Can a free weight management program "move the needle" for obese patients preparing for hernia surgery?: outcomes of a novel pilot program.

PURPOSE: Obesity is known to result in increased morbidity and risk of hernia recurrence after ventral hernia repair; however, many patients lack the resources to pursue guided weight loss. We sought to evaluate the effectiveness of a free Weight Management Navigator (WMN) program on preoperative weight loss for patients with Class 2 or 3 obesity and complex ventral hernias seeking surgical repair. METHODS: From September 2019 and December 2020, all patients with BMI ≥ 35 kg/m2 and ventral hernias seeking surgical care were identified in outpatient clinics at a high-volume hernia center and were offered participation in a free WMN program by the attending surgeon. Descriptive analysis was performed to analyze participation in the program and average weight loss during study period. RESULTS: One hundred ninety one patients were identified. Most patients declined to participate in a weight loss program, were unable to be reached, or did not respond to the WMN (58.1%). Eighty patients enrolled in a WMN program, forty-four of which were lost to follow-up (55%). Seventeen patients underwent hernia repair, nine of which were enrolled in a WMN program. Mean weight loss for those enrolled in a program was 5.97 kg compared to 1.8 kg for those who did not participate (p = 0.01). CONCLUSION: Enrollment in weight loss programs was low despite encouragement from surgeons, free programs, and accessible platforms. Participation in the WMN correlated with more successful weight loss. Our findings suggest that inability to lose weight may be multifactorial. Further study should be devoted to determining other common barriers to weight loss.

Understanding the role of psychopathology in bariatric surgery outcomes.

Bariatric surgery is the most effective treatment for morbid obesity; however, a subset of patients who undergo this procedure regain weight or achieve suboptimal weight loss results. A large number of studies have examined whether psychological variables play a role in weight loss surgery outcome. Although presurgical psychopathology has been found to be associated with suboptimal results in some studies, this literature is equivocal. These inconsistent findings are reviewed and considered in the context of contemporary models of psychopathology. More specifically, the review focuses on the limitations of atheoretical, descriptive diagnostic systems and examines whether comorbidity within the mood/anxiety disorders, impulse control/substance use disorders and thought disorders can account for the inconsistent findings reported to date. Contemporary models of psychopathology are highlighted and linked to the Research Domain Criteria, which have been advanced by the National Institute of Health. Means for assessing psychological constructs congruent with these models are reviewed. Recommendations are made for standardizing approaches to investigating how psychopathology contributes to suboptimal bariatric surgery outcomes.

Relative contribution of modifiable versus non-modifiable factors as predictors of racial variance in roux-en-Y gastric bypass weight loss outcomes.

African-Americans have been shown to have poorer weight loss outcomes after bariatric surgery, and many reasons for such outcomes have been postulated, including metabolic and genetic differences, socioeconomic factors, and differences in culture. African-Americans have also been noted to have differences from the majority population in other psychosocial correlates to weight loss outcomes. However, the relative contribution of targetable factors in relation to non-modifiable factors to such outcomes remains unclear. African-American and Caucasian patients who had received a Roux-en-Y gastric bypass and returned for a 12-month follow up appointment (n = 415) were selected for retrospective analysis. A stepwise hierarchical regression of 12 month percent excess weight loss (% EWL) was conducted that included race after controlling for psychosocial and demographic factors previously linked to postsurgical outcomes. These variables were then compared between racial groups using independent t tests and chi-square analyses. Race remained a significant predictor of % EWL after controlling for pertinent psychosocial and demographic variables. Age and preoperative BMI were significant negative predictors, whereas presurgical BMI loss and Caucasian race were positive (p < 0.05). Percentage of follow-up appointment attendance was borderline significant. No significant racial differences were noted in these variables. Non-modifiable factors inherent to race such as metabolism play small but significant roles in the postoperative weight loss in African-American patients. Further research is needed to better elucidate the roles of targetable factors in outcomes, particularly adherence and pay status as their evaluation in this study was limited.

Clinical course and short-term outcome of hospitalized adolescents with eating disorders: the success of combining adolescents and adults on an eating disorders unit.

Although significant controversy exists regarding the appropriate setting for treating adolescents with eating disorders, empirical studies have been lacking. This study aimed to evaluate, and compare with adults, the clinical course and short-term outcome of adolescents with eating disorders hospitalized on an adult eating disorders unit. One hundred forty-four consecutive inpatient admissions on a weight gain protocol (28% minors and 72% adults) completed psychometric measures and were assessed on clinical indices. No differences between minors and adults were demonstrated for weight gain per week on either inpatient or partial hospitalization admissions. Whereas inpatient length of stay was equivalent, adolescents stayed significantly longer in partial hospitalization than adults. Minors did not differ from adults on the presence of problematic eating disordered behaviors or most psychometric measures, although they had less functional interference due to their eating disorders. Results suggest that an adult eating disorders specialty program can be an appropriate and efficacious setting for adolescents.

Cigarette smoking and its relationship to other substance use among eating disordered inpatients.

OBJECTIVE: The present study examines prevalence rates of tobacco, caffeine, alcohol and other substance use and abuse among eating disordered inpatients and compares smokers (regular vs occasional vs non-smokers) and eating disorder (ED) subtypes [anorexia nervosa (AN) vs bulimia nervosa (BN); restrictors vs purgers] on substance use behaviors, family history, depressive symptoms and impulsivity. METHOD: Participants were 100 ED inpatients who completed assessment upon treatment entry. RESULTS: A high incidence of regular cigarette smoking (29%) and occasional smoking (13%) was detected and associations were found with caffeine abuse, alcohol and marijuana use, family history and depression. BNs were more likely to smoke occasionally and use alcohol than ANs, while Purgers demonstrated higher caffeine and alcohol use than Restrictors. DISCUSSION: Comprehensive assessment and intervention for smoking, caffeine and other substance use among ED patients is clearly indicated.

Suicidal intent in patients with chronic pain.

Suicidal ideation among individuals suffering from chronically painful conditions has not been widely studied, although rates of completed suicide are believed to be elevated in this population relative to the general population. The psychiatric literature on suicide documents the importance of controlling for the severity of depression when studying factors associated with suicidal ideation, attempts, or completion. The present study examined the relationships between suicidal ideation and the experience of pain, pain-related disability, and pain coping efforts among a sample of individuals experiencing chronically painful conditions. Of 200 patients evaluated on an inpatient rehabilitation unit in a psychiatric service, 13 individuals (6.5%) reported suicidal intent on a commonly used self-report measure of symptoms of depression, the Beck Depression Inventory. This group was compared to a matched (age, sex, pain duration) group of similarly depressed individuals (N=13) and a matched group of non-depressed individuals (N=13) on measures of pain, disability, pain beliefs, and pain coping strategies. A history of a suicide attempt was associated with suicidal intent. Family history of substance abuse was significantly more prevalent among the depressed groups, regardless of suicidal thinking. The depressed/suicidal group and depressed/non-suicidal groups reported higher levels of pain, higher levels of pain-related disability, lower use of active coping, and higher use of passive coping compared to the non-depressed group. The depressed groups did not differ from one another on any of the measures of pain experience. Depression, not suicidal status, consistently predicted level of functioning. The prevalence of suicidal intent was comparable to rates observed in other studies and relatively low. When individuals with chronic pain report suicidal intent, it is imperative that measures preventing self-harm be implemented immediately and the patient's depression be treated aggressively.

Effect of early body image dissatisfaction on subsequent psychological and physical adjustment after disfiguring injury.

OBJECTIVE: The impact of body image dissatisfaction on quality of life after severe burn injury was investigated after controlling for other determinants of outcome (i.e., injury, distress, and preburn quality of life). METHODS: The postburn quality of life (2-months postdischarge) of groups with and without body image dissatisfaction was studied after controlling for preburn quality of life (measured 2-3 days postadmission). The patient population (N = 86) was 77.9% men, had an average total body surface area burned of 17.02%, and average full-thickness burn of 6.09%. Forty percent had facial injuries, 68.6% required surgery, most were injured by flame (39.5%), and 76.8% were employed. RESULTS: Multivariate analysis of covariance (covarying preburn level of Mental quality of life, facial injury, and size of burn) contrasting body image dissatisfaction groups found significantly lower psychosocial adjustment at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 3.61; p<.01). A second MANCOVA (covarying the preburn level of Physical quality of life and both facial injury and size of burn) found significantly lower physical functioning at 2-month follow-up in those with greater body image dissatisfaction (multivariate F = 2.78; p < .03). Adding two more covariates (depression and posttrauma distress) eliminated the effect of body image dissatisfaction on postburn Physical but not Mental adjustment. CONCLUSIONS: Body image dissatisfaction affects quality of life after severe burn injury. Distress moderates this impact on aspects of physical but not psychosocial health.

Psychiatric symptoms and distress differ between patients with postherpetic neuralgia and peripheral vestibular disease.

OBJECTIVE: No previous studies have investigated the psychiatric characteristics of patients with postherpetic neuralgia (PHN). Similarly, no studies have been performed on patients with different chronic somatic symptoms due to a defined medical disease to compare the characteristics of psychiatric morbidity associated with each etiology. METHODS: After completing the subscales of the Symptom Checklist 90-R, a psychiatrist administered the Diagnostic Interview Schedule to all subjects. The psychiatric comorbidity in 35 patients with pain due to PHN was compared with a control group of 34 patients with the nonpainful aversive symptom of vertigo due to a peripheral vestibular disorder that caused unilateral hypofunction. RESULTS: PHN patients had significantly more symptoms of major depression and somatization disorder. No significant differences were found between groups for psychiatric diagnoses. Patients with PHN reported significantly less acutely distressing somatic symptoms. CONCLUSION: These results suggest that the psychiatric symptoms of patients with PHN are distinct from nonspecific acute distress and may be related to the experience of suffering from chronic neuropathic pain. Patients with PHN may not meet criteria for a psychiatric diagnosis, but their psychiatric comorbidity places them at substantial risk for increased pain, suicidal ideation, sustained disability, and the numerous complications of excessive medical evaluation and treatment. Patients with PHN should be evaluated specifically for psychiatric symptoms to reduce potential negative consequences through appropriate treatment.

Psychologic factors involved in the decision to undergo reconstructive surgery after burn injury.

Burn injuries often result in permanent changes in physical appearance and function. Although reconstructive surgery is often considered to improve function or physical appearance, or a combination, variables that may predict use of surgery are relatively unknown. Burn survivors (N = 46; 48% male) were assessed at an evaluation for potential reconstructive surgery. Measures of adjustment, distress, and personality were administered. Several psychologic and demographic variables differed among those who did versus those who did not subsequently undergo surgery. Social, sexual, and family relationships were poorer among those who later used surgery, and surgery patients had higher scores on somatization. Subjects who had not returned to work, and individuals with private insurance or managed care, were significantly less likely to follow-up with reconstructive surgery. Contrary to hypothesized results, indexes of burn severity and the injury location were not significantly different between the two groups. Results suggest that interventions designed to aid adjustment after injury may result in the best surgical candidates completing reconstruction.

Ethical issues in the management of chronic nonmalignant pain.

Chronic pain represents a challenge to patients, families, employers, and the physicians who care for these individuals. Opioids remain the mainstay of the analgesic medications for the treatment of both acute and chronic pain. Controlled release preparations of morphine, oxycodone, fentanyl and long acting opioid agents such as methadone and levorphanol have been medically and ethically accepted in managing chronic cancer pain. However, the continued use of these medications for patients with chronic noncancer pain has been fiercely debated. This article attempts to reconcile the medical and ethical dilemma of using opioid medications for chronic noncancer pain. Growing clinical experience in the field of pain medicine has helped to clarify: (1) the misunderstanding of addiction, physical dependence and analgesic tolerance, (2) the misconception that chronic opioid therapy inevitably causes personality changes, depression, and impairment of cognitive and physical function, (3) the lack of information on the correct use of opioid analgesics with regard to titration and management of related side effects. The behavioral management of pain patients undergoing chronic opioid therapy is also discussed. A protocol for optimal patient management is proposed. Particular emphasis is given to the consent form, behavioral contracting, and the consequences of noncompliance. The importance of psychologic evaluation before a long-term opioid trial, to minimize future complications, is stressed. Although most patients on the opioid regimen do well, special attention must be given to patients with current addiction, a past history of addiction, or current misuse of opioid medications. Pharmacologic and conservative interventions are often warranted in those patients with significant behavioral problems. If such strategies fail, and chronic opioid therapy is deemed necessary, some treatment guidelines are offered.

Development and validation of the Sociocultural Attitudes Towards Appearance Questionnaire.

The Sociocultural Attitudes Towards Appearance Questionnaire (SATAQ) was developed to assess women's recognition and acceptance of societally sanctioned standards of appearance. In Study 1, factor analyses revealed two clearcut factors: awareness/acknowledgment of a societal emphasis on appearance and an internalization/acceptance of these standards. These findings were cross-validated in Study 2, resulting in a six-item Awareness subscale (alpha = .71) and an eight-item Internalization subscale (alpha = .88). Study 3 obtained good convergence between both scales and multiple indices of body image and eating disturbance. Regression analyses indicated that both factors accounted for unique variance associated with body image and eating dysfunction, however, internalization of standards was a stronger predictor of disturbance. The SATAQ should prove useful for researchers and clinicians interested in body image and eating disorders.

Preliminary test of two hypotheses of body image disturbance.

The present study compared the ability of two hypotheses of body image disturbance, social comparison and negative verbal commentary (teasing), to explain variance associated with body dissatisfaction and eating disturbance. Female undergraduates (n = 146) completed measures of eating disturbance, body dissatisfaction, self-esteem, depression, history of being teased about physical appearance, frequency of appearance comparison, and importance of various individuals as appearance comparison targets. Utilizing multiple regression analyses, levels of self-esteem and depression were first entered to remove a general distress/negative affectivity variable from the analyses. The results indicated that specific teasing about weight/size, but not general appearance, was a significant and consistent predictor of body dissatisfaction and eating disturbance. In addition, the importance of others as comparison targets, but not general comparison frequency, also predicted unique variance after the removal of the general distress factor. The findings are discussed with regard to the need for longitudinal analyses of predictors of body image and eating disturbance, particularly the possible importance of negative verbal commentary as a developmental precursor to adult levels of dysfunction.