Adult separation anxiety in patients with complicated grief versus healthy control subjects: relationships with lifetime depressive and hypomanic symptoms

<p>Abstract</p> <p>Background</p> <p>Around 9% to 20% of bereaved individuals experience symptoms of complicated grief (CG) that are associated with significant distress and impairment. A major issue is whether CG represents a distinctive nosographic entity, independent from other mental disorders, particularly major depression (MD), and the role of symptoms of adult separation anxiety. The purpose of this study was to compare the clinical features of patients with CG versus a sample of healthy control subjects, with particular focus on adult separation anxiety and lifetime mood spectrum symptoms.</p> <p>Methods</p> <p>A total of 53 patients with CG and 50 healthy control subjects were consecutively recruited and assessed by means of the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I/P), Inventory of Complicated Grief (ICG), Adult Separation Anxiety Questionnaire (ASA-27), Work and Social Adjustment Scale (WSAS) and Mood Spectrum-Self Report (MOODS-SR) lifetime version.</p> <p>Results</p> <p>Patients with CG reported significantly higher scores on the MOODS-SR, ASA-27, and WSAS with respect to healthy control subjects. The scores on the ASA-27 were significantly associated with the MOODS-SR depressive and manic components amongst both patients and healthy control subjects, with a stronger association in the latter.</p> <p>Conclusions</p> <p>A major limitation of the present study is the small sample size that may reduce the generalizability of the results. Moreover, lifetime MOODS-SR does not provide information about the temporal sequence of the manic or depressive symptoms and the loss. The frequent comorbidity with MD and the association with both depressive and manic lifetime symptoms do not support the independence of CG from mood disorders. In our patients, CG is associated with high levels of separation anxiety in adulthood. However, the presence of lifetime mood instability, as measured by the frequent presence of depressive and hypomanic lifetime symptoms, suggests that cyclothymia might represent the common underlying feature characterizing the vulnerability to both adult separation anxiety and CG.</p

Colorectal cancer after bariatric surgery (Cric-Abs 2020): Sicob (Italian society of obesity surgery) endorsed national survey

Background The published colorectal cancer (CRC) outcomes after bariatric surgery (BS) are conflicting, with some anecdotal studies reporting increased risks. The present nationwide survey CRIC-ABS 2020 (Colo-Rectal Cancer Incidence-After Bariatric Surgery-2020), endorsed by the Italian Society of Obesity Surgery (SICOB), aims to report its incidence in Italy after BS, comparing the two commonest laparoscopic procedures-Sleeve Gastrectomy (SG) and Roux-en-Y gastric bypass (GBP). Methods Two online questionnaires-first having 11 questions on SG/GBP frequency with a follow-up of 5-10 years, and the second containing 15 questions on CRC incidence and management, were administered to 53 referral bariatric, high volume centers. A standardized incidence ratio (SIR-a ratio of the observed number of cases to the expected number) with 95% confidence intervals (CI) was calculated along with CRC incidence risk computation for baseline characteristics. Results Data for 20,571 patients from 34 (63%) centers between 2010 and 2015 were collected, of which 14,431 had SG (70%) and 6140 GBP (30%). 22 patients (0.10%, mean age = 53 +/- 12 years, 13 males), SG: 12 and GBP: 10, developed CRC after 4.3 +/- 2.3 years. Overall incidence was higher among males for both groups (SG: 0.15% vs 0.05%; GBP: 0.35% vs 0.09%) and the GBP cohort having slightly older patients. The right colon was most affected (n = 13) and SIR categorized/sex had fewer values &lt; 1, except for GBP males (SIR = 1.07). Conclusion Low CRC incidence after BS at 10 years (0.10%), and no difference between procedures was seen, suggesting that BS does not trigger the neoplasm development

Insight in cognitive impairment assessed with the Cognitive Assessment Interview in a large sample of patients with schizophrenia

The Cognitive Assessment Interview (CAI) is an interview-based scale measuring cognitive impairment and its impact on functioning in subjects with schizophrenia (SCZ). The present study aimed at assessing, in a large sample of SCZ (n = 601), the agreement between patients and their informants on CAI ratings, to explore patients' insight in their cognitive deficits and its relationships with clinical and functional indices. Agreement between patient- and informant-based ratings was assessed by the Gwet's agreement coefficient. Predictors of insight in cognitive deficits were explored by stepwise multiple regression analyses. Patients reported lower severity of cognitive impairment vs. informants. A substantial to almost perfect agreement was observed between patients' and informants' ratings. Lower insight in cognitive deficits was associated to greater severity of neurocognitive impairment and positive symptoms, lower severity of depressive symptoms, and older age. Worse real-life functioning was associated to lower insight in cognitive deficit, worse neurocognitive performance, and worse functional capacity. Our findings indicate that the CAI is a valid co-primary measure with the interview to patients providing a reliable assessment of their cognitive deficits. In the absence of informants with good knowledge of the subject, the interview to the patient may represent a valid alternative

First World Consensus Conference on pancreas transplantation: Part II - recommendations.

Funder: Fondazione Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/100007368Funder: Tuscany Region, Italy; Id: http://dx.doi.org/10.13039/501100009888Funder: Pisa University Hospital, Pisa, ItalyFunder: University of Pisa, Pisa, Italy; Id: http://dx.doi.org/10.13039/501100007514The First World Consensus Conference on Pancreas Transplantation provided 49 jury deliberations regarding the impact of pancreas transplantation on the treatment of diabetic patients, and 110 experts' recommendations for the practice of pancreas transplantation. The main message from this consensus conference is that both simultaneous pancreas-kidney transplantation (SPK) and pancreas transplantation alone can improve long-term patient survival, and all types of pancreas transplantation dramatically improve the quality of life of recipients. Pancreas transplantation may also improve the course of chronic complications of diabetes, depending on their severity. Therefore, the advantages of pancreas transplantation appear to clearly surpass potential disadvantages. Pancreas after kidney transplantation increases the risk of mortality only in the early period after transplantation, but is associated with improved life expectancy thereafter. Additionally, preemptive SPK, when compared to SPK performed in patients undergoing dialysis, appears to be associated with improved outcomes. Time on dialysis has negative prognostic implications in SPK recipients. Increased long-term survival, improvement in the course of diabetic complications, and amelioration of quality of life justify preferential allocation of kidney grafts to SPK recipients. Audience discussions and live voting are available online at the following URL address: http://mediaeventi.unipi.it/category/1st-world-consensus-conference-of-pancreas-transplantation/246

ECT in the elderly: age-related clinical features and effectiveness in treatment-resistant major depression

Objective: Several variables have been studied as possible predictors for response to ECT; results from studies assessing the influence of age on ECT outcome in major depression reported controversial results. Since in older patients suffering from severe depression, ECT is often the treatment of choice, investigating the relationship between age and ECT outcome is considered relevant. Moreover, since age-specific adverse events such as greater cognitive impairment and higher somatic risks may be limiting factors in geriatric patients, we also investigated the relationship between age and ECT tolerability. In this prospective naturalistic study, we compared clinical features, treatment outcomes and adverse events of young (18-45 years), middle-age (46 to 65 years), and old (65 years and older) patients treated with bilateral ECT for treatment-resistant major depression. Method: The study was conducted in a cohort of 402 patients with treatment-resistant major depression who received ECT between January 2006 and April 2016 at the Department of Psychiatry of the University of Pisa. All patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 item (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State examination (MMSE). Adverse events were clinically monitored by the treating physician and the ECT psychiatrist during all the ECT course and finally registered on a four points scale. Demographic variables, clinical characteristics, short-term outcomes and rates of adverse events of the three age groups were compared. The influence of age on the attainment of response and remission was further analysed with logistic regression models. Results: Old patients had the lowest percentage of males, highest ages of onset of any psychiatric illness, shorter lengths of current depressive episodes, higher baseline HAM-D-17 scores and lower baseline MMSE scores. Old patients underwent ECT courses characterized by shorter seizure durations and lower number of sessions. In the old group we observed the higher proportion of patients achieving response (69.6% versus 63.5% in young group and 55.5% in middle age group), but the differences were not statistically significant. No significant differences were detected in the proportions of remitters between the three age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). Age as a continuous variable had no significant effect on the attainment of response and remission, adjusted for potential confounding factors. One week after the end of the ECT course all age groups showed an increase in the MMSE score compared to baseline, but the magnitude of such an increase was statistically significant only for the middle age and old groups. We did not detect significant differences between the three age groups nor in the proportions of patients reporting ECT-related adverse events either in premature drop-outs due to side effects. Conclusion: The most surprising finding in our study was that old patients underwent shorter ECT courses; this finding is probably related to physician ‘s concerns about cognitive side effects in this group, leading to a tendency to stop the treatment as soon as possible. However, the risk of such a cautious approach is the under-treatment of old patients in clinical reality. We suggest that in the elderly, if the treatment is well tolerated, ECT should not be abandoned just because rapid response is not seen. Our results are in line with literature in indicating elderly patients treated with ECT as having a shorter duration of the current episode, which in turn is a predictor of a better responsivity to the treatment. We also confirm previous reports indicating late-life depression as frequently associated with cognitive impairment, which may resolve after ECT as a consequence of symptomatic improvement. Our data support previous studies indicating that ECT effectiveness is independent from age. We also found an excellent tolerability profile in the elderly in our patient sample. There was no mortality and no life-threatening adverse events. Such results support the further use of ECT in elderly patients experiencing treatment-resistant major depression

Sintomi di spettro dell'umore e ansia di separazione nell'adulto in pazienti con lutto complicato e/o disturbo post-traumatico da stress

ABSTRACT TESI La morte di una persona cara è uno degli eventi di vita più stressanti in grado di compromettere significativamente l’equilibrio fisico, psichico e sociale ma che riesce a essere affrontata e superata dalla maggior parte delle persone in un tempo variabile di alcuni mesi. Sempre più autori evidenziano come percentuali tra il 9 e il 20% dei soggetti rimangano bloccati, nonostante il passare dei mesi, in una condizione di sofferenza che si protrae nel tempo con una ricaduta gravemente invalidante. Recentemente gli sforzi della ricerca si sono concentrati sulla caratterizzazione clinica di queste forme di lutto definito traumatico o prolungato e, ad oggi, più comunemente lutto complicato (Complicated Grief, CG) o disturbo da sofferenza prolungata. I pazienti con CG sono caratterizzati dalla presenza di elevata suicidalità (ideazione e/o tentativi di suicidio), che risulta ulteriormente aggravata dalla comorbidità per Disturbo Bipolare (Bipolar Disorder, BD). Studi clinici hanno rilevato un’associazione significativa tra la presenza anche di sintomi di spettro maniacale e maggiori livelli di suicidalità, nella popolazione generale e in pazienti con disturbi dell’umore e d’ansia senza BD. Scopo primario di questa tesi è stato quello di indagare la frequenza e l’associazione tra il numero di sintomi dello spettro dell’umore (componente depressiva, maniacale e della ritmicità e funzioni vegetative) e la suicidalità in pazienti con CG. La ricerca è oggi orientata a definire i criteri diagnostici per il CG, al fine di inserirlo nel DSM-V, evidenziando i sintomi specifici da distress da separazione e traumatico che caratterizzano questo disturbo differenziandolo dalle altre condizioni patologiche derivabili da un’esperienza di lutto quali la depressione maggiore e il disturbo post-traumtico da stress (Post-traumatic stress disorder, PTSD). Obiettivo secondario di questa tesi è stato quindi quello di caratterizzare un gruppo di pazienti con CG rispetto a pazienti con PTSD o con entrambe le diagnosi in comorbidità per quanto riguarda i sintomi di spettro dell’umore e la presenza di disturbo di ansia di separazione nell’adulto, ancora mai esplorato in letteratura. Cinquanta pazienti con diagnosi di CG (Inventory of Complicated Grief≥ 25), e 66 pazienti con PTSD, sono stati valutati mediante SCID-P (DSM-IV-TR, 2000); Inventory of Complicated Grief (ICG); MOOD Spectrum-SR versione lifetime (MOODS-SR); Adult Separation Anxiety Questionnaire (ASA-27); Impact of Event Scale (IES); Work and Social Adjustment Scale (WSAS). Tra i tre gruppi diagnostici (CG, PTSD e CG+PTSD) è stata messa in evidenza una differenza statisticamente significativa nella comorbidità con MDD (pazienti con solo CG o CG+PTSD riportavano tassi significativamente più elevati, p=.008, rispetto ai pazienti con solo PTSD) e BD (pazienti con PTSD+CG riportavano tassi significativamente più elevati, p=.004, rispetto al solo PTSD). Nei CG (n=50) è emersa un’associazione significativa tra le componenti non solo depressiva (OR=1.08, 95% CI: 1.02-1.14), ma anche maniacale (OR=1.08, 95% CI: 1.02-1.16) e della ritmicità e funzioni vegetative (OR=1.19, 95% CI:1.05-1.36) del MOODS-SR e la presenza di ideazione suicidaria. I sintomi depressivi (OR=1.09, 95% CI: 1.02-1.16) e della ritmicità e funzioni vegetative (OR =1.22, 95% CI:1.03-1.45) erano inoltre associati a più frequenti tentativi di suicidio. Tali associazioni erano confermate anche controllando per la presenza di depressione maggiore e BD in comorbidità. I pazienti con diagnosi sia di CG che di PTSD presentavano punteggi significativamente più elevati nella IES (p=0.007) e nella ASA_27 (p=0.008) rispetto sia ai pazienti con solo CG che a quelli con solo PTSD. I pazienti con doppia diagnosi e quelli con solo PTSD riportavano punteggi significativamente più alti (p=0.02) nella componente maniacale del MOODS-SR. In conclusione, i risultati della presente tesi suggeriscono l’importanza di una maggiore attenzione alla valutazione lifetime dei sintomi di spettro dell’umore nei pazienti con CG, indipendentemente dai sintomi depressivi, in quanto associati a maggiore suicidalità. Inoltre, i risultati della presente tesi sottolineano la necessità di esplorare in maniera accurata i sintomi dell’umore sottosoglia lifetime nei pazienti che subiscono eventi traumatici o di perdita , al fine di identificare prontamente coloro che potrebbero essere più soggetti allo sviluppo di disturbi psichiatrici invalidanti, come il CG o il PTSD

The Role of Electroconvulsive Therapy (ECT) in Bipolar Disorder: Effectiveness in 522 Patients with Bipolar Depression, Mixed-state, Mania and Catatonic Features

We evaluated the effectiveness of Electroconvulsive Therapy (ECT) in the treatment of Bipolar Disorder (BD) in a large sample of bipolar patients with drug resistant depression, mania, mixed state and catatonic features. Method: 522 consecutive patients with DSM-IV-TR BD were evaluated prior to and after the ECT course. Responders and nonresponders were compared in subsamples of depressed and mixed patients. Descriptive analyses were reported for patients with mania and with catatonic features. Results: Of the original sample only 22 patients were excluded for the occurrence of side effects or consent withdrawal. After the ECT course, 344 (68.8%) patients were considered responders (final CGIi score ≤3) and 156 (31.2%) nonresponders. Response rates were respectively 68.1% for BD depression, 72.9% for mixed state, 75% for mania and 80.8% for catatonic features. Length of current episode and global severity of the illness were the only statistically significant predictors of nonresponse. Conclusion: ECT resulted to be an effective and safe treatment for all the phases of severe and drugresistant BD. Positive response was observed in approximately two-thirds of the cases and in 80% of the catatonic patients. The duration of the current episode was the major predictor of nonresponse. The risk of ECT-induced mania is virtually absent and mood destabilization very unlikely. Our results clearly indicate that current algorithms for the treatment of depressive, mixed, manic and catatonic states should be modified and, at least for the most severe patients, ECT should not be considered as a "last resort".</p

Electroconvulsive therapy and age: Age-related clinical features and effectiveness in treatment resistant major depressive episode

Objective This study was aimed to compare clinical features, treatments outcomes and tolerability between young (18â\u80\u9345 years), middle age (46â\u80\u9364 years) and old (â\u89¥ 65 years) patients treated with bilateral ECT for treatment resistant major depressive episode. Method 402 patients were evaluated 1 day prior to ECT and a week after the treatment termination using the Clinical Global Impression Scale (CGI), the Hamilton Rating Scale for Depression-17 items (HAM-D-17), the Brief Psychiatric Rating Scale (BPRS), the Young Mania Rating Scale (YMRS) and the Mini Mental State Examination (MMSE). Response was defined as a reduction of at least 50% from baseline on the HAM-D-17 score. Remission was defined as a score â\u89¤ 7 on the HAM-D-17 at the final evaluation. Results Rates of response were not statistically different in the three groups (69.6% in old versus 63.5% in young and 55.5% in middle age groups). No significant differences were also observed in the proportions of remitters between the age groups (31.4% in young group, 27.7% in middle age group and 29.3% in old group). One week after the end of the ECT course the middle and old age groups showed a statistically significant increase in the MMSE score compared to baseline. We did not find significant differences between the three age groups in rates of premature drops-out due to ECT-related side effects. Conclusion Our data support the use of ECT in elderly patients with treatment-resistant major depressive episode, with rates of response around 70% and effectiveness being independent from age. In the old age group the baseline cognitive impairment improved after ECT and no life-threatening adverse event was detected