Is the outpatient management of acute diverticulitis safe and effective? A systematic review and meta-analysis

BACKGROUND

In Western countries, the incidence of acute diverticulitis (AD) is increasing. Patients with uncomplicated diverticulitis can undergo a standard antibiotic treatment in an outpatient setting. The aim of this systematic review was to assess the safety and efficacy of the management of acute diverticulitis in an outpatient setting.

METHODS

A literature search was performed on PubMed, Scopus, Embase, Central and Web of Science up to September 2018. Studies including patients who had outpatient management of uncomplicated acute diverticulitis were considered. We manually checked the reference lists of all included studies to identify any additional studies. Primary outcome was the overall failure rates in the outpatient setting. The failure of outpatient setting was defined as any emergency hospital admission in patients who had outpatient treatment for AD in the previous 60 days. A subgroup analysis of failure was performed in patients with AD of the left colon, with or without comorbidities, with previous episodes of AD, in patients with diabetes, with different severity of AD (pericolic air and abdominal abscess), with or without antibiotic treatment, with ambulatory versus home care unit follow-up, with or without protocol and where outpatient management is a common practice. The secondary outcome was the rate of emergency surgical treatment or percutaneous drainage in patients who failed outpatient treatment.

RESULTS

This systematic review included 21 studies including 1781 patients who had outpatient management of AD  including 11 prospective, 9 retrospective and only 1 randomized trial. The meta-analysis showed that outpatient management is safe, and the overall failure rate in an outpatient setting was 4.3% (95% CI 2.6%-6.3%). Localization of diverticulitis is not a selection criterion for an outpatient strategy (p 0.512). The other subgroup analyses did not report any factors that influence the rate of failure: previous episodes of acute diverticulitis (p = 0.163), comorbidities (p = 0.187), pericolic air (p = 0.653), intra-abdominal abscess (p = 0.326), treatment according to a registered protocol (p = 0.078), type of follow-up (p = 0.700), type of antibiotic treatment (p = 0.647) or diabetes (p = 0.610). In patients who failed outpatient treatment, the majority had prolonged antibiotic therapy and only few had percutaneous drainage for an abscess (0.13%) or surgical intervention for perforation (0.06%). These results should be interpreted with some caution because of the low quality of available data.

CONCLUSIONS

The outpatient management of AD can reduce the rate of emergency hospitalizations. This setting is already part of the common clinical practice of many emergency departments, in which a standardized protocol is followed. The data reported suggest that this management is safe if associated with an accurate selection of patients (40%); but no subgroup analysis demonstrated significant differences between groups (such as comorbidities, previous episode, diabetes). The main limitations of the findings of the present review concern their applicability in common clinical practice as it was impossible to identify strict criteria of failure.

Longitudinal course of depression symptoms in multiple sclerosis

BACKGROUND

Despite the high lifetime prevalence of depression in multiple sclerosis (MS), its longitudinal course is poorly understood.

OBJECTIVE

To examine the longitudinal course of and reliable change in different depression symptom clusters in MS, and the longitudinal association of interferon beta treatment and coping with depression symptoms.

METHODS

53 MS patients were examined at two time points three years apart on the Beck Depression Inventory (BDI) and the Chicago Multiscale Depression Inventory (CMDI).

RESULTS

Correlations from time 1 to time 2 for BDI, CMDI-total, CMDI-evaluative scale, and CMDI-vegetative scale were all highly significant, and reliable change indices reflected little change over time. In contrast, the correlation over time for the CMDI-mood scale was significantly lower (p<0.05) than the CMDI-evaluative and CMDI-vegetative scale correlations, and over 40% of patients showed reliable change. Patients who improved in their mood showed increased use of active coping, while patients who worsened showed decreased active coping strategies; the latter were also significantly more likely to have been taking interferon beta drugs at both time points than patients who did not change in their mood functioning.

CONCLUSIONS

Mood symptoms of depression are significantly more variable over time than neurovegetative or negative evaluative symptoms in MS patients. Decreased use of active coping strategies may put patients at risk of increased depressed mood, whereas increased use of active coping may result in decreased depressed mood longitudinally. Interferon beta use may put patients at risk of increases in depressed mood.

Depression in multiple sclerosis: relationship to planning ability

Recent research has demonstrated deficits on effortful executive tasks involving planning in multiple sclerosis (MS) patients. Given the high prevalence of depression in MS and the commonly reported link between depression and performance on executive tasks, planning impairments in MS may be associated with depression. We compared the performance of depressed and nondepressed MS patients on a planning task (Tower of London-TOL) to evaluate this hypothesis. Compared with nondepressed MS patients, depressed MS patients made significantly (p < .05) more moves and took more time per trial on the TOL. A follow-up regression analysis was conducted that included the TOL and speeded attentional/working memory task indices found to be associated with depression in MS from the authors' prior reports. This analysis revealed that 25% of the variance in depression scores was predicted by the most sensitive speeded attentional/working memory task. Furthermore, this variance overlapped completely with variance predicted by the TOL-time/trial index. The only clearly nonspeeded task index, TOL-moves per trial, was associated with unique variance (8%) in predicting MS depression scores. These results suggest that slowed information processing speed and, secondarily, deficient nonspeeded central executive skill, may be core to the cognitive deficits characteristic of depressed MS patients.

Metamemory and tested cognitive functioning in multiple sclerosis

Metamemory, or one's knowledge and self-report of memory ability, has been researched extensively; however, few studies have examined it in multiple sclerosis (MS). Because impairment in cognitive domains besides memory may affect memory functioning, patients may self-report problems with memory that are indicative of impairment in cognitive domains besides memory. One goal of the current study was to test this hypothesis in MS. A group of 55 MS patients were administered a variety of cognitive tasks and a self-report metamemory measure; patients' significant others were also given a metamemory measure requiring them to rate patients' memory abilities. Results indicated that patients' metamemory reports were significantly (p < .05) correlated with verbal recall, attentional, and executive tasks. Significant other ratings of patients' metamemory were correlated with verbal recall and attentional measures. Stepwise regression analyses including all relevant cognitive and demographic variables indicated that only education and Symbol Digit accounted for significant independent variance in patients' current memory reports. Our results suggest: (1) subjective complaints of memory difficulties by MS patients reflect difficulty in cognitive domains besides memory, (2) MS patient self-reports of memory difficulty are at least as accurate as significant other reports, and (3) patients with more education are more accurate in their metamemory ratings. These findings have implications not only for a better understanding of metamemory in MS, but also for more effective treatment and rehabilitation of MS patients.

Neurovegetative symptoms in multiple sclerosis: relationship to depressed mood, fatigue, and physical disability

Some authors have suggested that when evaluating depression in multiple sclerosis (MS) patients, neurovegetative symptoms should be discounted and/or not considered, given the ostensibly high overlap between symptoms of MS (e.g., sleep disturbance, fatigue) and neurovegetative symptoms of depression. A further assertion is that inclusion of items assessing neurovegetative symptoms may artificially inflate overall depression scores and that mood scales may provide more accurate indices of depression in MS patients. The current study investigated the possibility that some neurovegetative symptoms may be specifically related to MS patients' depressed mood and are not simply indicators of physical disability and/or fatigue. Seventy-six clinically definite MS patients in the northwestern United States were administered two depression inventories and measures of physical disability and fatigue as part of a larger study. Results revealed that one neurovegetative symptom--disinterest in sex--was uniquely associated with depressed mood, and other neurovegetative symptoms were associated with both depression and fatigue but not physical disability. The present findings suggest that certain neurovegetative symptoms are differentially associated with depression, fatigue, and physical disability in MS. Routinely discounting all neurovegetative symptoms when assessing depression in MS patients may thus be unwarranted.

"Aggressive and socially disruptive behavior among maximum security psychiatric patients:" a perspective

The frequency of behavior or management problems for units of differing “security” within a maximum security hospital were compared. The frequency of such behaviors reflects a selection process more than the fact that the patients are in a “controlled treatment setting,” as suggested by the authors of a previous study.

The “Gambler Effect”: Choice and the Probability of Reinforcement of Small Response Outputs

Several types of concurrent-chains studies in which preference was found disproportionate to the rate of primary reinforcement were discussed. The disproportionality was attributed to the unusual effect on preference of the smallest interreinforcement interval components of schedules of reinforcement. The present study investigated an aspect of this factor in the control of preference. Concurrently available fixed-ratio 10 schedules were chained to a fixed-ratio 30 schedule on one key and a multiple fixed-ratio 5 fixed-ratio 80 on the alternative key. In the course of the study the relative frequency of the smallest interreinforcement interval (FR 5) in the multiple schedule option was reduced from 0.50 to 0. Pigeons could maximize reinforcement by always choosing the FR 30 schedule or choosing the multiple schedule and “gambling” that the FR 5 would be produced. Three pigeons chose the multiple schedule exclusively with one exception until the FR 5 was removed entirely from the multiple schedule. At this point, all birds chose the fixed schedule exclusively. Preference defined as rate of initial links responding was, in most instances, inversely related to rate of primary reinforcement.

A chained adjusting ratio schedule

3 pigeons were exposed to a chained FI 2, adjusting ratio schedule in which the ratio was equal to the number of responses emitted in the preceding interval. When the correlation between the interval output and the following ratio was removed, interval rates declined. A descriptive analysis of sequential interval output suggested an explanation for these findings.