Psychopathology and eating behaviour in people with type 2 diabetes referred for bariatric surgery.

PURPOSE: Psychopathology and disordered eating behaviours are putative pre-operative risk factors for suboptimal outcomes post-bariatric surgery. Documented psychopathology prevalence rates vary in bariatric candidate samples. Further, less attention has been paid to vulnerable subgroups such as people with diabetes who might be at an elevated risk. For these reasons, this study aimed to investigate the rates of psychopathology and disordered eating in pre-surgical candidates with type 2 diabetes mellitus (T2DM). METHODS: Participants were 401 consecutive patients from a state-wide bariatric surgery service for people with T2DM. Psychopathology was measured using multi-modal assessment including diagnostic interview and battery of validated questionnaires. The mean age of the sample was 51 years with a mean BMI of 46 kg/m2. The majority of the sample was female (60.6%), born in Australia (87%) and 18.2% identified as Aboriginal and/or Torres Strait Islander. RESULTS: Rates of current psychopathology in this sample included: major depressive disorder (MDD; 16.75%), generalised anxiety disorder (GAD; 20.25%), insomnia (17.75%) and binge eating disorder (BED; 10.75%). There were no significant differences on measures between people who endorsed Aboriginal and/or Torres Strait Islander status compared to those who did not endorse. The mean total score on the BES was 21.82 ± 10.40 (range 0-39), with 8.2% of participants meeting criteria for severe binge eating. Presence of an eating disorder was not significantly associated with degree of glycemic compensation. Average emotional eating scores were significantly higher in this study, compared to reference samples. Significantly increased binge eating severity and emotional eating severity was revealed for people with T2DM and comorbid MDD, social anxiety and eating disorders. Binge eating severity was associated with GAD, food addiction, substance use disorders, and history of suicide attempt but not emotional eating severity. CONCLUSION: Amongst people with T2DM seeking bariatric surgery, MDD, GAD and emotional eating were common. Psychopathology in a sample of people with T2DM seeking bariatric surgery was significantly associated with severity of disordered eating. These findings suggest people with T2DM seeking bariatric surgery may be vulnerable to psychopathology and disordered eating with implications for early identification and intervention. LEVEL OF EVIDENCE: Evidence obtained from cohort or case-control analytic studies.

The way to a man's heart is through his stomach? A unique case report of transient constrictive pericarditis secondary to infarction of herniated omentum following bariatric surgery.

Background: Intrapericardial diaphragmatic hernias are a rare form of diaphragmatic hernia. The presentation is usually acute due to trauma or from iatrogenic causes. In some instances however, these patients can present years later. We describe an unusual case of transient constrictive pericarditis associated with herniation of omentum through a diaphgragmatic hernia extending into the pericardial space, which infarcted following recent bariatric surgery. A multi-disciplinary approach was required with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space. Case summary: A 38-year-old gentleman with a history of a remote abdominal stab wound and recent laparoscopic gastric sleeve procedure presented with sharp central chest pain radiating to the shoulder. Chest imaging [echocardiography, computed tomography (CT), and cardiac magnetic resonance imaging (MRI)] revealed the presence of an intrapericardial diaphragmatic hernia and herniation of devascularized omentum into the pericardial space. Surgery was undertaken to remove the pericardial omentum. Echocardiography and cardiac MRI revealed changes of pericardial constriction which resolved with anti-inflammatories. Discussion: A multi-disciplinary approach was required in this case with surgical correction of the diaphragmatic defect and removal of omentum from the pericardial space. Multi-modal imaging proved essential in the diagnosis of this rare condition, aiding in timely diagnosis, ongoing management decisions, and for assessing therapeutic response.

Gastrogastric herniation: an unusual complication following greater curve plication for the treatment of morbid obesity.

Greater curve plication is an emerging procedure for the treatment of morbid obesity. A median weight loss of up to 61% at one year has been reported in initial reports. Thus far, operative morbidity is low and there is no reported mortality. We present a case of gastric herniation after greater curve plication. Severe nausea and vomiting occurred in our patient with an excessively tight greater curve plication. Two gastric hernias developed through the plication suture. Surgical reduction of these hernias and revision of the original procedure was required. We recommend that greater curve plication is performed over a bougie and that two rows of closely spaced interrupted sutures are used to secure the plication.

Laparoscopic conversion of failed gastric banding to Roux-en-Y gastric bypass: short-term follow-up and technical considerations.

BACKGROUND: The most common bariatric procedure in Australia is laparoscopic adjustable gastric banding (LAGB). Although successful, there is a substantial long-term complication and failure rate. Band removal and conversion to Roux-en-Y gastric bypass (RYGB) can be an effective treatment for complicated or failed bands. There is increasing evidence supporting good weight loss and resolution of band-related complications after conversion. METHODS: A prospective database of all bariatric procedures is maintained. Patients having revision of LAGB to RYGB between December 2007 and April 2011 were included in this study. Indications for surgery, operative details, morbidity and mortality, weight loss data, and post-operative symptoms were recorded. RESULTS: Eighty-two patients were included. Indications for surgery were inadequate weight loss (n = 42), adverse symptoms (reflux = 8, dysphagia = 2), and band complications (band erosion = 7, band sepsis = 1, band slip = 11, esophageal dilatation = 11). Seventy-eight percent of procedures were completed in a single stage and 96.3% laparoscopically. There was no 30-day mortality. Total morbidity was 46.3% (minor complications = 32.9%, major complications = 13.4%). Median BMI was 43 kg/m(2) pre-RYGB and 34 kg/m(2) after 12 months. All patients with adverse band-related symptoms had resolution. CONCLUSIONS: LAGB has a considerable complication and failure rate. Conversion of these patients to RYGB results in further weight loss and resolution of adverse symptoms. This is a challenging procedure, but can usually be performed in a single stage with acceptable morbidity and mortality. These patients should be treated in high-volume, subspecialty bariatric units.

Poster - Thur Eve - 33: A comprehensive analysis of the effect of respiratory motion on the delivery of IMRT to advanced stage non-small cell lung cancer.

The goal of this work was to quantify the interplay effect of various IMRT delivery techniques in the treatment of Stage III non-small cell lung cancer. Five patients with significant tumour motion were retrospectively planned on the average 4D-CT dataset with eight different IMRT techniques: three Tomotherapy techniques with different beam-widths, two step-and-shoot (SS-IMRT) with different complexity, one sliding-window (SW-IMRT), and two VMAT techniques (RapidArc and SmartArc). Each plan was calculated on a delivery verification phantom that was mounted on a programmable respiratory motion platform and delivered under the following motion conditions: 1) Static; 2) sinusoidal with 4 different amplitudes; 3) Real Patient Breathing. A standard 3%/3mm gamma analysis compared the sum of all 30 fractions to their corresponding 60Gy/30fx plan. One-way ANOVA was conducted for respiratory motion amplitude and IMRT modality, separately. There were no significant differences amongst the modalities at any amplitude level. However, for individual modalities, there were significant differences amongst different amplitudes except for Tomo-2.5cm (p=0.260). Post-hoc Tukey tests determined that detectable significant differences amongst any motion level, including real-patient breathing, were observed when compared to the 20mm amplitude for all modalities except Tomo-2.5cm and SmartArc. SW-IMRT showed significant differences at 15mm when compared to both static (p=0.033) and 5mm (p=0.008). All methods except for RapidArc averaged out to clinically acceptable gamma pass rates up to 15mm. In conclusion, for motion levels above 15mm, the interplay effect can be clinically unacceptable. However, the interplay effect at these motion levels does not appear to be modality dependent.

Laparoscopic distal pancreatectomy: the Brisbane experience of forty-six cases.

BACKGROUND AND AIMS: Laparoscopic distal pancreatectomy (LDP) is a safe alternative to conventional open distal pancreatectomy, with advantages that include smaller incisions, less pain, and shorter postoperative recovery. Despite these apparent advantages, however, uptake of the procedure has been slow, with only a handful of series published. MATERIAL AND METHODS: All LDPs performed in Brisbane, Australia, over a 10-year period (May 1996 to June 2006) were retrospectively reviewed. RESULTS: Forty-six consecutive LDPs were performed. A variety of lesions were resected, including nine cancers. Twelve patients were converted for oncological (6) or technical reasons (6). The spleen was retained in 14/29 patients, either by main splenic vessel preservation (9) or solely supported by the short gastric vessels (5), resulting in inferior pole infarction in 2 patients. Overall morbidity was 39%, including 15% pancreatic fistula. All fistulas resolved after a median of 6 weeks without re-operation. A non-significant trend toward fewer fistulas with stapled rather than sutured stump closure was observed (13% vs 19%; p=0.43). Median operative duration and hospital stay were 157 min and 7 days, respectively. There was no mortality. CONCLUSION: LDP is a safe alternative to conventional resection for a wide range of lesions. As with open resection, pancreatic fistula is the dominant morbidity, but is generally indolent. While spleen preservation is often possible, care must be taken to avoid infarction of the inferior pole if the Warshaw technique is utilized.

Quality of parent-child relationship and adolescent HIV risk behaviour in St. Maarten.

The highest incidence rates of HIV/AIDS in the Caribbean are recorded in heterosexual and youth populations. With sparse prevention and intervention programmes in place, there is a pressing need to address the HIV/AIDS risk of youth. The objective of this analysis was to describe the extent of youth risk behaviour in St. Maarten and explore the relationship between quality of parental-child relationship and adolescent HIV risk behaviours. The sample consisted of 1,078 students (age range 14-18, mean 15.6 (s.d. 1.7). The data were collected by self-report survey in the Spring of 2001 in the classrooms of all seven secondary schools in St. Maarten. The survey instrument included demographic information, and used questions derived from the Center for Disease Control's (CDC) Youth Risk Behavior Survey (YRBS) to assess health risk behaviour prevalence, including tobacco, alcohol, and drug use, and sexual activity. The survey also asked youth to rate their relationship with their parents. Analysis showed a relatively high rate of risk behaviour in this school population. Multi-variate analysis showed that a 'great' relationship with both parents, as perceived by the student, was significantly associated with lower rates of tobacco and alcohol use as well as lower rates of sexual activity.

Thrombolysis with saruplase versus streptokinase in acute myocardial infarction: five-year results of the PRIMI trial.

BACKGROUND: Short-term safety and efficacy of thrombolysis with saruplase in acute myocardial infarction have been shown in several trials. To assess long-term outcome of patients treated with saruplase or streptokinase for myocardial infarction, a 5-year follow-up of patients included in the Pro-Urokinase in Myocardial Infarction Trial was performed. METHODS AND RESULTS: Follow-up data are available from 8 centers on 255 (92.4%) of 276 included patients. The 5-year mortality rate was comparable with 20.8% of patients in the saruplase group and 16.9% in the streptokinase group (odds ratio 1.29, 95% confidence interval 0.69 to 2.42). In both groups, a considerable number of fatal cardiovascular events occurred more than 1 year after study inclusion. Rates of percutaneous transluminal coronary angioplasty and coronary artery bypass grafting were comparable in both groups. Reinfarction within 5 years occurred in 19.0% of patients in the saruplase group and tended to be less frequent at 10.8% after streptokinase treatment (odds ratio 1.94, 95% confidence interval 0.98 to 3.84). In both groups, the majority of reinfarctions took place more than 3 months after study inclusion. The 5-year stroke rate was 3.6% and 7.2% in the saruplase and streptokinase groups, respectively (odds ratio 0.49, 95% confidence interval 0.16 to 1.47). Subjective symptoms of heart failure and angina pectoris were comparable in both groups. CONCLUSIONS: Our data are consistent with a similar long-term outcome for patients treated with saruplase or streptokinase. Despite the low-risk profile of the patient cohort, there were considerable adverse event rates over a 5-year period.

AIDS risk among students attending Seventh-day Adventist school, in North America.

In 1995, a survey was conducted among students attending 69 Seventh-day Adventist (SDA) high schools within the United States and Canada. The survey assessed the extent that these students practiced sexual and drug-use behaviors which place them at risk for contracting or transmitting the human immunodeficiency virus (HIV). A total of 1,748 respondents enrolled in grades 9 through 12 completed questionnaires similar to the instrument used in the 1993 Youth Risk Behavior Survey (YRBS). Data were collected and compared to results from the 1993 YRBS. Students who attended SDA parochial schools reported lower rates of sexual intercourse compared to YRBS school counterparts (16.3% vs. 53.1%) and lower rates of all substances measured. Furthermore, respondents were more likely to engage in substance use and sexual intercourse if they had at least one parent who used tobacco, alcohol, or marijuana, as reported by the students.

Intraoperative radiotherapy in the treatment of neuroblastoma: report of a pilot study.

BACKGROUND: External beam radiotherapy in advanced neuroblastoma is limited by the volume of normal radiosensitive tissues included in the radiation field. Limitations to external radiation are the late effects to these tissues. Intraoperative radiotherapy (IORT) delivers a single high-radiation dose to a tumor while displacing normal tissues that would have been included in an external field. Standard external radiotherapy can still be done after "boost" IORT. METHODS: Eight advanced-stage neuroblastoma patients who received IORT as part of their multimodality therapy were reviewed to identify the impact of IORT on operative time, complications, and tumor control in the treatment field. The IORT was accomplished by patient transport from the OR to the radiation therapy suite; these were separated by three floors. RESULTS: IORT added 30-75 min to the operative procedure. Tumors in the resection/IORT fields showed no evidence of disease (one), stable tumor size (six), and tumor recurrence (one). Two complications were identified: a urinary fistula and CO2 retention, which was detected and corrected before the IORT. Neither of these complications was related to the IORT. Two patients who had subsequent tumor resection after IORT demonstrated tumor differentiation to ganglioneuromatous tissue. CONCLUSIONS: IORT usually can be completed in less than an hour. No IORT-associated complications were identified. IORT along with maximal tumor resection, external radiation, and chemotherapy enhances local tumor control.

Assessment of the beta-adrenergic receptor pathway in the intact failing human heart: progressive receptor down-regulation and subsensitivity to agonist response.

We developed methods for identifying beta-adrenergic receptors in human right ventricular endomyocardial biopsy tissue with the radioligand (-)[125I]iodocyanopindolol (ICYP). Specific ICYP binding in a crude, high-yield membrane preparation derived from endomyocardial biopsy tissue was high (specificity greater than 90%), of high affinity (KD around 20 pM), saturable and stereospecific for the (-) vs the (+) isomer of isoproterenol. Subjects with mild-moderate and severe biventricular dysfunction had respective decreases in beta-adrenergic receptor density of 38.2% and 57.7% when normalization methods were averaged, with no significant differences in ICYP dissociation constant. A subgroup of subjects was subdivided by left ventricular ejection fraction (LVEF) into those with mild cardiac dysfunction (LVEF less than 0.50 greater than 0.40) and severe heart failure (LVEF less than 0.20) and given graded sequential infusions of dobutamine and calcium gluconate. Those with severe cardiac dysfunction had marked impairment of the dobutamine dP/dt and stroke work index response, whereas these responses to calcium did not differ in the two groups. These data indicate that in the intact human heart endomyocardial biopsy may be used for direct analysis of beta-adrenergic receptors, heart failure-associated myocardial beta-adrenergic down-regulation begins with mild-moderate ventricular dysfunction, reduction in myocardial beta-receptor density is related to degree of heart failure, and beta-receptor down-regulation is associated with pharmacologically specific impairment of the beta-agonist-mediated contractile response.

Muscle changes in ankylosing spondylitis.

Muscle biopsy of the quadriceps femoris was carried out in 20 patients with classical ankylosing spondylitis (AS). Histological and histochemical studies revealed changes in all biopsies to a varying degree. Central migration of nuclei was present in 80%, reduced fibre size with some atrophy in 40%, localized reaction to acid phosphatase in 75% and a peripheral condensation of reaction product to NADH-TR stain in 55% of biopsies. Furthermore 14 out of 16 patients, whose quadriceps strength was measured, were found to be below the predicted values, when compared to healthy controls of similar weight, and quantitative surface electromyography in 10 showed lower mean power frequency than in controls. A raised plasma creatine kinase was found in only two patients. It is concluded that muscle changes occur in AS and these may account for some of the clinical features of the disease.

Ultrastructure of resting and activated storage pool deficient platelets from animals with the Chédiak-Higashi syndrome.

The ultrastructural of platelets from Chédiak-Higashi (CH) and normal cattle, mink, and cats at rest was studied. Platelets from CH animals had a virtual absence of platelet dense granules. Alpha granules, amorphous membrane-surrounded structures, mitochondria, and microtubules of CH bovine platelets were similar in number and appearance to those in normal bovine platelets. Giant CH granules, present in other cells and considered diagnostic of the syndrome, could not be identified in platelets from CH animals. The open canalicular system and dense tubule system were not readily identifiable in resting bovine platelets. The ultrastructure of normal and CH cattle platelets was evaluated at various stages of ADP-induced aggregation. After platelets changed shape during the first phase of aggregation, the ultrastructural appearance of CH platelets was similar to that of normal platelets. The CH platelets composing the aggregates during irreversible aggregation did not appear as activated as did normal platelets, even though the aggregation tracings were similar. Normal and CH cattle platelets treated with thrombin appeared morphologically similar and were characterized by centrifugal movement of granules.

Polyunsaturated fatty acids as promoters of mammary carcinogenesis induced in Sprague-Dawley rats by 7,12-dimethylbenz[a]anthracene.

The development of mammary tumors was examined in female noninbred Sprague-Dawley rats fed either a low-fat diet or high-fat diets containing different fats and fatty acid esters. Each rat was given 5 mg 7,12-dimethylbenz[a]anthracene by stomach tube 1 week before diets were introduced. Addition of 3% ethyl oleate (an ethyl ester of an unsaturated fatty acid) to a diet high in saturated fat (coconut oil) had no significant effect on tumor development, but the addition of 3% ethyl linoleate (an ethyl ester of a polyunsaturated fatty acid) increased the tumor yield to about twice that in rats fed either the high-saturated fat diet or a low-fat diet. Animals fed the high-saturated fat diet containing 3% ethyl linoleate developed as many tumors as those fed a 20% sunflower seed oil diet, though the sunflower seed oil diet contained about four times as much linoleate. Rats fed a high coconut oil diet containing 3% menhaden fish oil, which contains polyunsaturated fatty acids of the linolenate family (but having little linoleic acid), also developed as many tumors as those fed the 20% sunflower seed oil diet. These differences in mammary tumor yield could not be explained by alterations in the serum levels of prolactin, estrogen, or progesterone. However, the higher tumor yields were associated with increased unsaturation of mammary tissue phospholipids.

Pneumatic calf compression, fibrinolysis, and the prevention of deep venous thrombosis.

In a previous pilot study that did not reach statistical significance, intermittent single-leg pneumatic compression appeared effective in reducing the incidence of calf vein thrombosis not only in the pumped calf but also in the unpumped leg in 37 patients, using the 125I-fibrinogen (Abbott Laboratories) technique. The present study was undertaken to investigate mechanical induction of local and systemic fibrinolysis. The euglobulin lysis time in the arm venous effluent was determined in five volunteers before and after unilateral arm compression for 1/2 hour. Shortening averaged 19% (not significant). The experiment was repeated using bilateral calf-length boots with femoral vein sampling. Euglobulin lysis decreased 22% (P < 0.001). To uncover possible systemic effects, the protocol was altered using calf boots with sampling from the arm. The euglobulin lysis diminished 6% in 57 volunteers (P < 0.001). In 27 others the effects of thigh-length and calf-length boots were compared. In half, pumping with a short boot was undertaken first, and in the remainder, the long boot was applied initially. One-half hour of pumping was followed by 1/2 hour of rest. Immediately afterward the second period of pumping took place and continued for 1/2 hour. A total of four arm vein samples were obtained, one before and after each pumping period. Although, in retrospect, the 1/2-hour rest period was inadequate to permit the subjects to return to basal conditions, statistically significant decreases in euglobin lysis time (P = 0.05) occurred with the long boots. This study shows intermittent calf compression increases fibrinolytic potential locally and this effect can be demonstrated systemically. The greater the volume of tissue compressed, the greater the response. The efficacy of intermittent venous compression in reducing the incidence of deep venous thrombosis may be due, in part, to localized induction of fibrinolysis.