Mental health comorbidity and youth onset type 2 diabetes: A systematic review of the literature.

BACKGROUND: Type 2 diabetes (T2D) is a burgeoning epidemic in children and adolescents. Adult T2D doubles the risk of depression and mental health comorbidity, makes it more difficult to make the lifestyle, medication adherence and health behavior changes needed to optimize outcomes. There is limited research on the impact of depression and depressive symptoms on youth T2D. METHODS: A search of the literature in the last 10 years regarding youth with depression and T2D was conducted. Abstracts were screened by 2 randomly assigned authors for inclusion, and disagreement was resolved by a third author. Selected full-text articles were divided among all authors for review. RESULTS: 13 publications from 8 studies (N=2244, age 6-17) were included. 6 of 13 publications utilized Treatment Options for Type 2 Diabetes in Youth (TODAY) study data. While studies included evaluation of depressive symptoms, most did not formally assess for major depressive disorder (MDD) and excluded participants with a previous diagnosis of MDD. Depressive symptoms were common in this population and were associated with negative T2D outcomes. CONCLUSIONS: While there is a growing body of adult literature highlighting the extensive relationship between T2D and mental health, there is a dearth of data in youth. Future studies are needed that include, 1.) youth with diagnosed MDD, 2.) treatment studies of both T2D and MDD, 3.) larger, more racially diverse samples of youth with T2D, and 4.) studies that evaluate the impact of social determinants of health, including mental health comorbidity on outcomes of T2D.

Assessing depression severity with a self-rated vs. rater-administered instrument in patients with epilepsy.

RATIONALE: Up to 30-50% of individuals with epilepsy have depressive symptoms, which often complicate seizure management and reduce overall quality of life. To identify and manage depressive symptoms appropriately, clinicians need standardized instruments that can accurately identify and monitor those with clinically significant depression. The self-reported 9-item Patient Health Questionnaire (PHQ-9) has been used relatively widely to screen and monitor depression in epilepsy. The rater-administered Montgomery-Asberg Depression Rating Scale (MADRS) is a rater-administered instrument widely used in depression treatment trials but less widely applied in epilepsy. This secondary analysis from 2 epilepsy self-management clinical trials compared depression severity ratings using the PHQ-9 and the MADRS instruments. METHODS: Data for this analysis were derived from pooled baseline and longitudinal data from 2 prospective epilepsy self-management randomized controlled trials (RCTs). Both RCTs assessed depression with the PHQ-9 and the MADRS. For this analysis, total depression severity scores and case classification of individuals with no/minimal, mild, moderate/moderately severe, and severe depression were assessed using both PHQ-9 and MADRS. RESULTS: The sample contained 164 individuals with epilepsy. Demographic and clinical variables between the 2 studies were generally similar. There were 107 women (64.8%), 106 African-Americans (64.2%), and 51 Whites (30.9%). Individuals had epilepsy for an average of 22.1 (SD: 15.5). Mean past 30-day seizure frequency at baseline was 3.1 (SD: 11.6). Baseline mean PHQ-9 was 10.7 (SD: 6.80) with depression severity of 32 (19.6%) not or minimally depressed, 47 (28.8%) mildly depressed, 37 (22.7%) moderately depressed, 27 (16.6%) moderately severely depressed, and 20 (12.3%) severely depressed. Baseline mean MADRS severity was 18.5 (SD: 11.3) with 30 (18.8%) not or minimally depressed, 27 (16.9%) mildly depressed, 92 (56.1%) moderately depressed, and 11 (6.9%) severely depressed. The correlation between total PHQ-9 and total MADRS was 0.843 (p < .01) although case classification by depression severity varied somewhat between the two instruments. CONCLUSIONS: Standardized measures to evaluate depression severity in people with epilepsy can help identify cases and monitor treatment. The PHQ-9 and MADRS both perform well in assessing depression in people with epilepsy although administration burden is less with PHQ-9 thus making it likely preferable for settings where time and epilepsy specialty resources are limited.

Cost-utility analysis of minimally invasive versus open multilevel hemilaminectomy for lumbar stenosis.

STUDY DESIGN: Two-year cost-utility study comparing minimally invasive (MIS) versus open multilevel hemilaminectomy in patients with degenerative lumbar spinal stenosis. OBJECTIVE: The objective of the study was to determine whether MIS versus open multilevel hemilaminectomy for degenerative lumbar spinal stenosis is a cost-effective advancement in lumbar decompression surgery. SUMMARY OF BACKGROUND DATA: MIS-multilevel hemilaminectomy for degenerative lumbar spinal stenosis allows for effective treatment of back and leg pain while theoretically minimizing blood loss, tissue injury, and postoperative recovery. No studies have evaluated comprehensive healthcare costs associated with multilevel hemilaminectomy procedures, nor assessed cost-effectiveness of MIS versus open multilevel hemilaminectomy. METHODS: Fifty-four consecutive patients with lumbar stenosis undergoing multilevel hemilaminectomy through an MIS paramedian tubular approach (n=27) versus midline open approach (n=27) were included. Total back-related medical resource utilization, missed work, and health state values [quality adjusted life years (QALYs), calculated from EuroQuol-5D with US valuation] were assessed after 2-year follow-up. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost) and work-day losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Difference in mean total cost per QALY gained for MIS versus open hemilaminectomy was assessed as incremental cost-effectiveness ratio (ICER: COST(MIS)-COST(OPEN)/QALY(MIS)-QALY(OPEN)). RESULTS: MIS versus open cohorts were similar at baseline. MIS and open hemilaminectomy were associated with an equivalent cumulative gain of 0.72 QALYs 2 years after surgery. Mean direct medical costs, indirect societal costs, and total 2-year cost ($23,109 vs. $25,420; P=0.21) were similar between MIS and open hemilaminectomy. MIS versus open approach was associated with similar total costs and utility, making it a cost equivalent technology compared with the traditional open approach. CONCLUSIONS: MIS versus open multilevel hemilaminectomy was associated with similar cost over 2 years while providing equivalent improvement in QALYs. In our experience, MIS versus open multilevel hemilaminectomy is a cost equivalent technology for patients with lumbar stenosis-associated radicular pain.

VCP disease associated with myopathy, Paget disease of bone and frontotemporal dementia: review of a unique disorder.

Inclusion body myopathy (IBM) associated with Paget disease of the bone (PDB) and frontotemporal dementia (FTD) (now called IBMPFD), is a progressive autosomal dominant disorder that was recently identified as being caused by mutations in the VCP (p97 or CDC48) gene which plays a key role in the ubiquitin-proteasome dependent degradation of cytosolic proteins and in the retro translocation of misfolded proteins from the endoplasmic reticulum into the cytoplasm. Approximately 90% of the affected persons in the study have myopathy or muscle weakness particularly of the shoulder and hip girdles, which can lead to loss of walking ability and even death by complications of respiratory and cardiac failure. About half of affected study participants have Paget disease of bone characterized by abnormal rates of bone growth that can result in bone pain, enlargement and fractures. Findings of premature FTD affecting behavior and personality are seen in a third of affected individuals. Within 20 IBMPFD families whose data was analyzed for this study, ten missense mutations have been identified, the majority of which are located in the N-terminal ubiquitin binding domain. Inclusions seen in the muscle, brain and heart in VCP disease contain ubiquitin, beta amyloid and TDP-43, also seen in other neurodegenerative disorders thus implicating common pathways in their pathogenesis.

A systematic review of quantitative EEG as a possible biomarker in child psychiatric disorders.

Quantitative EEG (qEEG) has emerged as a potential intermediate biomarker for diagnostic clarification in mental illness. This systematic review examines published studies that used qEEG in youth with psychiatric illness between 1996 and 2017. We conducted a comprehensive database search of CINAHL, PubMed, and Cochrane using the following keywords: "quantitative EEG" and depression (MDD), anxiety, attention-deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), eating disorder, conduct, substance use, schizophrenia, post-traumatic stress disorder, and panic disorder. Our search yielded 516 titles; 33 met final inclusion criteria, producing a total of 2268 youth aged 4-18. qEEG was most frequently studied as a potential diagnostic tool in pediatric mental illness; few studies assessed treatment response. Studies show higher theta/beta ratio in ADHD vs healthy controls (HC). The most consistent finding in ASD was decreased coherence in ASD vs HC. Studies show MDD has lower temporal coherence and interhemispheric coherence in sleep EEGs than HC. Further research is needed in the areas of mood, anxiety, ASD, and relationship to treatment. It remains unknown if abnormalities in qEEG are nonspecific markers of pediatric psychiatric illness or if they have the potential to differentiate types of psychopathology.

Clinical studies in familial VCP myopathy associated with Paget disease of bone and frontotemporal dementia.

Inclusion body myopathy with Paget disease of the bone (PDB) and/or frontotemporal dementia (IBMPFD, OMIM 167320), is a progressive autosomal dominant disorder caused by mutations in the Valousin-containing protein (VCP, p97 or CDC48) gene. IBMPFD can be difficult to diagnose. We assembled data on a large set of families to illustrate the number and type of misdiagnoses that occurred. Clinical analysis of 49 affected individuals in nine families indicated that 42 (87%) of individuals had muscle disease. The majority were erroneously diagnosed with limb girdle muscular dystrophy (LGMD), facioscapular muscular dystrophy, peroneal muscular dystrophy, late adult onset distal myopathy, spinal muscular atrophy, scapuloperoneal muscular dystrophy, or amyotrophic lateral sclerosis (ALS) among others. Muscle biopsies showed rimmed vacuoles characteristic of an inclusion body myopathy in 7 of 18 patients (39%), however, inclusion body myopathy was correctly diagnosed among individuals in only families 5 and 15. Frontotemporal dementia (FTD) was diagnosed in 13 individuals (27%) at a mean age of 57 years (range 48.9-60.2 years); however, several individuals had been diagnosed with Alzheimer disease. Histopathological examination of brains of three affected individuals revealed a pattern of ubiquitin positive neuronal intranuclear inclusions and dystrophic neurites. These families expand the clinical phenotype in IBMPFD, a complex disorder caused by mutations in VCP. The presence of PDB in 28 (57%) individuals suggests that measuring serum alkaline phosphatase (ALP) activity may be a useful screen for IBMPFD in patients with myopathy.

Affective disorders influence clinical outcomes after revision lumbar surgery in elderly patients with symptomatic adjacent-segment disease, recurrent stenosis, or pseudarthrosis: clinical article.

OBJECT: Depression and persistent low-back pain (LBP) are common and disabling problems in elderly patients (> 65 years old). Affective disorders, such as depression and anxiety, are also common in elderly patients, with a prevalence ranging from 4% to 16%. Depressive symptoms are consistently associated with functional disability. To date, few studies have assessed the predictive value of baseline depression on outcomes in the setting of revision spine surgery in elderly patients. Therefore, in this study, the authors assessed the predictive value of preoperative depression on 2-year postoperative outcomes. METHODS: A total of 69 patients undergoing revision neural decompression and instrumented fusion for adjacent-segment disease (ASD, n = 28), pseudarthrosis (n = 17), or same-level recurrent stenosis (n = 24) were included in this study. Preoperative Zung Self-Rating Depression Scale (ZDS) scores were assessed for all patients. Preoperative and 2-year postoperative visual analog scale (VAS) scores for back pain (VAS-BP) and leg pain (VAS-LP) and the Oswestry Disability Index (ODI) were also assessed. The association between preoperative ZDS score and 2-year improvement in disability was assessed via multivariate regression analysis. RESULTS: Compared with preoperative status, 2-year postoperative VAS-BP was significantly improved after surgery for ASD (9 ± 2 vs. 4.01 ± 2.56, respectively; p = 0.001), as were pseudarthrosis (7.41 ± 1 vs. 5.0 ± 3.08, respectively; p = 0.02) and same-level recurrent stenosis (7 ± 2.00 vs. 5.00 ± 2.34, respectively; p = 0.003). Two-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs. 23.10 ± 10.18, respectively; p = 0.001), as were pseudarthrosis (28.47 ± 5.85 vs. 24.41 ± 7.75, respectively; p = 0.001) and same-level recurrent stenosis (30.83 ± 5.28 vs. 26.29 ± 4.10, respectively; p = 0.003). Independent of other factors-age, body mass index, symptom duration, smoking, comorbidities, severity of preoperative pain, and disability-increasing preoperative ZDS score was significantly associated with lower 2-year improvement in disability (ODI) after revision surgery in elderly patients with symptomatic ASD, pseudarthrosis, or recurrent stenosis. CONCLUSIONS: The extent of preoperative depression is an independent predictor of less functional improvement following revision lumbar surgery in elderly patients with symptomatic ASD, pseudarthrosis, or recurrent stenosis. Timely diagnosis and treatment of depression and somatic anxiety in this cohort of patients may contribute to improvement in postoperative functional status.

Cost-effectiveness of multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy.

BACKGROUND CONTEXT: Laminectomy for lumbar stenosis-associated radiculopathy is associated with improvement in pain, disability, and quality of life. However, given rising health-care costs, attention has been turned to question the cost-effectiveness of lumbar decompressive procedures. The cost-effectiveness of multilevel hemilaminectomy for radiculopathy remains unclear. PURPOSE: To assess the comprehensive medical and societal costs of multilevel hemilaminectomy at our institution and determine its cost-effectiveness in the treatment of degenerative lumbar stenosis. STUDY DESIGN: Prospective single cohort study. PATIENT SAMPLE: Fifty-four consecutive patients undergoing multilevel hemilaminectomy for lumbar stenosis-associated radiculopathy after at least 6 months of failed conservative therapy were included. OUTCOME MEASURES: Self-reported measures were assessed using an outcomes questionnaire that incorporated total back-related medical resource utilization, missed work, and improvement in leg pain (visual analog scale for leg pain [VAS-LP]), disability (Oswestry Disability Index [ODI]), quality of life (Short Form-12 [SF-12]), and health state values (quality-adjusted life years [QALYs], calculated from EuroQuol 5D [EQ-5D] with US valuation). METHODS: Over a 2-year period, total back-related medical resource utilization, missed work, and improvement in leg pain (VAS-LP), disability (ODI), quality of life (SF-12), and health state values (QALYs, calculated from EQ-5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Mean total 2-year cost per QALY gained after multilevel hemilaminectomy was assessed. RESULTS: Compared with preoperative health states reported after at least 6 months of medical management, a significant improvement in VAS-LP, ODI, and SF-12 (physical and mental components) was observed 2 years after multilevel hemilaminectomy, with a mean 2-year gain of 0.72 QALYs. Mean±standard deviation total 2-year cost of multilevel hemilaminectomy was $24,264±10,319 (surgery cost, $10,220±80.57; outpatient resource utilization cost, $3,592±3,243; and indirect cost, $10,452±9,364). Multilevel hemilaminectomy was associated with a mean 2-year cost per QALY gained of $33,700. CONCLUSIONS: Multilevel hemilaminectomy improved pain, disability, and quality of life in patients with lumbar stenosis-associated radiculopathy. Total cost per QALY gained for multilevel hemilaminectomy was $33,700 when evaluated 2 years after surgery with Medicare fees, suggesting that multilevel hemilaminectomy is a cost-effective treatment of lumbar radiculopathy.