Multimodal approach utilising a weight management programme prior to bariatric surgery in patients with BMI ≥50 kg/m2: A propensity score matching retrospective cohort study.

We evaluated preoperative weight loss and days from initial consult to surgery in patients with BMI ≥50 kg/m2 who were and were not enrolled in medical weight management (MWM) prior to laparoscopic sleeve gastrectomy. We retrospectively identified patients with BMI ≥50 kg/m2 who had primary sleeve gastrectomy between 2014 and 2019 at two bariatric surgery centres in our healthcare system. Patients presenting after 2017 that received preoperative MWM (n = 28) were compared to a historical cohort of non-MWM patients (n = 118) presenting prior to programme initiation in 2017 on preoperative percent total body weight loss (%TBWL) and days from initial consult to surgery. A total of 151 patients (MWM, 33; non-MWM, 118) met inclusion criteria. BMI was significantly greater in MWM versus non-MWM (p = .018). After propensity score matching, median BMI at initial consult in non-MWM versus MWM no longer differed (p = .922) neither were differences observed on the basis of weight, age, sex, race or ethnicity. After PSM, MWM had significantly lower BMI at surgery (p = .018), lost significantly more weight from consult to surgery (p < .001) and achieved significantly greater median %TBWL from consult to surgery (p < .001). We noted no difference between groups on 6-month weight loss (p = .533). Days from initial consult to surgery did not differ between groups (p < .863). A preoperative MWM programme integrated into multimodal treatment for obesity in patients with a BMI ≥50 kg/m2 resulted in clinically significant weight loss without prolonging time to surgery.

Incidence of Hiatal Hernia Repair During Primary Bariatric Surgery Conversion: an Analysis of the 2020 MBSAQIP Database.

The rate of hiatal hernia (HH) repair during conversion bariatric surgery is largely unknown. We sought to determine this rate in 12,788 patients undergoing conversion surgery using the 2020 participant use file of the MBSAQIP database. Concurrent HH repair was performed in 24.1% of conversion cases; most commonly during SG to RYGB (33.1%), followed by AGB to SG conversion (20.2%). The remaining conversion pathways had a repair rate around 13%. Only 12.1% of HH repairs were performed using a mesh. GERD was the primary indication for conversion in 65% of the SG to RYGB cases. A much higher proportion of patients with concomitant HH repair reported GERD as the main reason for conversion than those without a HH repair (44.5% vs. 23.7%; p<0.001).

A randomized controlled trial of an enhanced recovery after surgery protocol in patients undergoing laparoscopic sleeve gastrectomy.

BACKGROUND: The purpose of this study was to evaluate the effect of an enhanced recovery after surgery (ERAS) protocol on opioid and anti-emetic use, length of stay and safety after laparoscopic sleeve gastrectomy (LSG). METHODS: Patients who underwent LSG between March 2018 and January 2019 at our accredited, high-volume bariatric surgery center were randomized to either standard of care (SOC) or ERAS. ERAS included a pre- and post-surgical medication regimen designed to reduce postoperative nausea, vomiting and pain. Outcomes included post-operative symptom scores, opioid use, anti-emetic use, time to achieve readiness for discharge (RFD) and inpatient and 30-day adverse events, readmissions and emergency department visits. RESULTS: The final analysis included 130 patients, (SOC 65; ERAS 65). Groups did not differ on demographics or comorbidities. Relative to SOC, fewer ERAS patients utilized opioids in the hospital ward (72.3% vs. 95.4%; p < .001), peak pain scores were significantly lower, and median time to achieve RFD was shorter (28.0 h vs. 44.4 h; p = 0.001). More ERAS patients were discharged on post-operative day 1 (38.5% vs. 15.4%; p < .05). The overall use of rescue anti-emetic medications was not different between groups. Rates of postoperative 30-day events, readmissions, and emergency department visits did not differ between groups. CONCLUSION: Relative to SOC, ERAS was associated with earlier discharge, lower pain scores, less frequent use of opioids and use in lower amounts after LSG with no differences in 30 day safety outcomes.

Utility of a Novel Scale to Assess Readiness for Discharge After Bariatric Surgery.

BACKGROUND: The safe release of a patient from hospital care after bariatric surgery depends upon the achievement of satisfactory health status. Here, we describe a new objective scale (the Readiness for Discharge, RFD Scale) to measure the patient's suitability for hospital discharge after bariatric surgery. METHODS: We conducted a retrospective, observational analysis of data collected in a randomized clinical trial of an enhanced recovery after surgery protocol for laparoscopic sleeve gastrectomy from 3/15/2018 to 1/12/2019. Nursing staff assessed 122 patients every 4-8 h after surgery using a checklist to document 5 components: ambulation, vital signs, pain, nausea, and oral intake of clear fluid. Satisfaction of each component was scored as "1" (satisfactory) or "0" (not satisfactory). Scores were summed and analyzed for patterns. RFD = 5 marked the patient as ready for discharge. RESULTS: Sufficient intake of clear liquid was the last RFD component satisfied in 87% of patients. Two overall response patterns emerged: "Steady Progressors" (n = 51) whose RFD score rose steadily from 0 to 5 without reversion to a lower score; and "Oscillators" (n = 71) who had at least one temporary decrease in RFD score on the way to attaining 5, or showed a simultaneous oscillation of components without change in RFD. CONCLUSIONS: The RFD checklist allows objective scoring of medical readiness for discharge after LSG and has the potential to improve clinical communication.

Case Report: Off Label Utilization of Topiramate and Metformin in Patients With BMI ≥50 kg/m2 Prior to Bariatric Surgery.

FDA approved anti-obesity medications may not be cost effective for patients struggling with pre-operative weight loss prior to bariatric surgery. Metformin, a biguanide, and Topiramate, a carbonic anhydrase inhibitor, both cost effective medications, have demonstrated weight loss when used for the treatment of type 2 diabetes or seizures, respectively. The aim of the three cases is to demonstrate the clinical utility of topiramate and metformin for preoperative weight loss in patients with a body mass index (BMI) ≥ 50 kg/m2 prior to bariatric surgery who are unable to follow the bariatric nutritional prescription due to a dysregulated appetite system Each patient was prescribed metformin and/or topiramate in an off-label manner in conjunction with lifestyle modifications and achieved >8% total body weight loss during the preoperative period.

C Peptide Fails to Improve the Utility of the DiaRem Algorithm in Predicting Remission of Type II Diabetes After Bariatric Surgery.

We evaluated the utility of C peptide as an addition to the DiaRem score for predicting type 2 diabetes (T2D) remission 1 year after bariatric surgery in 175 patients. DiaRem score was significantly correlated with C peptide (r = - .43; p < .001). Both DiaRem and C peptide were significant predictors of remission of T2D (OR (95% CI) = .81 (.75-.86); p < 0001 and OR (95% CI) = 1.35 (1.15-1.60); p < .001, respectively). ROC analysis indicated that DiaRem was a significantly stronger predictor than C peptide (p < .001). Hierarchical regression indicated that C peptide failed to significantly improve the prediction of diabetes remission after accounting for DiaRem (OR (95% CI) = 1.079 (.87-1.26); p = .406). This study does not support the inclusion of C peptide in the DiaRem algorithm.

Impact of Famotidine Use on Clinical Outcomes of Hospitalized Patients With COVID-19.

INTRODUCTION: To compare outcomes in patients hospitalized with coronavirus (COVID-19) receiving famotidine therapy with those not receiving famotidine. METHODS: Retrospective, propensity-matched observational study of consecutive COVID-19-positive patients between February 24, 2020, and May 13, 2020. RESULTS: Of 878 patients in the analysis, 83 (9.5%) received famotidine. In comparison to patients not treated with famotidine, patients treated with famotidine were younger (63.5 ± 15.0 vs 67.5 ± 15.8 years, P = 0.021), but did not differ with respect to baseline demographics or preexisting comorbidities. Use of famotidine was associated with a decreased risk of in-hospital mortality (odds ratio 0.37, 95% confidence interval 0.16-0.86, P = 0.021) and combined death or intubation (odds ratio 0.47, 95% confidence interval 0.23-0.96, P = 0.040). Propensity score matching to adjust for age difference between groups did not alter the effect on either outcome. In addition, patients receiving famotidine displayed lower levels of serum markers for severe disease including lower median peak C-reactive protein levels (9.4 vs 12.7 mg/dL, P = 0.002), lower median procalcitonin levels (0.16 vs 0.30 ng/mL, P = 0.004), and a nonsignificant trend to lower median mean ferritin levels (797.5 vs 964.0 ng/mL, P = 0.076). Logistic regression analysis demonstrated that famotidine was an independent predictor of both lower mortality and combined death/intubation, whereas older age, body mass index >30 kg/m, chronic kidney disease, National Early Warning Score, and higher neutrophil-lymphocyte ratio were all predictors of both adverse outcomes. DISCUSSION: Famotidine use in hospitalized patients with COVID-19 is associated with a lower risk of mortality, lower risk of combined outcome of mortality and intubation, and lower levels of serum markers for severe disease in hospitalized patients with COVID-19.(Equation is included in full-text article.).

Use of an Endoscopic Suturing Platform for the Management of Staple Line Dehiscence After Laparoscopic Sleeve Gastrectomy.

BACKGROUND: Management of staple line dehiscence following laparoscopic sleeve gastrectomy (LSG) varies based on local expertise and timing of presentation. We present our experience with an endoscopic suturing platform to treat patients with staple line dehiscence following LSG. METHODS: We included all patients who presented to our institution with a staple line dehiscence following LSG from 2005 through November 2017. All endoscopic suturing procedures were performed by a single interventional endoscopist. RESULTS: Five patients, ages 25-69 years, received treatment of staple line dehiscence at a median time of 22 days following LSG (range 13-335 days). Four out of the five patients received a stent at some point during their treatment. One patient with a chronic leak required gastrectomy and esophago-jejunostomy as a definitive treatment. The remaining four patients experienced resolution of the leak at a median of 48 days post-operatively (range 21-82 days). CONCLUSION: Endoscopic suturing may have a role in the management of leaks following LSG, as a primary treatment or as an adjunct to treatment with a stent. However, given that the technique requires considerable endoscopic expertise and in light of a number of other available therapeutic choices, further studies are required to better define the role of this technology in the algorithm of LSG-related leak management.

Robot-assisted sleeve gastrectomy and Roux-en-y gastric bypass: results from the metabolic and bariatric surgery accreditation and quality improvement program data registry.

BACKGROUND: A stronger evidence base is needed to more fully understand the precise role that robot-assisted (RA) approaches may play in bariatrics. OBJECTIVE: To investigate the utilization and safety of RA-sleeve gastrectomy (RA-SG) and RA-Roux-en-Y gastric bypass (RA-RYGB) using data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) registry. SETTING: National Database. METHODS: We queried the MBSAQIP 2015 through 2016 registry for patients who underwent primary conventional laparoscopic or RA-SG and RA-RYGB. We compared pre- and perioperative characteristics and 30-day outcomes using logistic regression where number of events met statistical guidelines. RESULTS: We included 126,987 cases: conventional laparoscopic SG (n = 83,940), RA-SG (n = 6,780), conventional laparoscopic RYGB (n = 33,525), and RA-RYGB (n = 2,742). The RA significantly lengthened operation time by 24 and 23 minutes for SG and RYGB, respectively. Mortality and serious adverse events were similar for the 2 techniques. RA-SG was associated with higher rates of 30-day intervention (1.3% versus .8%, OR: 1.38, P < .05) and hospital stay >2 days (12.1% versus 9.3%, OR: 1.30, P < .001). RA-RYGB was associated with higher 30-day rates of reoperation (2.6% versus 2.0%, OR: 1.37, P < .05) and readmission (7.0% versus 5.8%, OR:1.21, P < .05) and lower rates of transfusion (0.62% versus 1.12%, OR: .54, P < .05) and hospital stay >2 days (15.7% versus 17%, OR: .89, P < .05). CONCLUSION: RA is as safe as the conventional laparoscopic approach in terms of mortality and serious adverse events.

Comparison of Non-routine Healthcare Utilization in the 2 years Following Roux-En-Y Gastric Bypass and Sleeve Gastrectomy: A Cohort Study.

BACKGROUND: Patients undergoing Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) have different healthcare needs after surgery. Our aim was to quantify non-routine healthcare utilization after RYGB vs. SG. METHODS: We compared non-routine (NR) visits made and associated services provided up to 2 years post-surgery for patients undergoing RYGB or SG at a Bariatric Surgery Comprehensive Center between March 2013 and April 2015. RESULTS: A total of 258 and 461 patients had primary RYGB and SG, respectively. Successful follow-up rates at one (76.2%) and 2 years post-surgery (52.6%) did not differ between groups. Rates for all NR visits, expressed as the number per 100 patients, were 68.6 in RYGB vs. 35.4 in SG patients (p < 0.0001). Emergency department visits with subsequent admission (EDA) or without subsequent admission (ED-only) and outpatient visits (OPV) were more frequent in RYGB vs. SG: EDA, 14.7 vs. 8.0 (p = 0.0076); ED-only, 17.8 vs. 7.6 (p = 0.0001); and OPV, 29.8 vs. 14.1 (p < 0.0001). RYGB required more services per 100 patients than SG, 120.9 vs. 75.3, respectively (p < 0.0001). Imaging was the resource most often used overall. Surgery type (RYGB) significantly predicted healthcare utilization even after controlling for gender, ethnicity, and other variables. Healthcare utilization peaked at 1 to 6 months post-surgery, driven by patients who underwent RYGB. CONCLUSIONS: RYGB required twice as many non-routine follow-up visits and 1.6 times greater use of healthcare services relative to SG. Computer-assisted tomography imaging and endoscopies showed the greatest differences. Peak healthcare utilization for RYGB occurred between 1 and 6 months following surgery.

Effects of regular endurance exercise on GlycA: Combined analysis of 14 exercise interventions.

BACKGROUND AND AIMS: GlycA is a relatively new biomarker for inflammation as well as cardiometabolic disease risk. However, the effect of exercise on GlycA is largely unknown. Therefore, the purpose of this study was to examine the effects of regular exercise on the inflammatory marker GlycA across seven studies and 14 exercise interventions. METHODS: Nuclear magnetic resonance spectroscopy, specifically signal amplitudes originating from the N-acetyl methyl group protons of the N-acetylglucosamine residues on the glycan branches of glycoproteins, was used to quantify GlycA concentrations. GlycA was measured before and after completion of an exercise intervention in 1568 individuals across seven studies and 14 exercise interventions. Random effects inverse variance weighting models were used to pool effects across interventions. RESULTS: Combined analysis of unadjusted data showed that regular exercise significantly (p = 2 × 10-6) reduced plasma GlycA (-8.26 ±â€¯1.8 µmol/L). This reduction remained significant (-9.12 ±â€¯1.9 µmol/L, p = 1.22 × 10-6) following adjustment for age, sex, race, baseline BMI, and baseline GlycA. Changes in GlycA were correlated with changes in traditional inflammatory markers, C-reactive protein, interleukin-6, and fibrinogen, however, these correlations were relatively weak (range r: 0.21-0.38, p < 0.0001). CONCLUSIONS: Regular exercise significantly reduced plasma GlycA across 14 different exercise interventions despite differences in exercise programs and study populations. The current study provides a greater understanding of the use of exercise as a potential therapy for the reduction of systemic inflammation. Further research is needed to understand the mechanisms behind the exercise-related reductions in GlycA.

Comparative physiogenomic analyses of weight loss in response to 2 modes of bariatric surgery: demonstration with candidate neuropsychiatric and cardiometabolic genes.

BACKGROUND: Surgical weight loss response is variable, with suboptimal outcomes in some patients. We hypothesized that genetic biomarkers may be related to weight change. METHODS: We tested 330 single nucleotide polymorphisms (SNPs) in genes relevant to metabolic regulation in 161 patients whose decrease in body mass index (BMI), 1 year after laparoscopic adjustable gastric banding (LAGB) or Roux-en-Y gastric bypass (RYGB), was small (lowest quartile response) or large (highest quartile response). LAGB patients whose BMI decreased≤4.7 or≥10.2 units comprised groups I (n = 43) and II (n = 40), respectively. RYGB patients whose BMI decreased≤13.6 or≥19.8 units comprised groups III (n = 39) and IV (n = 39), respectively. Within each surgery, SNPs with large differences in reference allele frequency (z score>2, corresponding to values displaced 2 standard deviations [SD] from the mean for all SNPs) in low versus high quartiles, were identified. We compared reference allele frequencies, within surgical procedure, using the χ(2) test (using Bonferroni correction for multiple testing). RESULTS: The mean percent excess weight losses (±SD) corresponding to groups I, II, III, and IV were: 16 (±12), 64 (±30), 55 (±16), and 75 (±17), respectively. SNPs with z score>2 were identified in genes involved in LAGB response, lipid metabolic regulation (APOE, rs439401; APOC4, rs2288911), neural processes (DRD3, rs167771; HTR3 B, rs3758987), and xeno- or endobiotic metabolism (CYP3 A4, rs12333983); and for RYGB response, in lipid transport (SCARB1, rs10846744), folate metabolism (MTHFR, rs2066470), regulation of glycolysis in immune cells (HIF1 A, rs1951795), vitamin K cycling (VKORC1, rs2359612), and xeno- or endobiotic metabolism (CYP3 A4, rs2242480). For LAGB response, APOE SNP frequencies were significantly different. CONCLUSIONS: With further validation, information derived from patient DNA may be useful to predict surgical weight loss outcomes and guide selection of surgical approach.

The effects of exercise on the lipoprotein subclass profile: A meta-analysis of 10 interventions.

OBJECTIVE: The goal was to examine lipoprotein subclass responses to regular exercise as measured in 10 exercise interventions derived from six cohorts. METHODS: Nuclear magnetic resonance spectroscopy was used to quantify average particle size, total and subclass concentrations of very low-density lipoprotein, low-density lipoprotein, and high-density lipoprotein particles (VLDL-P, LDL-P, and HDL-P, respectively) before and after an exercise intervention in 1555 adults from six studies, encompassing 10 distinct exercise programs: APOE (N = 106), DREW (N = 385), GERS (N = 79), HERITAGE (N = 715), STRRIDE I (N = 168) and II (N = 102). Random-effects meta-analyses were performed to evaluate the overall estimate of mean change across the unadjusted and adjusted mean change values from each exercise group. RESULTS: Meta-analysis of unadjusted data showed that regular exercise induced significant decreases in the concentration of large VLDL-P, small LDL-P, and medium HDL-P and mean VLDL-P size, with significant increases in the concentration of large LDL-P and large HDL-P and mean LDL-P size. These changes remained significant in meta-analysis with adjustment for age, sex, race, baseline body mass index, and baseline trait value. CONCLUSIONS: Despite differences in exercise programs and study populations, regular exercise produced putatively beneficial changes in the lipoprotein subclass profile across 10 exercise interventions. Further research is needed to examine how exercise-induced changes in lipoprotein subclasses may be associated with (concomitant changes in) cardiovascular disease risk.

Pharmacogenetic association study of warfarin safety endpoints in Puerto Ricans.

OBJECTIVE: This study was intended to determine the incidence rate of warfarin-related adverse events (e.g., bleeding) in Puerto Ricans and whether a genetic association between warfarin pharmacogenes and any of these adverse events was observed over the initiation period (i.e., the first 90 days of therapy). METHODS: We conducted an observational, retrospective cohort study of pharmacogenetic association in 122 warfarin-treated, male, Puerto Rican patients (69.9 +/- 9.6 years) from the Veterans Affair Caribbean Healthcare System (VACHS) who consented to participate. Genotyping was performed using the CYP2C9 and VKORC1 assays by Luminex. Event-free survival curves were estimated using the Kaplan-Meier method and analyzed by log-rank test. Cox regression models were constructed and hazard ratios (HR) calculated. RESULTS: Carriers of functional CYP2C9 and VKORC1 polymorphisms demonstrated a higher incidence rate of multiple adverse events (i.e., 5.2 vs. 1.0 cases per 100 patient-months; RR = 4.8, p = 0.12) than did wild types. A significant association was observed between multiple adverse events and carrier status (HR = 2.5; 95% CI: 1.0-6.3, p = 0.04). However, no significant associations between genotypes and individual outcomes over the first 90 days of therapy were found. CONCLUSION: The association of CYP2C9 and VKORC1 genotypes and risks for adverse events due to exposure to warfarin was examined for the first time in Puerto Ricans. Despite a lack of association with individual events in this study population, our findings revealed a potential utility of genotyping for the prevention of multiple adverse events during warfarin therapy.

Hyperleptinemia is associated with CRP, but not apolipoprotein E, and is reduced by exercise training.

The purpose of this study was to examine whether leptin levels affect the response of leptin to exercise training (ET) and whether this is also affected by C-reactive protein (CRP) or the three common Apolipoprotein E genotypes (APOE). Ninety-seven (male = 45, female = 52) sedentary individuals underwent 6 months of supervised ET. Blood was sampled before the initiation of ET, and again 24 and 72 hr after completion of the final training session. ET resulted in a small reduction in body mass (80.47 ± 18.03 vs 79.42 ± 17.34 kg, p < .01). Leptin was reduced 24 hr after the final exercise session (p < .01), but returned to normal after 72 hr (p > .05)--Pre: 13.51 ± 12.27, 24hr: 12.14 ± 12.34, 72 hr: 12.98 ± 11.40 ng/ml. The most hyperleptinemic individuals had a greater initial response, which was sustained through to 72 hr after the final session in the pooled study population (p < .01), and in both males (p < .05) and females (p < .05) separately. CRP was related to leptin independently of body weight and positively related to the reductions in leptin. APOE genotype was not related to leptin levels and did not affect the response to ET. Leptin levels may only be reduced by ET in those with hyperleptinemia. In addition, both the initial extent of hyperleptinemia and the subsequent reduction in leptin may be related to low grade chronic systemic inflammation.

Dietary carbohydrate restriction improves insulin sensitivity, blood pressure, microvascular function, and cellular adhesion markers in individuals taking statins.

Statins positively impact plasma low-density lipoprotein cholesterol, inflammation and vascular endothelial function (VEF). Carbohydrate restricted diets (CRD) improve atherogenic dyslipidemia, and similar to statins, have been shown to favorably affect markers of inflammation and VEF. No studies have examined whether a CRD provides additional benefit beyond that achieved by habitual statin use. We hypothesized that a CRD (<50 g carbohydrate/d) for 6 weeks would improve lipid profiles and insulin sensitivity, reduce blood pressure, decrease cellular adhesion and inflammatory biomarkers, and augment VEF (flow-mediated dilation and forearm blood flow) in statin users. Participants (n = 21; 59.3 ± 9.3 y, 29.5 ± 3.0 kg/m(2)) decreased total caloric intake by approximately 415 kcal at 6 weeks (P < .001). Daily nutrient intakes at baseline (46/36/17% carb/fat/pro) and averaged across the intervention (11/58/28% carb/fat/pro) demonstrated dietary compliance, with carbohydrate intake at baseline nearly 5-fold greater than during the intervention (P < .001). Compared to baseline, both systolic and diastolic blood pressure decreased after 3 and 6 weeks (P < .01). Peak forearm blood flow, but not flow-mediated dilation, increased at week 6 compared to baseline and week 3 (P ≤ .03). Serum triglyceride, insulin, soluble E-Selectin and intracellular adhesion molecule-1 decreased (P < .01) from baseline at week 3, and this effect was maintained at week 6. In conclusion, these findings demonstrate that individuals undergoing statin therapy experience additional improvements in metabolic and vascular health from a 6 weeks CRD as evidenced by increased insulin sensitivity and resistance vessel endothelial function, and decreased blood pressure, triglycerides, and adhesion molecules.

Length of psychiatric hospitalization is correlated with CYP2D6 functional status in inpatients with major depressive disorder.

AIM: This study aimed to determine the effect of the CYP2D6 genotype on the length of hospitalization stay for patients treated for major depressive disorder. METHODS: A total of 149 inpatients with a diagnosis of major depressive disorder at the Institute of Living, Hartford Hospital (CT, USA), were genotyped to detect altered alleles in the CYP2D6 gene. Prospectively defined drug metabolism indices (metabolic reserve, metabolic alteration and allele alteration) were determined quantitatively and assessed for their relationship to length of hospitalization stay. RESULTS: Hospital stay was significantly longer in deficient CYP2D6 metabolizers (metabolic reserve <2) compared with functional or suprafunctional metabolizers (metabolic reserve ≥2; 7.8 vs 5.7 days, respectively; p = 0.002). CONCLUSION: CYP2D6 enzymatic functional status significantly affected length of hospital stay, perhaps due to reduced efficacy or increased side effects of the medications metabolized by the CYP2D6 isoenzyme. Functional scoring of CYP2D6 alleles may have a substantial impact on the quality of care, patient satisfaction and the economics of psychiatric treatment.