Patología Dual y rasgos de personalidad:situación actual y líneas futuras de trabajo

Dual diagnosis (DD) is the co-occurrence, in the same person, of a mental disorder (MD) and a substance use disorder (SUD). Nowadays, the study of the personality with DD is realized mainly from a categorical view, focusing on the detection of personality disorders and not on the traits associated to DD and the possible differential profile compared to those patients with only MD or SUD. Studies analyzing personality traits of patients with DD and their possible differential profile are very limited. However, existing data indicates that DD patients show higher levels of Sensation Seeking, Impulsivity, Harm Avoidance and Neuroticism; and lower levels of Persistence, Self-Direction, Self-Transcendence and Cooperation. Therefore, DD is associated to personality characteristics that suggest more disruptive behaviors, fewer resources for recovering and keeping abstinent and worse prognosis compared to those with only one disorder. Progress in the characterization of personality traits in DD, taking into consideration the methodological aspects to be improved could allow better adaptation of the integrated treatment of these patients in the future.

Síndrome de Asperger y autismo de alto funcionamiento: comorbilidad con trastornos de ansiedad y del estado de ánimo

Introducción. La comorbilidad entre el síndrome de Asperger (SA) y los trastornos del estado de ánimo y de ansiedad parece ser altamente significativa. Por ello, se presenta una revisión de la bibliografía científica más actual que aporte evidencias empíricas a tal hipótesis con el objetivo de plantear una prospectiva de investigación. Desarrollo. La valoración y el diagnóstico del funcionamiento psicosocial analizado en personas con SA o autismo de alto funcionamiento (AAF) confirman una proporción significativa de casos con sintomatología depresiva y ansiosa, y en muchos de ellos se eleva a la categoría de trastornos comórbidos. Conclusión. Es necesaria una mejor formulación diagnóstica ya que las perturbaciones afectivo-emocionales y conductuales pueden aparecer enmascaradas como sintomatología asociada al SA/AAF. Identificar y reconocer dicha comorbilidad psiquiátrica mejorará el funcionamiento psicosocial de estas personas.

Grande fréquence des prescriptions médicamenteuses à visée cardiovasculaire potentiellement inappropriées dans la population âgée [Potentially inappropriate prescribing cardiovascular medications in the aged population: prospective study in a district hospital centre (France)].

OBJECTIVES: Cardiovascular disease is a leading cause of morbidity and mortality in the elderly population. We evaluated the adequacy of prescribing (miss and under used) with respect to STOPP-START criteria. METHODS: A sample of 100 patients hospitalized in cardiovascular specialty divisions (medicine or surgery) or in the different sectors making up the geriatric network (day-care hospital, short or rehabilitation ward, nursing home) has been considered. Drug prescriptions at the admission time were analysed. RESULTS: Eight hundred and seventy-four prescriptions were analysed. In 65% of patients, from 5 to 10 medications were prescribed and in 28% over 10. Fifty-four percent of patients had, at least, one potentially inappropriate prescription (PIP) by STOPP. Among them, 48% of PIP prescriptions contained 1, 41% 2 and 11% 3 or more. The omission of one medication according to START criteria concerned 57% of the sample. Among them, 46% had one omission, 44% 2 to 3 and 10% 4 omissions or over. The cardiovascular system is the one most concerned by the PIP. Whether 28.1% of the PIP by STOPP criteria concerned cardiovascular drugs, the omission of prescription, according to START criteria, was 41.8%. There was no significant difference between the different settings studied. There was no effect of age or sex on the impact of PIP (P>0.20) or being polymédiqué (P=0.44). According to the criteria STOPP-A, the prescription of antiplatelet (indication and dose) was highlighted. Prescribing omission also concerned antiplatelet agents but also statins in patients with atherosclerosis as well as antiplatelet and anticoagulant in patients with permanent atrial fibrillation and inhibitor of angiotensin converting enzyme (ACE) after myocardial infarction or with chronic heart failure. CONCLUSION: Potentially inappropriate prescribing medications were very common in elderly patients with cardiovascular conditions. They concerned as much as underusing of important drugs with potential benefits and prescribing commission of treatment that did not fit with patients' comorbidities and/or characteristics.

Gender differences in cancer patients with acute venous thromboembolism.

BACKGROUND: The outcome of cancer patients with acute venous thromboembolism (VTE) may differ according to gender. METHODS: We used the RIETE database to compare the rate of VTE (pulmonary embolism [PE] or deep vein thrombosis [DVT]) recurrences), major bleeding and mortality during the course of anticoagulation, according to gender. RESULTS: As of August 2014, 11,055 patients with active cancer were enrolled in RIETE, of whom 5,104 (46%) were women. During the course of anticoagulation (mean: 142 days), 505 patients developed recurrent VTE, 429 bled and 2730 died. Compared with men, women had a significantly lower rate of fatal bleeding (risk ratio [RR]: 0.69; 95% CI: 0.47-0.99) and death (RR: 0.90; 95% CI: 0.83-0.97), and a non-significantly lower rate of PE recurrences (RR 0.83; 95% CI: 0.65-1.06) and major bleeding (RR: 0.89; 95% CI: 0.74-1.08). CONCLUSIONS: During the course of anticoagulation, cancer women with VTE had a better outcome than men.

International comparison of the German evidence-based S3-guidelines on the diagnosis and multimodal treatment of early and locally advanced gastric cancer, including adenocarcinoma of the lower esophagus.

BACKGROUND: Clinical guidelines are essential in implementing and maintaining nationwide stage-specific diagnostic and therapeutic standards. In 2011, the first German expert consensus guideline defined the evidence for diagnosis and treatment of early and locally advanced esophagogastric cancers. Here, we compare this guideline with other national guidelines as well as current literature. METHODS: The German S3-guideline used an approved development process with de novo literature research, international guideline adaptation, or good clinical practice. Other recent evidence-based national guidelines and current references were compared with German recommendations. RESULTS: In the German S3 and other Western guidelines, adenocarcinomas of the esophagogastric junction (AEG) are classified according to formerly defined AEG I-III subgroups due to the high surgical impact. To stage local disease, computed tomography of the chest and abdomen and endosonography are reinforced. In contrast, laparoscopy is optional for staging. Mucosal cancers (T1a) should be endoscopically resected "en-bloc" to allow complete histological evaluation of lateral and basal margins. For locally advanced cancers of the stomach or esophagogastric junction (≥T3N+), preferred treatment is preoperative and postoperative chemotherapy. Preoperative radiochemotherapy is an evidence-based alternative for large AEG type I-II tumors (≥T3N+). Additionally, some experts recommend treating T2 tumors with a similar approach, mainly because pretherapeutic staging is often considered to be unreliable. CONCLUSIONS: The German S3 guideline represents an up-to-date European position with regard to diagnosis, staging, and treatment recommendations for patients with locally advanced esophagogastric cancer. Effects of perioperative chemotherapy versus chemoradiotherapy are still to be investigated for adenocarcinoma of the cardia and the lower esophagus.

Reframing video gaming and internet use addiction : empirical cross-national comparison of heavy use over time and addiction scales among young users

BACKGROUND AND AIMS: Evidence-based and reliable measures of addictive disorders are needed in general population-based assessments. One study suggested that heavy use over time (UOT) should be used instead of self-reported addiction scales (AS). This study compared UOT and AS regarding video gaming and internet use empirically, using associations with comorbid factors. DESIGN: Cross-sectional data from the 2011 French Survey on Health and Consumption on Call-up and Preparation for Defence-Day (ESCAPAD), cross-sectional data from the 2012 Swiss ado@internet.ch study and two waves of longitudinal data (2010-13) of the Swiss Longitudinal Cohort Study on Substance Use Risk Factors (C-SURF). SETTING: Three representative samples from the general population of French and Swiss adolescents and young Swiss men, aged approximately 17, 14 and 20 years, respectively. PARTICIPANTS: ESCAPAD: n =22 945 (47.4% men); ado@internet.ch: n =3049 (50% men); C-SURF: n =4813 (baseline + follow-up, 100% men). MEASUREMENTS: We assessed video gaming/internet UOT ESCAPAD and ado@internet.ch: number of hours spent online per week, C-SURF: latent score of time spent gaming/using internet] and AS (ESCAPAD: Problematic Internet Use Questionnaire, ado@internet.ch: Internet Addiction Test, C-SURF: Gaming AS). Comorbidities were assessed with health outcomes (ESCAPAD: physical health evaluation with a single item, suicidal thoughts, and appointment with a psychiatrist; ado@internet.ch: WHO-5 and somatic health problems; C-SURF: Short Form 12 (SF-12 Health Survey) and Major Depression Inventory (MDI). FINDINGS: UOT and AS were correlated moderately (ESCAPAD: r = 0.40, ado@internet.ch: r = 0.53 and C-SURF: r = 0.51). Associations of AS with comorbidity factors were higher than those of UOT in cross-sectional (AS: .005 ≤ |b| ≤ 2.500, UOT: 0.001 ≤ |b| ≤ 1.000) and longitudinal analyses (AS: 0.093 ≤ |b| ≤ 1.079, UOT: 0.020 ≤ |b| ≤ 0.329). The results were similar across gender in ESCAPAD and ado@internet.ch (men: AS: 0.006 ≤ |b| ≤ 0.211, UOT: 0.001 ≤ |b| ≤ 0.061; women: AS: 0.004 ≤ |b| ≤ 0.155, UOT: 0.001 ≤ |b| ≤ 0.094). CONCLUSIONS: The measurement of heavy use over time captures part of addictive video gaming/internet use without overlapping to a large extent with the results of measuring by self-reported addiction scales (AS). Measuring addictive video gaming/internet use via self-reported addiction scales relates more strongly to comorbidity factors than heavy use over time.

Possible new ways in the pharmacological treatment of bipolar disorder and comorbid alcoholism.

Possible new ways in the pharmacological treatment of bipolar disorder and comorbid alcoholism. Azorin JM, Bowden CL, Garay RP, Perugi G, Vieta E, Young AH. Source Department of Psychiatry, CHU Sainte Marguerite, Marseilles, France. Abstract About half of all bipolar patients have an alcohol abuse problem at some point of their lifetime. However, only one randomized, controlled trial of pharmacotherapy (valproate) in this patient population was published as of 2006. Therefore, we reviewed clinical trials in this indication of the last four years (using mood stabilizers, atypical antipsychotics, and other drugs). Priority was given to randomized trials, comparing drugs with placebo or active comparator. Published studies were found through systematic database search (PubMed, Scirus, EMBASE, Cochrane Library, Science Direct). In these last four years, the only randomized, clinically relevant study in bipolar patients with comorbid alcoholism is that of Brown and colleagues (2008) showing that quetiapine therapy decreased depressive symptoms in the early weeks of use, without modifying alcohol use. Several other open-label trials have been generally positive and support the efficacy and tolerability of agents from different classes in this patient population. Valproate efficacy to reduce excessive alcohol consumption in bipolar patients was confirmed and new controlled studies revealed its therapeutic benefit to prevent relapse in newly abstinent alcoholics and to improve alcohol hallucinosis. Topiramate deserves to be investigated in bipolar patients with comorbid alcoholism since this compound effectively improves physical health and quality of life of alcohol-dependent individuals. In conclusion, randomized, controlled research is still needed to provide guidelines for possible use of valproate and other agents in patients with a dual diagnosis of bipolar disorder and substance abuse or dependence.

Camino hacia el coraje: terapia de constructos personales en un caso de depresión mayor, fibromialgia y otras comorbilidades

Se presenta el caso de Sara, una mujer con fibromialgia, depresión, y otras comorbilidades. A nivel psicológico, una de sus mayores dificultades estriba en poner límites a los demás. Ello perjudica la relación que mantiene tanto con sus seres queridos como con ella misma. Analizando sus constructos personales con la técnica de rejilla y la autocaracterización se observa que vive como incompatibles la satisfacción de sus necesidades y el acceder a las demandas de los demás. Termina por ceder con el fin de preservar para sí misma una imagen de buena persona que resulta central en su sentido de identidad y nuclear en su sistema de constructos. La terapia de constructos personales realizada en un formato breve aborda este dilema y se producen algunos cambios significativos que perduran al seguimiento.

Improving interMediAte Risk management. MARK study

Background: Cardiovascular risk functions fail to identify more than 50% of patients who develop cardiovascular disease. This is especially evident in the intermediate-risk patients in which clinical management becomes difficult. Our purpose is to analyze if ankle-brachial index (ABI), measures of arterial stiffness, postprandial glucose, glycosylated hemoglobin, self-measured blood pressure and presence of comorbidity are independently associated to incidence of vascular events and whether they can improve the predictive capacity of current risk equations in the intermediate-risk population. Methods/Design: This project involves 3 groups belonging to REDIAPP (RETICS RD06/0018) from 3 Spanish regions. We will recruit a multicenter cohort of 2688 patients at intermediate risk (coronary risk between 5 and 15% or vascular death risk between 3-5% over 10 years) and no history of atherosclerotic disease, selected at random. We will record socio-demographic data, information on diet, physical activity, comorbidity and intermittent claudication. We will measure ABI, pulse wave velocity and cardio ankle vascular index at rest and after a light intensity exercise. Blood pressure and anthropometric data will be also recorded. We will also quantify lipids, glucose and glycosylated hemoglobin in a fasting blood sample and postprandial capillary glucose. Eighteen months after the recruitment, patients will be followed up to determine the incidence of vascular events (later follow-ups are planned at 5 and 10 years). We will analyze whether the new proposed risk factors contribute to improve the risk functions based on classic risk factors. Discussion: Primary prevention of cardiovascular diseases is a priority in public health policy of developed and developing countries. The fundamental strategy consists in identifying people in a high risk situation in which preventive measures are effective and efficient. Improvement of these predictions in our country will have an immediate, clinical and welfare impact and a short term public health effect

Predictors of remission in the treatment of major depressive disorder: real-world evidence from a 6-month prospective observational study

BACKGROUND: This study examined potential predictors of remission among patients treated for major depressive disorder (MDD) in a naturalistic clinical setting, mostly in the Middle East, East Asia, and Mexico. METHODS: Data for this post hoc analysis were taken from a 6-month prospective, noninterventional, observational study that involved 1,549 MDD patients without sexual dysfunction at baseline in 12 countries worldwide. Depression severity was measured using the Clinical Global Impression of Severity and the 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16). Depression-related pain was measured using the pain-related items of the Somatic Symptom Inventory. Remission was defined as a QIDS-SR16 score ≤5. Generalized estimating equation regression models were used to examine baseline factors associated with remission during follow-up. RESULTS: Being from East Asia (odds ratio [OR] 0.48 versus Mexico; P<0.001), a higher level of depression severity at baseline (OR 0.77, P=0.003, for Clinical Global Impression of Severity; OR 0.92, P<0.001, for QIDS-SR16), more previous MDD episodes (OR 0.92, P=0.007), previous treatments/therapies for depression (OR 0.78, P=0.030), and having any significant psychiatric and medical comorbidity at baseline (OR 0.60, P<0.001) were negatively associated with remission, whereas being male (OR 1.29, P=0.026) and treatment with duloxetine (OR 2.38 versus selective serotonin reuptake inhibitors, P<0.001) were positively associated with remission. However, the association between Somatic Symptom Inventory pain scores and remission no longer appeared to be significant in this multiple regression (P=0.580), (P=0.008 in descriptive statistics), although it remained significant in a subgroup of patients treated with selective serotonin reuptake inhibitors (OR 0.97, P=0.023), but not in those treated with duloxetine (P=0.182). CONCLUSION: These findings are largely consistent with previous reports from the USA and Europe. They also highlight the potential mediating role of treatment with duloxetine on the negative relationship between depression-related pain and outcomes of depression.

Són els símptomes de la fibromiàlgia la histèria del segle XXI?

Nowadays, fribromialgya is one of the nervous diseases with the highest comorbidity and chronic index. The peculiarity of this symptomatology is becausephysiological pain goes to different parts of the body. The symptomatology of fribromialgya and hysteria could have relation between them and even, sharing many similar simptoms. Therefore, we will focus on studyng two cases to resolve these questions and we will be able to see if fibromialgya has histerical symptoms.

Comorbilidad entre los factores de ansiedad del SCARED y la sintomatología depresiva en niños de 8-12 años

El objetivo de este estudio fue examinar la comorbilidad entre los factores de ansiedad del SCARED y síntomas depresivos en niños de 8-12 años. 792 niñas y 715 niños completaron el Screen for Child Anxiety Related Emotional Disorder (SCARED), el Children’s Depression Inventory (CDI) y un cuestionario de datos sociodemográficos. El 47% de la muestra presentó síntomas ansiosos y el 11,5% presentó síntomas depresivos. La comorbilidad heterotípica fue del 82% en niños con riesgo de depresión y del 20% en niños con riesgo de ansiedad. La comorbilidad homotípica entre los factores de ansiedad fue del 87%. La comorbilidad homotípica y heterotípica fueron elevadas, su detección hará posible prevenir la continuidad de un trastorno de ansiedad y el desarrollo de depresión

Fatores prognósticos e impacto da comorbidade na laringectomia fronto-lateral

OBJETIVO: Avaliar sobrevida, impacto da comorbidade, complicações e fatores de falha da laringectomia como tratamento de tumores malignos glóticos. MÉTODOS: Foram analisadas 38 pacientes com tumor glótico sob estadiamento clínico T1b/T2N0M0 submetidos à laringectomia fronto-lateral com reconstrução, de janeiro de 1995 a dezembro de 2006. Foram avaliados os resultados oncológicos, comorbidades (através da escala Adult Comorbidity Evaluation - 27 ACE-27) e complicações, sendo correlacionados com dados demográficos e características do tumor. RESULTADOS: Oito pacientes apresentaram recidiva local e foram resgatados cirurgicamente. Complicações não foram verificadas em 33 pacientes. Não houve diferença significativa das sobrevidas global em cinco anos e livre de doença ao considerarem-se as diferentes categorias de comorbidades. Somente o envolvimento patológico das margens mostrou diferenças significativas na sobrevida global (p=0,0033) e sobrevida livre de doença (p<0,0001). CONCLUSÃO: A sobrevida global em cinco anos foi de 67,6% e a sobrevida livre de doença de 73,7%; a comorbidade não representou fator prognóstico independente; o índice de complicações pós-operatórias foi de 13,2% e somente o envolvimento patológico das margens mostrou diferenças significativas na sobrevida global e livre de doença.

Bariatric surgery: impact on sexuality of the obese person

Objective: To assess the impact of surgical treatment in the sexuality of the obese.Methods: We conducted a qualitative / quantitative research with 30 patients who had undergone Fobi-Capella Roux-Y gastric bypass for at least one year. We collected data through individual interviews using a questionnaire with 10 mixed questions and one open, between May and June 2011. The objective data were quantified in absolute numbers and percentages, and the subjective ones were analyzed using the Discourse of the Collective Subject (DCS) and discussed in view of reference published on the subject.Results: 30 patients were enrolled, with a mean age 44 ± 12 years, 24 (80%) were female and six (20%) were male, 23 (77%) were married, 23 (96%) were hypertensive and eight (33%) were diagnosed with Diabetes Mellitus. After the operation, 11 (37%) individuals reported no change in the number sexual intercourses, but 19 (63%) reported that this number was altered, 16 (53%) informed increased frequency, one (3%) reported a decrease in frequency, one (3%) did not practice sexual intercourse anymore and one (3%) did not report the frequency. The central ideas (CI) raised originated four DCSs: Experience of female sexuality; No experience of female sexuality; Experience of male sexuality; and improvements of comorbidities and psychological factor.Conclusion: there are positive repercussions of physical and emotional orders of the surgical treatment of obesity, favoring the quality of life, including sexuality.

Chronic subdural hematoma: epidemiological and prognostic analysis of 176 cases

Objective : To characterize patients with chronic subdural hematoma undergoing surgery and to identify prognostic indicators. Methods : We conducted a retrospective analysis of patients diagnosed with chronic subdural hematoma (CSDH) undergoing surgical treatment. We analyzed: age, period from trauma to diagnostic imaging, pre and postoperative Glasgow coma scale, type of surgery, associated comorbidities, use of postoperative drainage and outpatient treatment. Results : The sample consisted of 176 patients, 126 male and 50 female patients (ratio 2.5 : 1), ages ranged from six months to 97 years, with an average of 59.3 years. CSDH was caused by trauma in 52% of patients, with the time from trauma to imaging averaging 25.05 days; 37.7% were hypertensive patients and 20% had a neurological disease. Eighty-five (48.3%) patients were elderly and altered consciousness was present in 63% of cases. Of the 91 (51.7%) non-elderly patients, 44% presented with headache, altered consciousness occurred in 40% and motor abnormalities in 27.5%. The CSDH was located on the right in 41%, left in 43% and bilaterally in 16% of patients. Conclusion : the change of consciousness was the most common clinical alteration in the elderly and headache in non-elderly. The most associated comorbidity was the arterial hypertension and the most frequent cause, head trauma. The trepanation with two oriffices associated with a closed drainage system was the most used operating, with high efficacy and low complication rate.