Management of iatrogenic urorectal fistulae in men with pelvic cancer.

INTRODUCTION: Urorectal fistula (URF) is a devastating complication of pelvic cancer treatments and a surgical challenge for the reconstructive surgeon. We report a series of male patients with URF resulting from pelvic cancer treatments, specifically prostate (PCa), bladder (BCa), and rectal cancer (RCa), and explore the differences and impact on outcomes between purely surgical and non-surgical treatment modalities. METHODS: Between October 2008 and June 2015, 15 male patients, aged 59-78 years (mean 67), with URF induced by pelvic cancer treatments were identified in our institutions. Patients with a history of diverticulitis, inflammatory bowel disease, or other benign conditions were excluded. We reviewed the patients' medical records for symptoms, diagnostic tests performed, type and etiology of the fistula, type of surgical reconstruction, followup, and outcomes. RESULTS: Fourteen patients underwent surgical reconstruction. One patient developed metastatic disease before URF repair and, therefore, was excluded from this study. Mean followup (FU) was 32.7 months (14-79). All patients received diverting colostomy and temporary urinary diversion. An exclusively transperineal approach was used in nine (64.3%) patients and a combined abdominoperineal in five (35.7%). Overall successful URF closure was achieved in 12 (85.7%) patients, nine (64.3%) of whom at the first reconstructive attempt, two (14.3%) after two attempts (in our institution), and one (7.1%) after three attempts (two of which elsewhere). An interposition flap was used in seven (50%) patients. Surgical reconstruction failed ultimately in two (14.3%) patients who still have a colostomy and do not wish any further reconstruction. CONCLUSIONS: Our study has several limitations, including its retrospective nature and the heterogeneity of our small patient cohort. Nonetheless, although surgical reconstruction of URF may be extremely difficult and complex in the non-surgical/energy ablation patients, its successful reconstruction is possible in most through a transperineal, or a more aggressive abdominoperineal, approach with tissue interposition in selected patients.

Prevalence and correlates of electroconvulsive therapy delivery in 1001 obsessive-compulsive disorder outpatients.

Individuals with obsessive-compulsive disorder (OCD) who sought treatment in seven different specialized centers (n=1001) were evaluated with a structured assessment battery. Thirteen OCD patients (1.3% of the sample) reported having been treated with electroconvulsive therapy (ECT) in the past. They were older and exhibited higher global severity of OCD symptoms, but were less likely to display symmetry/ordering and contamination/washing symptoms. They also had greater suicidality and increased rates of psychosis. Finally, OCD patients exposed to ECT were more frequently treated with antipsychotics, although they did not differ in terms of responses to adequate trials with serotonin reuptake inhibitors.

Electroconvulsive therapy for obsessive-compulsive disorder: a systematic review.

OBJECTIVE: Surgical therapies for treatment-refractory obsessive-compulsive disorder (OCD), such as deep brain stimulation or psychosurgery, remain unattainable for many patients. Despite the long-held view that electroconvulsive therapy (ECT) is an ineffective treatment for OCD, there is no systematic review to support or refute this claim, which is the basis of the current review. DATA SOURCES: A systematic search of MEDLINE, Web of Science, Scopus, and LILACS databases was conducted on December 22, 2013, using the terms obsessive-compulsive disorder and electroconvulsive therapy. Reference lists, specific journals, and clinical trial registries were also scrutinized. No date or language limitation was imposed on the search. STUDY SELECTION: After irrelevant and redundant records from the 500 identified titles were excluded, the 50 articles reporting the acute treatment effects of ECT in OCD and related constructs (involving a total of 279 patients) were analyzed for this study. DATA EXTRACTION: The relevant sociodemographic, clinical, and outcome data of individual cases were extracted. Data from individual cases were used to compare the characteristics of responders versus nonresponders to ECT. RESULTS: Most selected records were case reports/series; there were no randomized controlled trials. A positive response was reported in 60.4% of the 265 cases in which individual responses to ECT were available. ECT responders exhibited a significantly later onset of OCD symptoms (P = .003), were more frequently nondepressed (P = .009), more commonly reported being treated with ECT for severe OCD (P = .01), and received a fewer number of ECT sessions (P = .03). ECT responders were also less frequently previously treated with adequate trials of serotonin reuptake inhibitors (P = .05) and cognitive-behavioral therapy (P = .005). CONCLUSIONS: Although 60% of the reported cases reviewed exhibited some form of a positive response to ECT, it cannot be stated that this provides evidence that ECT is indeed effective for OCD.

Electroconvulsive therapy in obsessive-compulsive disorder: a chart review and evaluation of its potential therapeutic effects.

In a chart review of patients with obsessive-compulsive disorder (OCD) attending a university clinic, ECT was prescribed for five subjects (1.2%), only because of severe intervening manic (N=1) or depressive episodes (N=4). Although affective symptoms improved in four of the five patients, OCD symptoms remained unchanged (N=3) or transiently worsened (N=2).

Exaggerating, mislabeling or simulating obsessive-compulsive symptoms: case reports of patients claiming to have obsessive-compulsive disorder.

BACKGROUND: There are no reported cases of factitious or simulated obsessive-compulsive disorder (OCD). However, over the last years, our clinic has come across a number of individuals that seem to exaggerate, mislabel or even intentionally "produce" obsessive and/or compulsive symptoms in order to be diagnosed with OCD. METHODS: In this study, experienced clinicians working on a university-based OCD clinic were requested to provide clinical vignettes of patients who, despite having a formal diagnosis of OCD, were felt to display non-genuine forms of this condition. RESULTS: Ten non-consecutive patients with a self-proclaimed diagnosis of OCD were identified and described. Although patients were diagnosed with OCD according to various structured interviews, they exhibited diverse combinations of the following features: (i) overly technical and/or doctrinaire description of their symptoms, (ii) mounting irritability, as the interviewer attempts to unveil the underlying nature of these descriptions; (iii) marked shifts in symptom patterns and disease course; (iv) an affirmative "yes" pattern of response to interview questions; (v) multiple Axis I psychiatric disorders; (vi) cluster B features; (vii) an erratic pattern of treatment response; and (viii) excessive or contradictory drug-related side effects. CONCLUSIONS: In sum, reliance on overly structured assessments conducted by insufficiently trained or naïve personnel may result in invalid OCD diagnoses, particularly those that leave no room for clinical judgment.