Controversies revisited: a systematic review of the comorbidity of depression and anxiety with inflammatory bowel diseases

BACKGROUND: Although mental health concerns are known to occur commonly for those with inflammatory bowel diseases (IBD), the nature of this comorbid relationship has not been systematically reviewed to date. A review in 2007 identified 5 controversies regarding anxiety/depression rates and various comparators between and within IBD. We aimed to systematically analyze and critique the current evidence regarding this comorbidity, providing an update to the 5 controversies.

METHODS: Ebscohost Medline, CINAHL, Embase, and PsychINFO were searched between 2005 and 2014 using systematic review methodology. Controlled quantitative studies examining either symptoms or diagnoses of anxiety and depression in IBD were included in the review, with study quality assessed using a scale developed a priori to evaluate observational research.

RESULTS: (1) IBD versus healthy controls (pooled mean proportions) (n = 13 studies): anxiety 19.1% versus 9.6%, depression 21.2% versus 13.4%; (2) IBD inactive versus IBD active disease (n = 26): anxiety 28.2% versus 66.4%, depression 19.9% versus 34.7%; (3) ulcerative colitis versus Crohn's disease (n = 28): anxiety 31% versus 37%, depression 22% versus 24.4%; (4) IBD versus other chronic medical conditions (n = 17): anxiety 41.9% versus 48.2%, depression 14.5% versus 28.4%; (5) onset of anxiety/depression before or after IBD onset (n = 2): adults more likely to develop anxiety/depression before IBD onset, but a substantial proportion develops depression after onset; an increased risk for children of developing anxiety/depression after IBD onset.

CONCLUSIONS: The high rates of anxiety and depression for those with IBD, particularly when disease is active, warrant a systemic approach to screening and treatment.

Will he get back to normal? survival and functional status after intensive care therapy

The study aim was to address healthcare workers’ and patients’ questions about the likely level of recovery at 6 months of patients admitted to an Australian intensive care unit (ICU). Ninety-three consecutive, eligible adults were identified and followed prospectively. Severity of illness on admission was assessed using Acute Physiological and Chronic Health Evaluation (APACHE II), while functional status at 6 months was evaluated using the Sickness Impact Profile (SIP). Cumulative mortality was 25%. Admission severity of illness was associated with survival at 6 months (P≤0.001). Fifty-one (78%) of the 70 survivors were interviewed. Admission severity of illness scores correlated with functional status at 6 months (r=0.34, P=0.01), a finding reported in only one other study. More than half of those interviewed had returned to near pre-admission functional status. Those with poor functional status included high proportions of people with chronic illness and head injury. Overall, physical recovery was more complete than psychosocial recovery. The findings provide useful information for addressing questions relating to physical and psychosocial recovery, appetite, sleep patterns and return to work post discharge.

Changes in sedentary behavior among adolescent girls: a 2.5-Year prospective cohort study

Purpose: To describe longitudinal changes in leisure-time sedentary behavior among girls, during early to mid-adolescence. Methods: A 2.5-year prospective cohort study, comprising 5 data collections, 6 months apart, between 2000 and 2002. Girls aged 12–15 years (n = 200) from 8 high schools located in Sydney, Australia, self-reported the usual time spent each week in a comprehensive range of sedentary behaviors.  Results: Retention rate for the study was 82%. Girls aged 12.8 years spent approximately 45% of their discretionary time in sedentary behavior, which increased to 63% at age 14.9 years. Watching TV, videos, and playing video games (small screen recreation; SSR) was the most popular sedentary pastime, accounting for 33% of time spent in sedentariness, followed by homework and reading (25%). Sedentary behavior increased 1.4 and 3.3 hours on week and weekend days, respectively. On weekdays, increased time was spent on hobbies (27 min/day) and on weekend days, increased time was spent sitting around talking with friends (60 min/day), computer use (37 min/day), and television viewing (34 min/day). Conclusions: Among girls, the transition between early and mid-adolescence was accompanied by a significant increase in leisure-time sedentary behavior. Interventions to reduce sedentariness among adolescent girls are best to focus on weekend behaviors. Studies seeking to examine the association between inactivity and the development of chronic health problems need to examine a diverse range of activities that comprehensively measure sedentariness. This information will provide a better understanding of inactivity patterns among adolescent girls.

The DALY, context and the determinants of the severity of disease: an exploratory comparison of paraplegia in Australia and Cameroon

This paper summarises the findings of an empirical investigation of some of the technical and social assumptions on which the disability adjusted life year (DALY) is based. The objectives of the study were to examine the notion that the burden of disease is broadly similar without regard to country, environment, gender or socio-economic status and to develop detailed descriptions of the experiences of the burden of disease as they related to these contextual factors. The study was a multi-factorial exploratory study employing qualitative and quantitative techniques to obtain data on the effects of country (development), environment (urban versus rural), gender and socio-economic status on people with paraplegia. The data provided an extensive and detailed compilation of context rich descriptions of living with paraplegia. Striking features of the data were the differences between countries with respect to the impact of the health conditions on functioning and highlight a context in which paraplegia of like clinical severity can be fatal in one environment and not in another. While there has been some focus on the control of social determinants of disease, there has been little work on the social determinants of the severity of disease. The underlying assumptions of the DALY, which ignore context in the assessment of the burden of disease, risk exacerbating inequalities by undervaluing the burden of disease in less-developed countries. There is a need to continue to subject the development of indicators to rigorous debate to determine a balance between the assumption of a global “average social milieu” and the treatment of each individual as belonging to their own context in the assessment of population health in order for indicators to be meaningful cross-culturally.

A randomized trial of protocol-directed sedation management for mechanical ventilation in an Australian intensive care unit

Objective: To compare protocol-directed sedation management with traditional non-protocol-directed practice in mechanically ventilated patients. Design: Randomized, controlled trial. Setting: General intensive care unit (24 beds) in an Australian metropolitan teaching hospital. Patients: Adult, mechanically ventilated patients (n = 312). Interventions: Patients were randomly assigned to receive sedation directed by formal guidelines (protocol group, n = 153) or usual local clinical practice (control, n = 159). Measurements and Main Results: The median (95% confidence interval) duration of ventilation was 79 hrs (56-93 hrs) for patients in the protocol group compared with 58 hrs (44-78 hrs) for patients who received control care (p = .20). Lengths of stay (median [range]) in the intensive care unit (94 [2-1106] hrs vs. 88 (14-962) hrs, p = .58) and hospital (13 [1-113] days vs. 13 (1-365) days, p = .97) were similar, as were the proportions of subjects receiving a tracheostomy (17% vs. 15%, p = .64) or undergoing unplanned self-extubation (1.3% vs. 0.6%, p = .61). Death in the intensive care unit occurred in 32 (21%) patients in the protocol group and 32 (20%) control subjects (p = .89), with a similar overall proportion of deaths in hospital (25% vs. 22%, p = .51). A Cox proportional hazards model, after adjustment for age, gender, Acute Physiology and Chronic Health Evaluation II score, diagnostic category, and doses of commonly used drugs, estimated that protocol sedation management was associated with a 22% decrease (95% confidence interval 40% decrease to 2% increase, p = .07) in the occurrence of successful weaning from mechanical ventilation. Conclusions: This randomized trial provided no evidence of a substantial reduction in the duration of mechanical ventilation or length of stay, in either the intensive care unit or the hospital, with the use of protocol-directed sedation compared with usual local management. Qualified high-intensity nurse staffing and routine Australian intensive care unit nursing responsibility for many aspects of ventilatory practice may explain the contrast between these findings and some recent North American studies. (C) 2008 Lippincott Williams & Wilkins, Inc.

The relationship betwen NaCl concentration and taste perception of saltiness in bread

Background – Sodium (Na+ ) is present in food in the form of sodium chloride (NaCl). There is strong evidence that high dietary Na+ intakes increase the risk of developing various adverse health conditions. Many international organisations encourage Na+ reduction in both the diet and the food supply. One of the major dietary sources of NaCl is bread, where NaCl has the essential function of imparting flavour. At present, no literature has been published examining taste interactions that may play a role in limiting the maximum saltiness perception in bread.
Objective – To determine the extent the physical structure of bread inhibits salty taste perception. Additionally, to determine whether common commercial bread additives suppress saltiness of bread.
Design – Subjects (n=14, 12 females) tasted and rated samples with varying NaCl concentrations in water (0 – 1724 mg NaCl/100 g) and bread (125 – 1550 mg NaCl/100 g) using the general Labelled Magnitude Scale. Psychophysical curves plotting NaCl concentration against NaCl intensity were constructed for water and bread. Breads of fixed NaCl concentration (1125 mg NaCl/100 g) and various common additives (sucrose, soya flour, canola oil, gluten) were also rated to assess perceived saltiness.
Outcomes – There was a significant difference between Na+ psychophysical curves in water and bread (P<0.05) with the bread matrix suppressing maximum possible saltiness by 25% to 70%. Suppression of saltiness was observed after the addition of sucrose (55% decrease) or soya flour (60% decrease) during bread production compared to prototypical bread (both P<0.05).
Conclusions – The physical structure of bread and some common additives have a major influence on perceptual saltiness of bread. The removal of additives that suppress saltiness combined with strategies to modify the texture of bread could lead to significant reduction in dietary Na+, whilst maintaining optimal salty taste.

Responding to the ageing profile of emergency department patients

Background
Older people with acute superimposed on chronic health problems are becoming a core aspect of emergency department (ED) caseload. This project explored the ED experience from the perspective of older patients and their carers.

Method
A convenience sample of thirty participants was recruited across three participating EDs: tw o metropolitan and one regional. The project utilised two approaches to data collection: 1) an observation approach where a project officer observed participants from the time of ED presentation until discharge, or for up to six hours; and 2) a subsequent interview was conducted with the participant and their carer within a week of the ED presentation. Data from both sources were integrated, and independently thematically analysed by two members of the team.

Results
Thirty participants aged over 65 were recruited. Their average age was 77.1 (sd=6.7) years, 59% w ere female, and 74% were triage category 1- 3 (indicating moderate/high acuity). Participants spent on average 7 hours 47 minutes in the ED, with 50% discharged home, 43% admitted to general wards or MAPU, and 7% discharged to residential care/hospice. Key themes in the factors influencing the patient experience and examples of quality care were identified, along with opportunities to improve the capacity for EDs to be “older person friendly”, and “person-centred.” Challenges include improving the effectiveness of communication between staff and patients/carers (including issues around people from culturally and linguistically diverse backgrounds), availability of allied health professionals to assist with discharge planning, and a tendency for older people not to seek ED care until the health problem was severe. Patient exemplars highlight key themes.

Discussion and implications
Results of the project highlight positive aspects of emergency department care for older people and inform targets for improvement strategies. These can be used to drive ongoing improvements in care for older people presenting to EDs.

Beneficial associations of physical activity with 2-h, but not fasting, blood glucose in Australian adults

OBJECTIVE--We examined the associations of physical activity with fasting plasma glucose (FPG) and with 2-h postload plasma glucose (2-h PG) in men and women with low, moderate, and high waist circumference.

RESEARCH DESIGN AND METHODS--The Australian Diabetes, Obesity and Lifestyle (AusDiab) study provided data on a population-based cross-sectional sample of 4,108 men and 5,106 women aged [greater than or equal to] 25 years without known diabetes or health conditions that could affect physical activity. FPG and 2-h PG were obtained from an oral glucose tolerance test. Self-reported physical activity level was defined according to the current public health guidelines as active ([greater than or equal to] 150 min/week across five or more sessions) or inactive (<150 min/week and/or less than five sessions). Sex-specific quintiles of physical activity time were used to ascertain dose response.

RESULTS--Being physically active and total physical activity time were independently and negatively associated with 2-h PG. When physical activity level was considered within each waist circumference category, 2-h PG was significantly lower in active high-waist circumference women ([beta] -0.30 [95% CI -0.59 to -0.01], P = 0.044) and active low-waist circumference men ([beta] -0.25 [-0.49 to -0.02], P = 0.036) compared with their inactive counterparts. Considered across physical activity and waist circumference categories, 2-h PG levels were not significantly different between active moderate-waist circumference participants and active low-waist circumference participants. Associations between physical activity and FPG were nonsignificant.

CONCLUSIONS--There are important differences between 2-h PG and FPG related to physical activity. It appears that 2-h PG is more sensitive to the beneficial effects of physical activity, and these benefits occur across the waist circumference spectrum.

The cost-effectiveness of removing television advertising of high-fat and/or high-sugar food and beverages to Australian children

Objective: To model the health benefits and cost-effectiveness of banning television (TV) advertisements in Australia for energy-dense, nutrient-poor food and beverages during children's peak viewing times.

Methods: Benefits were modelled as changes in body mass index (BMI) and disability-adjusted life years (DALYs) saved. Intervention costs (AUD$) were compared with future health-care cost offsets from reduced prevalence of obesity-related health conditions. Changes in BMI were assumed to be maintained through to adulthood. The comparator was current practice, the reference year was 2001, and the discount rate for costs and benefits was 3%. The impact of the withdrawal of non-core food and beverage advertisements on children's actual food consumption was drawn from the best available evidence (a randomized controlled trial of advertisement exposure and food consumption). Supporting evidence was found in ecological relationships between TV advertising and childhood obesity, and from the effects of marketing bans on other products. A Working Group of stakeholders provided input into decisions surrounding the modelling assumptions and second-stage filters of 'strength of evidence', 'equity', 'acceptability to stakeholders', 'feasibility of implementation', 'sustainability' and 'side-effects'.

Results: The intervention had a gross incremental cost-effectiveness ratio of AUD$ 3.70 (95% uncertainty interval (UI) $2.40, $7.70) per DALY. Total DALYs saved were 37 000 (95% UI 16 000, 59 000). When the present value of potential savings in future health-care costs was considered (AUD$ 300m (95% UI $130m, $480m), the intervention was 'dominant', because it resulted in both a health gain and a cost offset compared with current practice.

Conclusions: Although recognizing the limitations of the available evidence, restricting TV food advertising to children would be one of the most cost-effective population-based interventions available to governments today. Despite its economic credentials from a public health perspective, the initiative is strongly opposed by food and advertising industries and is under review by the current Australian government.

Internet-based treatment for panic disorder : does frequency of therapist contact make a difference?

Internet-based interventions with therapist support have proven effective for treating a range of mental health conditions. This study examined whether frequency of therapist contact affected treatment outcomes. Fifty-seven people with panic disorder (including 32 with agoraphobia) were randomly allocated to an 8-week Internet-based cognitive behavioural treatment intervention (Panic Online) with either frequent (three e-mails per week) or infrequent (one e-mail per week) support from a psychologist. Posttreatment, intention-to-treat analyses revealed that both treatments were effective at improving panic disorder and agoraphobia severity ratings, panicrelated cognitions, negative affect, and psychological and physical quality of life domains, with no differences between conditions. High end-state functioning was achieved by 28.6% of the frequent and infrequent participants, respectively. Therapist alliance, treatment credibility, and satisfaction also did not differ between groups, despite significantly greater therapist time invested in the frequent contact condition. The results provide evidence that the effectiveness of Internet-based mental health interventions may be independent of the frequency of therapist support and may, therefore, be more cost-effective than previously reported.

Oxidative stress : emerging mitochondrial and cellular themes and variations in neuronal injury

Oxidative stress plays a central role in neuronal injury and cell death in acute and chronic pathological conditions. The cellular responses to oxidative stress embrace changes in mitochondria and other organelles, notably endoplasmic reticulum, and can lead to a number of cell death paradigms, which cover a spectrum from apoptosis to necrosis and include autophagy. In Alzheimer's disease, and other pathologies including Parkinson's disease, protein aggregation provides further cellular stresses that can initiate or feed into the pathways to cell death engendered by oxidative stress. Specific attention is paid here to mitochondrial dysfunction and programmed cell death, and the diverse modes of cell death mediated by mitochondria under oxidative stress. Novel insights into cellular responses to neuronal oxidative stress from a range of different stressors can be gained by detailed transcriptomics analyses. Such studies at the cellular level provide the key for understanding the molecular and cellular pathways whereby neurons respond to oxidative stress and undergo injury and death. These considerations underpin the development of detailed knowledge in more complex integrated systems, up to the intact human bearing the neuropathology, facilitating therapeutic advances.

All around Patrick

With the help from the RCH Education Institute which supports students with health conditions, Patrick Mackenzie, who has cystic fibrosis, is able to attend primary school.

Promoting fit bodies, healthy eating and physical activity among Indigenous Australian men : a study protocol

Background: Overall the physical health of Indigenous men is among the worst in Australia. Research has indicated that modifiable lifestyle factors, such as poor nutrition and physical inactivity, appear to contribute strongly to these poor health conditions. To effectively develop and implement strategies to improve the health of Australia’s Indigenous peoples, a greater understanding is needed of how Indigenous men perceive health, and how they view and care for their bodies. Further, a more systematic understanding of how sociocultural factors affect their health attitudes and behaviours is needed. This article presents the study protocol of a communitybased investigation into the factors surrounding the health and body image of Indigenous Australian men.
Methods and design: The study will be conducted in a collaborative manner with Indigenous Australian men using a participatory action research framework. Men will be recruited from three locations around Australia (metropolitan, regional, and rural) and interviewed to understand their experiences and perspectives on a number of issues related to health and health behaviour. The information that is collected will be analysed using modified grounded theory and thematic analysis. The results will then be used to develop and implement community events in each location to provide feedback on the findings to the community, promote health enhancing strategies, and determine future action and collaboration.
Discussion: This study will explore both risk and protective factors that affect the health of Indigenous Australian men. This knowledge will be disseminated to the wider Indigenous community and can be used to inform future health promotion strategies. The expected outcome of this study is therefore an increased understanding of health and health change in Indigenous Australian men, the development of strategies that promote healthy eating and positive patterns of physical activity and, in the longer term, more effective and culturally-appropriate interventions to improve health.

There are plenty of medical problems, but only one real crisis

Fixing the disgraceful state of indigenous health conditions would benefit us all in the long-term, writes Jim Hyde.

Illness burden and medical comorbidity in the systematic treatment enhancement program for bipolar disorder

Objective:  Coexisting chronic medical conditions are common in bipolar disorder. Here, we report the prevalence and correlates of medical comorbidity in patients enrolled in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD). We were particularly interested in associations between variables reflecting illness chronicity and burden with comorbid medical conditions.

Method:  We used intake data from the open-label component of the STEP-BD. History of medical comorbidity was obtained from the affective disorders evaluation, and its presence was the outcome of interest. The sample size in analyses varied from 3399 to 3534. We used multiple Poisson regression to obtain prevalence ratios.

Results:  The prevalence of any medical comorbidity in the sample was 58.8%. In addition to demographic variable, several clinical characteristics were associated with the frequency of medical comorbidity. Having more than 10 previous mood episodes, childhood onset, smoking, lifetime comorbidity with anxiety, and substance use disorders were independently associated with having a medical comorbidity in the final multivariate model.

Conclusion:  The results presented here reveal strong associations between variables related to illness chronicity and medical burden in bipolar disorder. This lends further support to recent multidimensional models incorporating medical morbidity as a core feature of bipolar disorder.