More articles by this author Bernard Bochner New York, NY More articles by this author Guido Dalbagni New York, NY More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

The cost of major lower limb amputation

The amputee population is elderly, has significant medical co-morbidities and perioperative mortality leading to high financial implications. Commonly used outcomes in the literature are survival, prosthetic use and mobility. Our study aims to share our 12-year experience of amputee care, concentrating on perioperative mortality and patient rehabilitation. Observational study in the form of a retrospective case series. In total, 130 amputations, performed between January 1998 and December 2009, were followed up for a mean of three and a half years and analyzed for demographics, vascular history, operation details, prosthetic use, mobility and mortality. The population was 59.2% male, had a mean age of 73 and the most common indication for amputation was critical ischaemia (78.5%). The average length of acute inpatient stay was 63 days with a 30-day mortality rate of 15.3% and inpatient mortality of 29.3%. In total, 63.3% of patients were issued with a prosthesis with 48.2% of all patients achieving at least indoor mobility, transtibial (49.9%) rehabilitated better than transfemoral amputees (24.3%). Our data support the urgent need for action to improve perioperative mortality in the amputee population, with the added advantage of reducing its financial impact. Clinical relevance Our study gives an overview of the clinical journey taken by a 12-year amputee population. By following this cohort from initial procedure through to rehabilitation or mortality we provide the reader with a valuable insight into the difficulties of managing this population and the likely outcomes for these patients.

The efficacy of endoscopic therapy in bleeding peptic ulcer patients

Endotherapy is the primary modality for the control of bleeding from peptic ulceration. To assess the efficacy of endoscopic intervention for high-risk bleeding peptic ulcer disease and to benchmark our surgical and mortality rates. Two hundred and twenty-seven patients with peptic ulcers stratified by Rockall and Forrest scores as at high risk for re-bleeding underwent therapeutic intervention (adrenalin injection) between January 2004 and December 2009. The median age of the patients was 57 years (range 19 - 87 years); 60% were males. Results. Primary endoscopic haemostasis failed in 51/227 patients (22.5%); 18 patients (7.9%) required surgery for bleeding not controlled at initial or second endoscopy; and 29 patients (12.8%) died, 12 by day 3 and 17 by day 30. Fifteen patients, all with significant medical co-morbidity, died after successful primary endotherapy, and 4 died after surgery. Surgical patients required more blood (odds ratio (OR) 1.45, p=0.0001) than those not undergoing surgery, but had similar mortality. Rebleeding was the only predictor of death in patients who died by day 3 (OR 18.77). A high Rockall score was the only predictor of death by day 30 (OR 1.98). The overall surgical and mortality rates were 7.9% and 12.8%, respectively. Over half the deaths resulted from medical co-morbidity, despite successful primary endotherapy. This finding is supported by the use of the Rockall score as a predictor of mortality at day 30. Improving the technical success of primary endoscopic haemostasis, currently 77.5%, has the potential to reduce rebleeding after primary endotherapy, a predictor of death at day 3 in this study.

Adjunctive ultrasonography during carotid artery stenting to minimize iodine contrast use

Carotid artery stenting (CAS) in patients with chronic kidney disease carries a significant risk of contrast-induced nephropathy. We report a case of CAS with adjunctive sonography to reduce the amount of contrast medium during angiography. A 71-year-old man presented with a symptomatic right carotid stenosis. He was selected for CAS due to significant medical comorbidity, which included severe renal impairment. A preoperative noncontrast CT was performed to assess anatomical suitability and to plan arch vessel cannulation. We undertook CAS with the use of intraoperative ultrasound. Sonography was used to monitor the manipulation of wires, catheters, and stents. Four milliliters of contrast was required to complete the procedure successfully with no deterioration in postoperative renal function. Adjunctive ultrasound is feasible to reduce contrast use in patients with severe renal impairment undergoing CAS.

Is advanced age a barrier to effective cancer treatment? The experience of nonagenarians receiving radiation therapy

Decision-making about elderly patients is difficult due to the absence of clinical experience or evidence-based results to develop optimal treatment plans. This study aims to determine the tolerability and impact of radiation therapy (RT) when delivered to patients aged >89 years. A retrospective review was conducted on all nonagenarian patients (defined as aged 90 years or over) managed with RT between 2005 and 2007. Patients' records were reviewed in regard to their characteristics, the presence of significant medical comorbidities, performance status, management intent, cancer diagnosis and RT modality. Outcome end-points were overall survival and the tolerability of RT (presence of grade 3 or 4 morbidity, hospital admission or treatment interruption). Between 2005 and 2007, 2762 new courses of RT were delivered to patients at the Northern Sydney Cancer Centre, of whom 55, or 2%, were nonagenarians. Median age at treatment was 92 years, with range 90-104 years. A total of 56% were managed with radical intent, 31% had significant comorbidities, 55% had non-skin primary tumors and 78% received linac-based treatment. The mean follow up for survivors was 19.8 months (10.2-41.8 months). RT was well tolerated, with 89% completing planned RT and only 18% requiring interruption. One patient was hospitalized due to RT toxicity. Median survival post-RT was 13.0 months, with 56% of patients alive at 12 months. Survival duration was associated with radical management intent (P= 0.001), cutaneous primary site (P= 0.001) and female gender (P= 0.043). Nonagenarian patients receiving treatment had satisfactory tolerability and achieved expected survival rates post-RT.

Management of opioid substitution therapy during medical intervention

Opioid substitution therapy (OST) for opioid dependence is common, and injection drug users have significant medical and psychiatric comorbidity. Many physicians will encounter OST patients in their usual practice. This article provides guidance on management of common clinical problems in this population, including OST management in hepatic failure, respiratory disease, pain management and potential drug interactions.

Postoperative Infection Treatment Score for the Spine (PITSS): construction and validation of a predictive model to define need for single versus multiple irrigation and debridement for spinal surgical site infection

There is very little evidence to guide treatment of patients with spinal surgical site infection (SSI) who require irrigation and debridement (I&D) in deciding need for single or multiple I&Ds or more complex wound management such as vacuum-assisted closure dressing or soft-tissue flaps. The purpose of this study was to build a predictive model that stratifies patients with spinal SSI, allowing us to determine which patients will need single versus multiple I&D. The model will be validated and will serve as evidence to support a scoring system to guide treatment. A consecutive series of 128 patients from a tertiary spine center (collected from 1999 to 2005) who required I&D for spinal SSI were studied based on data from a prospectively collected outcomes database. More than 30 variables were identified by extensive literature review as possible risk factors for SSI and tested as possible predictors of risk for multiple I&D. Logistic regression was conducted to assess each variable's predictability by a "bootstrap" statistical method. A prediction model was built in which single or multiple I&D was treated as the "response" and risk factors as "predictors." Next, a second series of 34 different patients meeting the same criteria as the first population were studied. External validation of the predictive model was performed by applying the model to the second data set, and predicted probabilities were generated for each patient. Receiver operating characteristic curves were constructed, and the area under the curve (AUC) was calculated. Twenty-four of one hundred twenty-eight patients with spinal SSI required multiple I&D. Six predictors: anatomical location, medical comorbidities, specific microbiology of the SSI, the presence of distant site infection (ie, urinary tract infection or bacteremia), the presence of instrumentation, and the bone graft type proved to be the most reliable predictors of need for multiple I&D. Internal validation of the predictive model yielded an AUC of 0.84. External validation analysis yielded AUC of 0.70 and 95% confidence interval of 0.51 to 0.89. By setting a probability cutoff of .24, the negative predictive value (NPV) for multiple I&D was 0.77 and positive predictive value (PPV) was 0.57. A probability cutoff of .53 yielded a PPV of 0.85 and NPV of 0.46. Patients with positive methicillin-resistant Staphylococcus aureus culture or those with distant site infection such as bacteremia were strong predictors of need for multiple I&D. Presence of instrumentation, location of surgery in the posterior lumbar spine, and use of nonautograft bone graft material predicted multiple I&D. Diabetes also proved to be the most significant medical comorbidity for multiple I&D. The validation of this predictive model revealed excellent PPV and good NPV with appropriately chosen probability cutoff points. This study forms the basis for an evidence-based classification system, the Postoperative Infection Treatment Score for the Spine that stratifies patients who require surgery for SSI, based on specific spine, patient, infection, and surgical factors to assess a low, indeterminate, and high risk for the need for multiple I&D.

Managing pain in high-risk patients within a patient-centered medical home

Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.

Free Flap Scalp Reconstruction in a 91-Year-Old Patient under Local-Regional Anesthesia: Case Report and Review of the Literature

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

Complications arising in simple and polycystic liver cysts

Liver cysts are common, affecting 5%-10% of the population. Most are asymptomatic, however 5% of patients develop symptoms, sometimes due to complications and will require intervention. There is no consensus on their management because complications are so uncommon. The aim of this study was to perform a collected review of how a series of complications were managed at our institutions. Six different patients presenting with rare complications of liver cysts were obtained from Hepatobiliary Units in the United Kingdom and The Netherlands. History and radiological imaging were obtained from case notes and computerised radiology. As a result, 1 patient admitted with inferior vena cava obstruction was managed by cyst aspiration and lanreotide; 1 patient with common bile duct obstruction was first managed by endoscopic retrograde cholangiopancreatography and stenting, followed by open fenestration; 1 patient with ruptured cysts and significant medical co-morbidities was managed by percutaneous drainage; 1 patient with portal vein occlusion and varices was managed by open liver resection; 1 patient with infected cysts was treated with intravenous antibiotics and is awaiting liver transplantation. The final patient with a simple liver cyst mimicking a hydatid was managed by open liver resection. In conclusion, complications of cystic liver disease are rare, and we have demonstrated in this series that both operative and non-operative strategies have defined roles in management. The mainstays of treatment are either aspiration/sclerotherapy or, alternatively laparoscopic fenestration. Medical management with somatostatin analogues is a potentially new and exciting treatment option but requires further study.

Surgical Management of Medically Refractory Trigeminal Neuralgia

The role of surgery for patients with medically refractory trigeminal neuralgia (TN) is well established. High-quality magnetic resonance imaging, including gadolinium-enhanced and volume acquisition sequences, should be performed to exclude intracranial tumors or demyelinating disease as the cause of the pain, as well as to clearly demonstrate the trigeminal nerve and adjacent blood vessels. For physiologically healthy patients with Type 1 TN, a microvascular decompression (MVD) is the preferred surgical approach because of its high rate of complete pain relief, the durability of the pain relief, and the fact that trigeminal injury is not required for pain relief. Patients with recurrent TN after a failed MVD, patients with significant medical comorbidities, and patients with multiple sclerosis-related TN are generally recommended to undergo less invasive, destructive surgical techniques aimed at providing pain relief by damaging the trigeminal nerve.

Cardiac Rehabilitation Outcomes

Medical comorbidities (CM) contribute to cardiac rehabilitation (CR) underutilization. Whether individuals with coronary heart disease and an increased CM burden achieve similar benefits from CR as those with a low CM burden is unknown. We analyzed 794 patients with coronary heart disease completing CR from 1/96 to 4/08. Medical CM burden was assessed using a comorbidity index (CMI) previously validated in a CR population. Distance achieved on a 6-minute walk test, body mass index, and the physical and mental component scores on the Medical Outcomes Short Form 36 were measured at baseline and at CR completion. We performed multivariable linear regression to compare changes in these parameters between individuals with a low CM burden (CMI = 0) and those with a moderate (CMI = 1-2) or high (CMI > 2) CM burden by age group (<56, 56-65, and >65 years of age). Mean age was 61.6 ± 10.6 years, 29% were women, 31% nonwhite; 305 individuals had a CMI = 0, 305 had a CMI = 1 to 2, and 184 had a CMI > 2. All subgroups, regardless of age or CMI, demonstrated improvements with CR on virtually all parameters measured. Among individuals younger than 56 years, those with a CMI = 0 had greater improvements in these parameters after multivariable adjustment than those with a CMI of 1 to 2 or more than 2. In contrast, in older age groups, the degree of improvement was similar regardless of CMI. All patient groups, regardless of CM burden, benefited from CR. Medical CM burden, especially among older patients, should not discourage referral to CR.

Assessment and treatment of abuse risk in opioid prescribing for chronic pain.

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no “gold standard” for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.

Extreme Lateral Interbody Fusion Approach for Isolated Thoracic and Thoracolumbar Spine Diseases

Retrospective review of prospective collected data on 22 patients. To describe our initial clinical experience and outcomes with the extreme lateral interbody fusion (XLIF) approach for spinal diseases requiring access to the thoracic cavity. Minimally invasive anterior approaches to the thoracic spine have traditionally consisted of thoracoscopic and mini-open thoracotomy techniques. We present our initial experience with employing the XLIF technique to treat thoracic spine diseases. Clinical, radiographic, operative, postoperative, and functional outcomes were analyzed. A total of 22 patients (15 females, 7 males, average age 64.6 y) with isolated thoracic and thoracolumbar spine diseases were treated between 2005 and 2009. The indications for surgery included degenerative scoliosis (11), pathological fractures from tumors (2), adjacent level disease from prior fusions (5), thoracic disc herniations (3), and discitis/osteomyelitis (1). A total of 47 levels were treated. In the subset of patients treated for degenerative scoliosis, the mean preoperative and postoperative coronal Cobb angles were 22 and 14, respectively. The mean preoperative and postoperative sagittal angles were 39 and 44, respectively. The average estimated blood loss and length of stay were 227.5 mL and 4.8 d, respectively. Three complications consisting of wound infection, subsidence, and adjacent level disease requiring additional procedures were encountered. There were no neural, vascular, visceral injuries, or death. At a mean follow-up of 16.4 months (range, 3-50), we observed a 95.5% substantial clinical benefit. All patients who had reached a minimum of 6 months (95.5%) demonstrated radiographic evidence of fusion. The XLIF technique can be expanded to treat diseases in the thoracic spine. Although the magnitude of deformity correction achieved is less than that of the traditional open approaches, the lesser invasiveness of this technique may be tolerable for the elderly and in patients with significant medical comorbidities.

Psychological treatment of depressive symptoms in Chinese elderly inpatients with significant medical comorbidity: A meta-analysis

BackgroundAs it is uncertain whether psychological treatments for depressive symptoms are effective in elderly inpatients with significant medical comorbidity, we aimed to assess the treatment effectiveness not only on depressive symptoms but also on somatic symptoms in these inpatients.MethodsWe performed a meta-analysis of randomized controlled studies assessing the effects of psychological treatments in Chinese older inpatients with significant medical comorbidity based upon extensive searches of the most comprehensive computerized Chinese academic database.ResultsThe overall effect size for depressive symptoms of twelve studies which compared psychological treatments with a care-as-usual control group was d = 0.80 (95% Confidence Intervals (CI) = 0.60-0.99; p < 0.001). The relative risk of psychological intervention of being effective or not, compared to control condition, was 1.52 (95% CI = 1.25-1.85; p < 0.001).ConclusionsWe conclude that psychological treatments of depressive symptoms are effective for Chinese elderly inpatients with significant medical comorbidity which should receive more attention in medical settings.

Brief Interventions in Dependent Drinkers: A Comparative Prospective Analysis in Two Hospitals

To investigate whether brief interventions (BIs) delivered by a dedicated Alcohol Specialist Nurse (ASN) to non-treatment-seeking alcohol-dependent patients in an acute hospital setting are effective in reducing alcohol consumption and dependence. A prospective cohort control study in two acute NHS Hospital Trusts in the North West England, one of which provided BI (university teaching hospital-test site) while the other did not (district general hospital-control site), including follow-up BIs. Subjects were alcohol-dependent patients aged ≥18 years. A total of 100 patients were recruited at each site. No differences were found between the groups in the baseline demographic parameters or medical co-morbidities. At the test site, further sessions were sometimes offered, and 46 patients received more than one intervention (median 4, mean 6.3 and maximum 20). At 6 months, alcohol consumption (P < 0.0001), Alcohol Use Disorders Identification Tool (AUDIT) score (P < 0.0001) and Severity of Alcohol Dependence Questionnaire score (P = 0.0001) were significantly lower at the test site than the control site. Outcomes were found to be independent of both the baseline level of dependence and medical co-morbidity. BI delivered by a dedicated ASN for non-treatment-seeking alcohol-dependent individuals, who often have significant medical co-morbidities, seem to be effective in an acute hospital setting. This study provides a framework to inform the design of a future randomized controlled trial.