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.

Surrogate Markers of Tumoral Angiogenesis

Background

Angiogenesis is a prerequisite for tumor growth and metastasis. Vascular cell adhesion molecule-1 (VCAM-1) is expressed on endothelial cells as a result of vascular endothelial growth factor (VEGF) stimulation.

Purpose

To determine if measurement in serum of VEGF or VCAM-1 provides an accurate measure of tumor angiogenesis.

Methods

VCAM-1 and VEGF were measured in the serum of women with early and advanced breast cancer by ELISA. Levels were compared to levels of VCAM-1 and VEGF in women with normal breasts and levels of the endothelial glycoprotein von Willebrand factor. Levels of VEGF and VCAM-1 in women with early breast cancer were correlated with established clinicopathological prognostic markers and intratumoral microvessel density (IMD).

Results

In early breast cancer serum VCAM-1 correlated closely with the microvessel density in tumors (r=0.61, p<0.001). Women with lymph node-positive and high-grade tumors had higher levels of serum VCAM-1 than women with lymph node-negative and low-grade tumors. Serum VEGF demonstrated no correlation with established prognostic features or IMD. Levels of VCAM-1 and VEGF were raised in women with advanced breast cancer.

Conclusion

Serum VCAM-1 is a surrogate marker of angiogenesis in breast cancer and its measurement may help in the assessment of antiangiogenic drugs currently in phase II trials.

Validation of the interRAI Cognitive Performance Scale against independent clinical diagnosis and the Mini-Mental State Examination in older hospitalized patients

OBJECTIVE

To compare the diagnostic accuracy of the interRAI Acute Care (AC) Cognitive Performance Scale (CPS2) and the Mini-Mental State Examination (MMSE), against independent clinical diagnosis for detecting dementia in older hospitalized patients.

DESIGN, SETTING, AND PARTICIPANTS

The study was part of a prospective observational cohort study of patients aged ≥70 years admitted to four acute hospitals in Queensland, Australia, between 2008 and 2010. Recruitment was consecutive and patients expected to remain in hospital for ≥48 hours were eligible to participate. Data for 462 patients were available for this study.

MEASUREMENTS

Trained research nurses completed comprehensive geriatric assessments and administered the interRAI AC and MMSE to patients. Two physicians independently reviewed patients' medical records and assessments to establish the diagnosis of dementia. Indicators of diagnostic accuracy included sensitivity, specificity, predictive values, likelihood ratios and areas under receiver (AUC) operating characteristic curves.

RESULTS

85 patients (18.4%) were considered to have dementia according to independent clinical diagnosis. The sensitivity of the CPS2 [0.68 (95%CI: 0.58-0.77)] was not statistically different to the MMSE [0.75 (0.64-0.83)] in predicting physician diagnosed dementia. The AUCs for the 2 instruments were also not statistically different: CPS2 AUC = 0.83 (95%CI: 0.78-0.89) and MMSE AUC = 0.87 (95%CI: 0.83-0.91), while the CPS2 demonstrated higher specificity [0.92 95%CI: 0.89-0.95)] than the MMSE [0.82 (0.77-0.85)]. Agreement between the CPS2 and clinical diagnosis was substantial (87.4%; κ=0.61).

CONCLUSION

The CPS2 appears to be a reliable screening tool for assessing cognitive impairment in acutely unwell older hospitalized patients. These findings add to the growing body of evidence supporting the utility of the interRAI AC, within which the CPS2 is embedded. The interRAI AC offers the advantage of being able to accurately screen for both dementia and delirium without the need to use additional assessments, thus increasing assessment efficiency.

Early changes in the haemostatic and procoagulant systems after chemotherapy for breast cancer

Venous thromboembolism (VTE) following breast cancer chemotherapy is common. Chemotherapy-induced alterations in markers of haemostasis occur during chemotherapy. It is unclear how rapidly this occurs, whether this is upregulated in patients developing VTE and whether changes predict for VTE. Markers of haemostasis, functional clotting assays and vascular endothelial growth factor were measured before chemotherapy and at 24 h, 4 days, 8 days and 3 months following commencement of chemotherapy in early and advanced breast cancer patients and in age- and sex-matched controls. Duplex ultrasound imaging was performed after 1 month or if symptomatic. Of 123 patients, 9.8% developed VTE within 3 months. Activated partial thromboplastin time (APTT), prothrombin time (PT), D-dimer, fibrinogen, platelet count, VEGF and fibrinogen were increased in cancer. Fibrinogen, D-dimer, VEGF and tissue factor were increased, at baseline, in patients subsequently developing VTE. D-dimer of less than 500 ng ml⁻¹ has a negative predictive value of 97%. Activated partial thromboplastin time, PT and thrombin–antithrombin showed significantly different trends, as early as within 24 h, in response to chemotherapy in patients subsequently developing VTE. Markers of coagulation and procoagulants are increased, before chemotherapy, in patients who subsequently develop VTE. A group of patients at minimal risk of VTE can be identified, allowing targeted thrombopropylaxis to the higher risk group.

Angiogenic characteristics of circulating and tumoural thrombospondin-1 in breast cancer

In cancer models, thrombospondin-1 (TSP-1) has been shown to inhibit angiogenesis or promote metastasis by increasing adhesion of malignant cells to endothelium. To determine the role of TSP-1 in breast cancer and breast cancer angiogenesis, we have measured TSP-1 in plasma and tumour cytosols and compared levels to established clinicopathological prognostic parameters and intratumoural microvessel density. TSP-1 was measured, by radioimmunoassay, in plasma (pTSP-1) and tumour cytosols (cTSP-1) of women with early breast cancer (EBC) (n=71). pTSP-1 in EBC was compared to pTSP-1 levels in women with advanced breast cancer (ABC) (n=66), normal controls (n=77) and was correlated with prognostic features and microvessel density (MVD) (measured by CD31 immunostaining). cTSP-1 levels were compared to prognostic features and microvessel density. pTSP-1 in women with EBC (median 484, IQR 344-877 ng/ml) and ABC (median 588, IQR 430-952 ng/ml) were elevated when compared to normal controls (median 21, IQR 175-247) (p<0.001). Women with lymph node metastases (n=35) had higher levels of TSP-1 (median 799 ng/ml, IQR 455-943) than women who were node negative (median 343 ng/ml, IQR 267-514) (n=36) (p<0.05). Levels of pTSP-1 in EBC correlated with MVD (R=0.39, p<0.05). Levels of TSP-1 in tumour cytosols of women with EBC (median 1714, IQR 893-5283 ng/ml) correlated with microvessel density (R=0.46, p<0.01). Circulating levels of TSP-1 appear to be a marker of breast cancer aggressiveness and in breast cancer may have a pro-angiogenic rather than anti-angiogenic role.

Serum vascular endothelial growth factor in breast cancer

Many studies have reported elevated serum concentrations of vascular endothelial growth factor (VEGF) in patients with cancer and claimed that the measurement of circulating VEGF is a surrogate marker of angiogenesis and/or metastasis. To determine the value of VEGF measurement in the diagnosis and prognosis of breast cancer, we measured levels in women with and without breast cancer. Platelet-depleted plasma VEGF levels were measured in premenopausal women at four-day intervals across the menstrual cycle, postmenopausal women and postmenopausal women who had undergone hysterectomy. Platelet-depleted plasma VEGF was also measured in pre- and postmenopausal women with early breast cancer (EBC) and levels compared with intratumoral levels, clinicopathological prognostic parameters and microvessel density. Levels of VEGF were determined using ELISA and immuno-histochemistry. Microvessel density was determined by immunohistochemical CD34 staining. Plasma VEGF in premenopausal women remained stable across the menstrual cycle except for a peak between days 8 and 12. VEGF levels in postmenopausal women were higher than in premenopausal women unless postmenopausal women had undergone hysterectomy. Amongst premenopausal women, levels of VEGF were high in 22 EBC patients when compared to normal premenopausal controls. No correlation was found between plasma and intratumoral VEGF, clinicopathological prognostic parameters or tumour microvessel density. The origin of circulating VEGF differs between pre- and postmenopausal women. Its measurement is unlikely to provide clinically useful diagnostic and prognostic information in women with early and advanced breast cancer.

Prevention of venous thromboembolism in surgical patients with breast cancer

Background

No randomized trial has yet studied venous thromboembolism (VTE) prophylaxis in patients undergoing surgery for breast cancer.

Methods

Relevant articles were identified using Medline searches. Secondary articles were identified from the reference lists of key papers.

Results and conclusion

The absence of randomized trials comparing different methods of VTE prophylaxis with controls makes an evidence-based consensus among breast cancer surgeons difficult. Intermittent pneumatic compression (IPC) and graduated compression (GC) are effective in reducing VTE without the haemorrhagic complications associated with heparin; their effects are additive. The authors suggest the following strategy. All patients undergoing surgery for breast cancer should receive both IPC and GC, with heparin reserved for those at very high risk. A controlled trial should randomize women to receive heparin or not, and all women should have both IPC and GC. The primary endpoints should be the development of VTE and/or haemorrhagic complications.

Current UK practice of thromboprophylaxis for breast surgery

A plea for evidence

Alteration in platelet function in patients with early breast cancer

The aim of this study was to examine our hypothesis that platelets of patients with breast cancer were functionally altered compared to healthy controls. The results have shown that the platelets from women with early breast cancer released significantly more vascular endothelial growth factor (VEGF) when stimulated with thrombin, tissue factor, clotting, or over a period of time. Similarly, release of thrombospondin (TSP) with thrombin and tissue factor was higher, but failed to reach a significant level. Thus, the observed differences in platelet response support our hypothesis, but warrant further work to determine the reason underlying the observed difference and potential clinical relevance of our findings.

Increased soluble intercellular adhesion molecule-1, breast cancer and the acute phase response

Abnormal levels of soluble intercellular adhesion molecule-1 (sICAM-1), C-reactive protein (CRP) and von Willebrand factor (vWf) are commonly found in breast and other cancers. However, the relationship between these molecules is unclear as raised sICAM-1 and vWf may simply reflect an acute phase response. We tested the hypothesis that raised sICAM-1 and vWf are related to the acute phase response by measuring both markers by enzyme-linked immunosorbent assay, and CRP by dry chemistry, in 40 women with breast cancer (cases) and 40 age-matched controls. All three markers were raised in the cases compared with the controls [sICAM-1 (mean +/- SD), 281 +/- 70 versus 230 +/- 40 ng/ml; vWf (mean +/- SD), 139 +/- 33 versus 106 +/- 16 IU/dl; CRP (median), 7 (interquartile range, 5-11) versus 5 (4-6) mg/dl; all P < 0.01]. However, sICAM-1 correlated strongly with CRP (r = 0.67, P < 0.001) in the cases but there was no significant relationship between vWf and CRP (r = -0.15, P = 0.351). There were no significant correlations in the controls. We conclude that raised sICAM-1 in breast cancer, like the acute phase response, reflects inflammation, and that raised vWf seems likely to be independent of the acute phase response.

Disruptive vocalization and depression in older nursing home residents

Screaming and other types of disruptive vocalization are commonly observed among nursing home residents. Depressive symptoms are also frequently seen in this group, although the relationship between disruptive vocalization and depressive symptoms is unclear. Accordingly, we sought to examine this relationship in older nursing home residents. We undertook a controlled comparison of 41 vocally disruptive nursing home residents and 43 nonvocally-disruptive nursing home residents. All participants were selected to have Mini-Mental State Examination (MMSE) scores of at least 10. Participants had a mean age of 81.0 years (range 63-97 years) and had a mean MMSE score of 17.8 (range 10-29). Nurse ratings of disruptive vocalization according to a semioperationalized definition were validated against the noisy behavior subscale of the Cohen-Mansfield Agitation Inventory. Subjects were independently rated for depressive symptoms by a psychiatrist using the Dementia Mood Assessment Scale, the Cornell Scale for Depression in Dementia, and the Depressive Signs Scale. Vocally disruptive nursing home residents scored significantly higher than controls on each of these three depression-in-dementia scales. These differences remained significant when the effects of possible confounding variables of cognitive impairment, age, and sex were removed. We conclude that depressive symptoms are associated with disruptive vocalization and may have an etiological role in the generation of disruptive vocalization behaviors in elderly nursing home residents.

Serum soluble vascular cell adhesion molecule-1: role as a surrogate marker of angiogenesis

BACKGROUND

Angiogenesis, the development of new blood vessels from pre-existing vasculature, is a prerequisite for tumor growth and metastasis. Surrogate markers for angiogenesis would be useful for studying the effectiveness of antiangiogenesis drugs. We examined the potential of three serum glycoproteins-vascular cell adhesion molecule-1 (VCAM-1), endothelial selectin (E-selectin), and von Willebrand factor (VWF)-to serve as markers for angiogenesis.

METHODS

Preoperative serum levels of VCAM-1, E-selectin, and VWF were measured by enzyme-linked immunosorbent assay in 93 women with early breast cancer and were compared with microvessel density in each tumor, histologic features, and recurrence after surgery. Serum samples were taken from 55 women with advanced breast cancer who were commencing hormonal therapy, both immediately before therapy and 3 months later. Changes in serum levels of VCAM-1, E-selectin, and VWF were compared with the response of the disease to hormonal therapy assessed 6 months after the start of hormone therapy or at disease progression. All P: values are two-sided.

RESULTS

In women with early breast cancer, serum levels of VCAM-1 (but not of E-selectin or VWF) correlated closely with microvessel density in tumors (r =.65; P:<.001), and women who developed early recurrence had higher preoperative levels of serum VCAM-1 than those who remained disease free (P: =.01). Serum VCAM-1 levels rose in women with advanced breast cancer whose disease progressed (P:<.001) but remained unchanged or fell in women with advanced breast cancer whose disease remained stable or showed a partial response to hormonal therapy.

CONCLUSION

Serum VCAM-1 appears to be a surrogate marker of angiogenesis in breast cancer. Its measurement may, therefore, help in the assessment of antiangiogenesis drugs currently in phase II trials.

The clinical utility of the Hopkins Verbal Learning Test as a screening test for mild dementia

OBJECTIVE

The purpose of this study was to determine whether the Hopkins Verbal Learning Test (HVLT) could be used as a valid and reliable screening test for mild dementia in older people, and to compare its performance to that of the Mini-Mental State Examination (MMSE).

METHOD

Using a cross-sectional design, we studied three groups of older subjects recruited from a district geriatric psychiatry service: (1) 26 patients with DSM-IV dementia and MMSE scores of 18 or better; (2) 15 patients with psychiatric diagnoses other than dementia; and (3) 15 normal controls. The relationship of each potential cutting point on the HVLT and the MMSE was examined against the independently ascertained DSM-IV diagnoses of dementia using a Receiver Operating Characteristic (ROC) analysis.

RESULTS

The subjects consisted of 21 (37.5%) males and 35 (62.5%) females with a mean age of 74.7 (SD 6.1) years and a mean of 8.5 (SD 1.8) years of formal education. ROC analysis indicated that the optimal cutting point for detecting mild dementia in this group of subjects using the HVLT was 18/19 (sensitivity=0.96, specificity=0.80) and using the MMSE was 25/26 (sensitivity=0.88, specificity=0.93).

CONCLUSIONS

The HVLT can be recommended as a valid and reliable screening test for mild dementia and as an adjunct in the clinical assessment of older people. The HVLT had better sensitivity than the MMSE in detecting patients with mild dementia, whereas the MMSE had better specificity.

Alcohol consumption and psychological distress in recently widowed older men

OBJECTIVE

The relationship between severe adverse life events and subsequent health-related behaviour is not well established for older people. To address this issue, we studied self-reported alcohol consumption in recently widowed older men and matched married men.

METHOD

We carried out a double cohort study in community-residing men aged 65 years and over. Recently widowed men (n = 57; mean age = 74.5 years) were identified from the death records of their wives and assessed at 6 weeks, 6 months and 13 months post-bereavement. Matched married men (n = 57; mean age = 75.4 years) were identified from the electoral roll and assessed at similar intervals. Self-report measures of alcohol consumption, grief and state anxiety were employed.

RESULTS

Similar proportions of older widowers and married men reported that they consumed some alcohol, although recently widowed older men reported significantly greater frequency (chi2 = 4.64, df = 1, p = 0.031) and quantity (chi2 = 7.75, df = 1, p = 0.005) of alcohol consumption than matched married men. A significant minority of subjects reported hazardous levels of alcohol consumption with 18.9% of widowers and 8.3% of married men reporting that they drank five or more standard drinks per drinking day. However, among widowers, self-reported alcohol consumption was not significantly correlated with levels of either self-reported grief or state anxiety.

CONCLUSIONS

Hazardous alcohol consumption occurs commonly among recently widowed older men, but is not related to their levels of self-reported grief or psychological distress. Loss of spousal care and control may be an alternative explanation for this drinking behaviour. Older widowers should be regarded as a high-risk group for hazardous alcohol consumption and would be a suitable target group for preventive interventions.

Depressive symptoms and depressive episodes in recently widowed older men

Older widowers have high rates of completed suicide but have rarely been the subject of systematic inquiry. We investigated the prevalence of depressive symptoms and major depressive episodes (MDEs) in recently widowed older men over the first 13 months after bereavement. We employed a matched-pair longitudinal design and recruited subjects from a suburban community population. Fifty-seven recently widowed older men were identified from official death records and 57 matched married men were identified from the electoral roll. Subjects were assessed for the presence of current DSM-III-R MDEs using the Composite International Diagnostic Interview (CIDI), a fully structured psychiatric interview. Widowers were assessed at 6 weeks after bereavement (T1) and 13 months after bereavement (T2). Married men were assessed at similar intervals. At T1, seven widowers (12.3%) and no married men were found to have CIDI cases of current MDE. At T2, one widower (1.9%) and no married men were found to have CIDI cases of current MDE. Current MDE was not predicted by a past history of dysphoria. At T1, 14.0% (8/57) of widowers reported specific suicidal thoughts or actions. At T2, 15.4% (8/52) of widowers reported suicidal thoughts or actions. We conclude that health workers should monitor closely the clinical course of MDEs in recently widowed older men. Routine inquiry about suicidal ideation should be an essential component of the clinical assessment of recently widowed older men.

Surgical audit: the junior doctors' viewpoint

Clinical audit is now an integral part of surgical practice. The Royal College of Surgeons of England has stated that all members of the clinical team should participate in the clinical audit. Junior surgical doctors from the West Midlands Region were interviewed, using a questionnaire, to investigate their attitudes towards audit. Sixty-eight junior doctors were interviewed from six hospitals. Sixty-one (90%) felt that audit was necessary in routine surgical practice, 21 (31%) had presented data at audit meetings and only three (4%) were allocated study periods to prepare for their audit topics. In those hospitals in which all elective work was cancelled, there was a higher attendance rate at audit meetings by junior doctors. Many junior doctors felt that they lacked direction from senior colleagues and had not received any formal training in clinical audit. Clinical audit should become part of undergraduate and postgraduate medical training and junior doctors need to take a more active role in clinical audit.

The psychological symptoms of conjugal bereavement in elderly men over the first 13 months

OBJECTIVE

The purpose of this study was to investigate the psychological symptoms experienced by recently widowed older men. It was hypothesized that conjugal bereavement in this group would be characterized by a mixture of depression, anxiety and loneliness.

DESIGN

Double cohort study.

SETTING

Suburban community population of Brisbane, Australia.

PARTICIPANTS

Consecutive widowers (65+ years; N = 57) identified from official death records. Married men (65+ years; N = 57) identified from the electoral roll. Widowers interviewed at 6 weeks, 6 months and 13 months post-bereavement. Married men interviewed at similar intervals.

MEASURES

Bereavement Phenomenology Questionnaire (BPQ), a 22-item self-report measure employing a four-point response scale to rate the frequency of phenomena over the previous fortnight. Zung Self-rating Depression Scale (SDS). State component of the Spielberger State/Trait Anxiety Inventory (STAI). Revised UCLA Loneliness Scale (ULS). 28-item General Health Questionnaire (GHQ).

RESULTS

Widowers reported more state anxiety and general psychological distress, but not more depression or loneliness, than matched married men over the first 13 months post-bereavement. Widowers also reported more sleep disturbance and thoughts of death and suicide than married men. Level of state anxiety was strongly correlated with intensity of grief, but not with age, income, education, occupational prestige, cognitive function, duration of wife's final illness or expectedness of wife's death.

CONCLUSIONS

The main hypothesis was not supported, as anxiety symptoms were the predominant clinical feature of recent conjugal bereavement among older men. The nature of these anxiety symptoms requires further investigation in recently widowed older persons.

A longitudinal study of bereavement phenomena in recently widowed elderly men

A three-phase longitudinal design was used to study bereavement phenomena in a cohort (N = 78) of recently widowed elderly Australian men. One group of 57 widowers was compared with a second group of 21 widowers on a waiting list. A brief, interviewer-administered, structured questionnaire was used to rate the frequency of 22 self-reported bereavement phenomena. The prevalence and temporal evolution of these phenomena are described. Half of a subgroup of elderly widowers reporting high levels of bereavement phenomena at 6 weeks post-bereavement went on to exhibit persistent or chronic grief at 13 months post-bereavement. The prevalence of persistent or chronic grief throughout the first 13 months post-bereavement was 8.8%. Income, education and expectedness of the death were all negatively correlated with frequency of self-reported bereavement phenomena at 6 weeks post-bereavement. In a multiple regression analysis only expectedness of the death contributed significantly to prediction of the frequency of bereavement phenomena at 6 weeks post-bereavement. Widowers who were unable to anticipate their wife's death, even when their wife had suffered a long final illness, had a more severe bereavement reaction.