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Purpose: Surgery is a major risk factor for chronic opioid use among patients who had not recently been prescribed opioids. This study identifies the rate of, and risk factors for, persistent opioid use following laparoscopic cholecystectomy and open inguinal hernia repair in patients not recently prescribed opioids. Methods: This retrospective population-based cohort study included all patients who had not been prescribed opioids in the 6 months prior to undergoing open inguinal hernia repair or laparoscopic cholecystectomy from January 2013 to July 2016 in Ontario. Opioid prescription was identified from the provincial Narcotics Monitoring System and data were obtained from the Institute for Clinical Evaluative Sciences. The primary outcome was persistent opioid use after surgery (3, 6, 9 and 12 months). Associated risk factors and prescribing patterns were also examined. Results: Among the 90,326 patients in the study cohort, 80% filled an opioid prescription after surgery, with 11%, 9%, 5% and 1% filling a prescription at 3, 6, 9 and 12 months, respectively. Significant variability was identified in the type of opioid prescribed (41% codeine, 31% oxycodone, 18% tramadol) and in regional prescribing patterns (mean prescription/region range, 135–225 oral morphine equivalents). Predictors of continued opioid use included age, female gender, lower income quintile and being operated on by less experienced surgeons. Conclusion: Most patients who undergo elective cholecystectomy and hernia repair will fill a prescription for an opioid after surgery, and many will continue to fill opioid prescriptions for considerably longer than clinically anticipated. There is important variability in opioid type, regional prescribing patterns and risk factors that identify strategic targets to reduce the opioid burden in this patient population.

Background Multidisciplinary conference presentation may provide recommendations for diagnosis, monitoring and treatment for patients with inflammatory bowel disease. Methods A prospective observational study was completed evaluating if case presentation resulted in a direct change in management for patients presented over a 2-year period in a tertiary Canadian centre. Change in management was defined as hospital admission, surgery or surgical referral, start/change in biologic therapy or other medication or initiation of parenteral nutrition. Secondary outcomes included the involvement of specialists and other referrals. Data were analyzed using frequencies and means with standard deviations. Results In 63 multidisciplinary conferences, 181 patients were presented, of whom 136 patients met the inclusion criteria of inflammatory bowel disease (Crohn’s n = 45, ulcerative colitis n = 88, undifferentiated n = 3). The majority were outpatient cases 110 (81%). Indications included 71 (52%) patients presented for IBD management with diagnosis > 1 year, 37 (27%) with an acute IBD flare in a chronic patient (>1 year since diagnosis) and 24 (18%) with new diagnosis of IBD. Change in management was recommended in 35 (26%) patients. The most common change was referral to surgery in 17 (13%), surgery in 12 (9%) or change in biologic therapy 11 (8%). Compliance with the recommendations was 85%. There was frequent specialist involvement in case discussions (gastroenterologist 100%, surgeon 60%, radiologist 68% and pathologist 32%). Conclusions Presentation of complex inflammatory bowel disease cases at multidisciplinary conference leads to a direct change in treatment in one quarter of cases, with surgical referral as the most frequent outcome.

Reduced nigrostriatal uptake on N-(3-fluoropropyl)-2β-carbomethoxy-3β-(4-[123I]iodophenyl) nortropane (123I-FP-CIT) SPECT reflects dopamine dysfunction, while other imaging markers could be complementary when used together. We assessed how well 123I-FP-CIT SPECT differentiates dementia with Lewy bodies (DLBs) from Alzheimer's disease dementia (ADem) and whether multimodal imaging provides additional value. 123I-FP-CIT SPECT, magnetic resonance imaging, [18F]2-fluoro-deoxy-D-glucose-positron emission tomography (PET), and 11C-Pittsburgh compound B (PiB)-PET were assessed in 35 participants with DLBs and 14 participants with ADem (autopsy confirmation in 9 DLBs and 4 ADem). Nigrostriatal dopamine transporter uptake was evaluated with 123I-FP-CIT SPECT using DaTQUANT software. Hippocampal volume was calculated with magnetic resonance imaging, cingulate island sign ratio with FDG-PET, and global cortical PiB retention with PiB-PET. The DaTQUANT z-scores of the putamen showed the highest c-statistic of 0.916 in differentiating DLBs from ADem among the analyzed imaging biomarkers. Adding another imaging modality to 123I-FP-CIT SPECT had c-statistics ranging from 0.968 to 0.975, and 123I-FP-CIT SPECT in combination with 2 other imaging modalities presented c-statistics ranging from 0.987 to 0.996. These findings suggest that multimodal imaging with 123I-FP-CIT SPECT aids in differentiating DLBs and ADem and in detecting comorbid Lewy-related and Alzheimer's disease pathology in patients with DLBs and ADem.

The relationship between clinicopathologic diagnosis and 123I-FP-CIT SPECT in 18 patients with dementia (12 with Lewy body disease) from one center in the United States was assessed. The sensitivity and specificity of abnormal 123I-FP-CIT SPECT with reduced striatal uptake on visual inspection for predicting Lewy body disease were 91.7% and 83.3%, respectively. The mean calculated putamen to occipital ratio (mPOR) based on regions of interest was significantly reduced in Lewy body disease compared to non-Lewy body disease cases (P = 0.002). In this study, abnormal 123I-FP-CIT SPECT was strongly associated with underlying Lewy body disease pathology, supporting the utility of 123I-FP-CIT SPECT in the clinical diagnosis of dementia with Lewy bodies.

This study aimed to investigate the functional outcomes of infants who underwent neurotization for shoulder abduction and elbow flexion in Narakas grade 1 birth-related brachial plexus palsy (BRBPP) and compare this cohort to children who progressed past the point of needing intervention. A cohort study was conducted at a single center between 1999 and 2010. Two-hundred and eight infants were identified with BRBPP that presented for neurosurgical care as infants. Of those, 38 (18 %) received neurosurgical intervention with approximate 2-year follow-up. Only infants undergoing cranial nerve XI to suprascapular nerve neurotization for shoulder abduction (SA) weakness and medial pectoral nerve to musculocutaneous nerve neurotization for elbow flexion (EF) weakness were included. In addition, 30 infants who improved past the need for surgical intervention and had been followed for close to 24 months were identified for comparison. Descriptive statistics and exploratory analysis were performed using SAS 9.2 and JMP 9.0.2. Shoulder abduction For SA, there were no differences in age at presentation between the operative (6–9 months) and non-operative (5–9 months) groups (p = 0.99). Infants in the operative cohort had significantly worse initial function (p = 0.008). At 2-year follow-up, the two groups had become similar (p = 1.0). Elbow flexion For EF, there were no differences in age at presentation between the operative (6–8 months) and non-operative (5–8.5 months) groups (p = 0.98). Infants in the operative cohort had significantly worse initial function (p = 0.002). At 2-year follow-up, those two groups had become similar (p = 0.26). Infants undergoing neurotization for Narakas grade 1 brachial plexus injury had similar long-term function to those who had improved and never required surgery. The preoperative exam findings were significantly different between the intervened and non-intervened groups, while the postoperative exam findings were not.

Most studies evaluating acute care surgery (ACS) models of care for patients with emergency general surgery (EGS) conditions have focused on patients who undergo surgery while admitted under the care of the ACS service. The purpose of this study was to prospectively examine the case mix of admissions and consultations to an ACS service at a tertiary centre to identify the frequency and distribution of both operatively and nonoperatively managed EGS conditions.In this prospective cohort study, we evaluated consecutive patients assessed by the ACS team between July 1 and Aug. 31, 2015, at a large Canadian tertiary care centre. This included all consultations and outside hospital transfers. Diagnoses, demographic characteristics, comorbidities, intervention(s), complications, readmission and in-hospital death were captured.The ACS team was involved in the care of 359 patients, 176 (49.0%) of whom were admitted under the direct care of the ACS team. Nonoperative care was indicated in 82 patients (46.6%) admitted to the ACS service and 151 (82.5%) of those admitted to a non-ACS service (Acute care surgery teams care for a wide breadth of disease, a considerable amount of which is managed nonoperatively.La plupart des études qui ont évalué les modèles de soins chirurgicaux aigus (SCA) chez des patients souffrant de problèmes de santé nécessitant un traitement de chirurgie générale (TCG) d'urgence ont porté sur des patients ayant subi une intervention lors de leur admission dans un service de SCA. Le but de cette étude était d'analyser de manière prospective la clientèle admise ou vue en consultation dans le service de SCA d'un centre de soins tertiaires pour connaître la fréquence et la distribution des problèmes de santé nécessitant un TCG d'urgence effectivement traités chirurgicalement ou autrement.Dans cette étude de cohorte prospective, nous avons évalué des patients consécutifs vus par l'équipe de SCA entre le 1er juillet et le 31 août 2015 dans un grand centre canadien de soins tertiaires. Cela incluait toutes les consultations et les transferts en provenance d'autres hôpitaux. Nous avons noté les diagnostics, les caractéristiques démographiques, les comorbidités, les interventions, les complications, réadmissions et les décès en cours d'hospitalisation.L'équipe de SCA a assuré les soins de 359 patients, dont 176 (49,0 %) avaient été admis directement au service de SCA. Des soins non chirurgicaux étaient indiqués chez 82 patients (46,6 %) admis au service de SCA et chez 151 (82,5 %) patients admis dans d'autres services (Les équipes de soins chirurgicaux aigus prennent en charge un vaste éventail de pathologies, dont une part importante est gérée de manière non chirurgicale.

Renal transplantation offers a significant survival benefit over dialysis for patients with end-stage renal disease. Furthermore, transplantation with a living donor kidney offers superior survival when compared to a deceased donor. However, supply of transplantable kidneys continues to fall short of demand; living donation offers a solution to help decrease this disparity. For those patients who have willing donors, many will be incompatible secondary to blood group or tissue mismatches. In this setting, a crucial decision must be made—pursue living donor transplantation by overcoming the incompatibility through desensitization or kidney paired donation, or wait on the deceased donor transplant list for a compatible kidney to become available. This review explores the regimens for desensitization, clinical outcomes, and potential adverse sequelae for both tissue incompatibility [that is, patients with anti-human leukocyte antigen (anti-HLA) antibodies] and blood group (ABO) incompatibility. This review also summarizes the different strategies involved in kidney paired donation (KPD) and addresses challenges unique to this model of transplantation. The decision to utilize desensitization versus KPD is an individualized one, guided by donor and recipient characteristics and preferences.

BACKGROUND AND PURPOSE: Cerebral mycotic aneurysms are a rare and deadly type of aneurysm that have no definitive treatment guidelines. Our purpose was to retrospectively review known or suspected cases of CMA in order to identify patient populations that may be associated with higher morbidity and mortality. We hope that the identification of patients with these risk factors will lead to early stratification upon presentation, and more urgent treatment of their CMAs. We also hoped to identify any benefit or complication that was specific to either the endovascular or neurosurgical repair of CMAs. MATERIALS AND METHODS: A retrospective multi-institutional study was performed examining cases of CMA during a 15-year period. Patients were considered strongly immunocompromised if there were long-term severely immunocompromised states: AIDS, chemotherapy, or steroid immunosuppression. Patients were excluded if angiographic findings suggested an alternative diagnosis or if an infectious etiology was unknown. Antibiotics were considered “noninvasive treatment.” Endovascular and neurosurgical repair were considered “invasive treatment.” Data were recorded by reviewing electronic medical records and imaging reports. RESULTS: Twenty-six patients with 40 CMAs were included. Three patients were considered strongly immunocompromised and presented with 4 CMAs, which demonstrated larger average size and more rapid growth; 3 of these patients' aneurysms were treated invasively in the acute period, with the one that was not ruptured causing death. Technical success (aneurysm occlusion without rupture or recanalization) and clinical success (no neurologic complication attributable to the intervention) were obtained equally endovascularly and neurosurgically. Clipping was aborted in favor of coiling for 1 patient. Anticoagulation needed reversal before 2 patients underwent craniotomy for clipping after valve replacement. For CMAs treated with antibiotics alone with angiographic follow-up ( n = 11), initial aneurysm size was unrelated to persistence and 64% completely regressed. CONCLUSIONS: We recommend initial invasive treatment for CMAs in strongly immunocompromised patients. Testing for underlying immunocompromised states is warranted in patients with CMAs. Endovascular treatment is favored over neurosurgical treatment in patients requiring acute cardiac valve repair due to delays with anticoagulation reversal. CMA : cerebral mycotic aneurysms ECA : external carotid artery ICP : intracranial pressure IE : infective endocarditis IPH : intra-parenchymal hemorrhage

Background Recent evidence suggests that deep brain stimulation of the subthalamic nucleus (STN-DBS) may have a disease modifying effect in early Parkinson9s disease (PD). A randomised, prospective study is underway to determine whether STN-DBS in early PD is safe and tolerable. Objectives/methods 15 of 30 early PD patients were randomised to receive STN-DBS implants in an institutional review board approved protocol. Operative technique, location of DBS leads and perioperative adverse events are reported. Active contact used for stimulation in these patients was compared with 47 advanced PD patients undergoing an identical procedure by the same surgeon. Results 14 of the 15 patients did not sustain any long term (>3 months) complications from the surgery. One subject suffered a stroke resulting in mild cognitive changes and slight right arm and face weakness. The average optimal contact used in symptomatic treatment of early PD patients was: anterior −1.1±1.7 mm, lateral 10.7±1.7 mm and superior −3.3±2.5 mm (anterior and posterior commissure coordinates). This location is statistically no different (0.77 mm, p>0.05) than the optimal contact used in the treatment of 47 advanced PD patients. Conclusions The perioperative adverse events in this trial of subjects with early stage PD are comparable with those reported for STN-DBS in advanced PD. The active contact position used in early PD is not significantly different from that used in late stage disease. This is the first report of the operative experience from a randomised, surgical versus best medical therapy trial for the early treatment of PD.

This study examined attrition in a multisite clinical trial for panic disorder. Of 379 eligible patients, 19 refused treatment (5% Refusal Rate), 104 discontinued treatment prematurely (19% Dropout Rate) or were withdrawn by the investigators (8% Withdrawal Rate), and 256 completed the treatment (68% Completion Rate). Logistic regression was used to examine 5 domains theorized to be related to attrition (e.g., diagnostic severity, treatment factors). Few variables were associated with increased odds of attrition at padj0.004. Younger age was the only independent predictor of attrition in the demographic factor model. Diagnostic severity and comorbidity, panic disorder symptom severity, treatment factors, and therapist factors were unrelated to study attrition. Patient dropout was highest after treatment sessions that targeted interoceptive and situational exposure exercises. Findings suggest that attrition may not strongly threaten the validity of results from treatment outcome studies.

This study examined the relationships among anxiety sensitivity (AS), catastrophizing, somatization and pain in 240 non-clinical children (121 girls; mean age = 12.7 years). Children with pain problems ( n = 81; 33.8%) reported greater AS and catastrophizing ( ps < .01) relative to children without pain problems. AS but not catastrophizing was significantly associated with current pain. However, both AS and catastrophizing were significantly associated with somatization. AS and catastrophizing represent related but partially distinct cognitive constructs that may be targeted by interventions aimed at alleviating pain and somatization in children.

Objective Cognitive-behavioral therapy (CBT) is well documented as an efficacious treatment for panic disorder. We provided open CBT treatment to patients who subsequently participated in a maintenance treatment study. This article reports on predictors and trajectory of response in 381 participants who completed treatment at 4 sites. Method Participants who met criteria for panic disorder with or without agoraphobia (N = 381) completed assessment and entered treatment. Of these, 256 completed 11 sessions of CBT delivered by trained and supervised research therapists. Raters trained to reliability obtained demographic data and administered structured diagnostic interviews and the Hamilton Rating Scales for Depression and Anxiety and the Panic Disorder Severity Scale (PDSS) measures at baseline and posttreatment. We obtained self-report (SR) measures of anxiety sensitivity and adult separation anxiety at baseline and posttreatment and PDSS-SR ratings weekly. The study was conducted between November 1999 and July 2002. Results Treatment response rate was 65.6% for completers and 44.1% for the intent-to-treat sample. Greater severity of panic disorder and lower levels of adult separation anxiety predicted response. Beginning at week 4, responders showed greater mean decreases in PDSS scores than non-responders and maintained the advantage throughout the treatment. By week 6, 76% of responders, compared to 36% of nonresponders, recorded PDSS scores at least 40% below baseline on 2 consecutive weeks (odds ratio = 5.42, 95% CI = 3.10 to 9.48). Conclusion These results suggest that CBT is just as effective for more severe panic disorder patients as it is for those with less severe panic disorder, regardless of other comorbid disorders, including agoraphobia. However, patients experiencing adult separation anxiety disorder are less likely to respond. Our results further inform clinicians that many people who will respond to 11 weeks of treatment will have done so by the middle of the treatment.

This study compared the effects of a higher dose of cognitive behavioral therapy (CBT) for panic disorder versus CBT for panic disorder combined with "straying" to CBT for comorbid disorders in individuals with a principal diagnosis of panic disorder with or without agoraphobia. Sixty-five participants were randomly assigned to one of two treatment conditions, either CBT focused solely upon panic disorder and agoraphobia or CBT that simultaneously addressed panic disorder and agoraphobia and, to a lesser degree, the most severe comorbid condition. Results indicated a significant reduction in panic disorder severity and a decline in severity of comorbid diagnoses across both treatment conditions. However, individuals receiving CBT focused only on panic disorder were more likely to meet high end-state functioning at post-treatment, even in intent-to-treat analyses, and report zero panic attacks at the 1-year follow-up, although this effect was not retained in intent-to-treat analyses. At follow-up, CBT focused only on panic disorder yielded more substantial improvement in the most severe baseline comorbid condition, although not in intent-to-treat analyses, and a greater proportion of individuals in this treatment condition were rated as having no comorbid diagnoses, even in intent-to-treat analyses. These findings raise the possibility that remaining focused on CBT for panic disorder may be more beneficial for both principal and comorbid diagnoses than combining CBT for panic disorder with 'straying' to CBT for comorbid disorders.

Over 40 years of development of cognitive behavioral approaches to treating anxiety and related emotional disorders have left us with highly efficacious treatments that are increasingly widely accepted. Nevertheless, these manualized protocols have become numerous and somewhat complex, restricting effective training and dissemination. Deepening understanding of the nature of emotional disorders reveals that commonalities in etiology and latent structure among these disorders supercedes differences. This suggests the possibility of distilling a set of psychological procedures that would comprise a unified intervention for emotional disorders. Based on theory and data emerging from the fields of learning, emotional development and regulation, and cognitive science, we identify three fundamental therapeutic components relevant to the treatment of emotional disorders generally. These three components include (a) altering antecedent cognitive reappraisals; (b) preventing emotional avoidance; and (c) facilitating action tendencies not associated with the emotion that is dysregulated. This treatment takes place in the context of provoking emotional expression (emotional exposure) through situational, internal, and somatic (interoceptive cues), as well as through standard mood-induction exercises, and differs from patient to patient only in the situational cues and exercises utilized. Theory and rationale supporting this new approach are described along with some preliminary experience with the protocol. This unified treatment may represent a more efficient and possibly a more effective strategy in treating emotional disorders, pending further evaluation.

Chloral hydrate, which is used as a sedative in pediatric medicine and is a by-product of water chlorination, is hepatocarcinogenic in B6C3F1 mice, a strain that can exhibit high rates of background liver tumor incidence, which are associated with increased body weight. In this study, dietary control was used to manipulate body growth in male B6C3F1 mice in a 2-year bioassay of chloral hydrate. Male B6C3F1 mice were treated with water or 25, 50, or 100 mg/kg chloral hydrate by gavage. The study compared ad libitum-fed mice with dietary controlled mice. The latter received variably restricted feed allocations to maintain their body weights on a predetermined "idealized" weight curve predictive of a terminal background liver tumor incidence of 15-20%. These mice exhibited less individual body weight variation than did their ad libitum-fed counterparts. This was associated with a decreased variation in liver to body weight ratios, which allowed the demonstration of a statistically significant dose response to chloral hydrate in the dietary controlled, but not the ad libitum-fed, test groups. Chloral hydrate increased terminally adjusted liver tumor incidence in both dietary controlled (23.4, 23.9, 29.7, and 38.6% for the four dose groups, respectively) and ad libitum-fed mice (33.4, 52.6, 50.6, and 46.2%), but a statistically significant dose response was observed only in the dietary controlled mice. This dose response positively correlated with markers of peroxisomal proliferation in the dietary controlled mice only. The study suggests that dietary control not only improves terminal survival and decreases interassay variation, but also can increase assay sensitivity by decreasing intra-assay variation.

Angiogenic growth factors could prove to be useful in managing peripheral arterial insufficiency. The present study was designed to evaluate the dose response of basic fibroblast growth factor (bFGF), the efficacy of critical routes and dosing regimens, and the specificity of action in rats with peripheral arterial insufficiency. Bilateral ligation of femoral arteries greatly reduces blood flow capacity to the calf muscles but does not impair resting flow needs. Collateral blood flow to calf muscles was determined 16 days postocclusion, during treadmill running, with 85Sr and 141Ce microspheres, in blinded-randomized trials that included intra-arterial and intravenous infusions and subcutaneous injections of recombinant human bFGF. Peak blood flow of 75–80 ml ⋅ min− 1 ⋅ 100 g− 1 for calf muscle was observed at a bFGF dose of 5 μg ⋅ kg− 1 ⋅ day− 1(ia for 14 days) compared with 50 ml ⋅ min− 1 ⋅ 100 g− 1 for vehicle groups. Similar increases in collateral blood flow were observed with short-term or prolonged and continuous or intermittent delivery of bFGF by any route. Collateral blood flows were similar in corresponding muscles across both limbs. Vascular remodeling induced by bFGF required attendant vascular occlusion, inasmuch as vessels in the normal nonoccluded vascular tree were unresponsive to circulating bFGF. Improvement in collateral blood flow with exogenous bFGF is robust, amenable to short-term administration, and requires vascular occlusion to be effective.

Chronic pain disorders represent a significant public health concern, particularly for children and adolescents. High rates of comorbid anxiety and unipolar mood disorders often complicate psychological interventions for chronic pain. Unified treatment approaches, based on emotion regulation skills, are applicable to a broad range of emotional disorders and suggest the possibility of extending these interventions to chronic pain and pain-related dysfunction. This case report describes the use of a unified protocol for treatment of an adolescent boy with chronic daily headache and social anxiety and an adolescent girl with whole body pain and depression. Following weekly, 50-minute individual treatment sessions, the boy demonstrated notable improvement in emotional symptoms, emotion regulation skills, somatization, and functional disability. The girl showed some improvement on measures of anxiety and depression, although there appeared to be a worsening of pain symptoms and somatization. However, both patients demonstrated improvement over follow-up. This case study illustrates the potential utility of a unified treatment approach targeting pain and emotional symptoms from an emotion regulation perspective in an adolescent population.

A link between alexithymia and somatization has been widely established, yet little is known about different factors that may influence this relationship. Evidence supporting the idea of psychopathology as a mediator has been presented but not widely tested, particularly in children. The present study examined depressive symptoms as a mediator of alexithymia and somatization in a sample of healthy children in order to better understand the alexithymia—somatization link from a developmental perspective. Results indicated that depression significantly partially mediated this relationship, at least for two facets of alexithymia (difficulty identifying and describing feelings). Possible mechanisms, implications, and directions for future research are discussed.

Background This protocol is for a study of a new program to improve outcomes in children suffering from chronic pain disorders, such as fibromyalgia, recurrent headache, or recurrent abdominal pain. Although teaching active pain self-management skills through cognitive-behavioral therapy (CBT) or a complementary program such as hypnotherapy or yoga has been shown to improve pain and functioning, children with low expectations of skill-building programs may lack motivation to comply with therapists' recommendations. This study will develop and test a new manualized peer-mentorship program which will provide modeling and reinforcement by peers to other adolescents with chronic pain (the mentored participants). The mentorship program will encourage mentored participants to engage in therapies that promote the learning of pain self-management skills and to support the mentored participants' practice of these skills. The study will examine the feasibility of this intervention for both mentors and mentored participants, and will assess the preliminary effectiveness of this program on mentored participants' pain and functional disability. Methods This protocol will recruit adolescents ages 12-17 with chronic pain and randomly assign them to either peer mentorship or a treatment-as-usual control group. Mentored participants will be matched with peer mentors of similar age (ages 14-18) who have actively participated in various treatment modalities through the UCLA Pediatric Pain Program and have learned to function successfully with a chronic pain disorder. The mentors will present information to mentored participants in a supervised and monitored telephone interaction for 2 months to encourage participation in skill-building programs. The control group will receive usual care but without the mentorship intervention. Mentored and control subjects' pain and functioning will be assessed at 2 months (end of intervention for mentored participants) and at 4 month follow-up to see if improvements persist. Measures of treatment adherence, pain, disability, and anxiety and depression will be assessed throughout study participation. Qualitative interviews for mentors, mentored participants, and control subjects will also be administered. Trial registration ClinicalTrials.gov NCT01118988.

Research evaluating the relationship of comorbidity to treatment outcome for panic disorder has produced mixed results. The current study examined the relationship of comorbid depression and anxiety to treatment outcome in a large-scale, multi-site clinical trial for cognitive-behavior therapy (CBT) for panic disorder. Comorbidity was associated with more severe panic disorder symptoms, although comorbid diagnoses were not associated with treatment response. Comorbid generalized anxiety disorder (GAD) and major depressive disorder (MDD) were not associated with differential improvement on a measure of panic disorder severity, although only rates of comorbid GAD were significantly lower at posttreatment. Treatment responders showed greater reductions on measures of anxiety and depressive symptoms. These data suggest that comorbid anxiety and depression are not an impediment to treatment response, and successful treatment of panic disorder is associated with reductions of comorbid anxiety and depressive symptoms. Implications for treatment specificity and conceptual understandings of comorbidity are discussed.

Theory and research suggest treatments targeting experiential avoidance may enhance outcomes for patients with GAD (Roemer & Orsillo, 2002; 2007). Preliminary findings demonstrate that distress about emotions and avoidance of internal experiences share unique variance with GAD above and beyond chronic reports of worry (Roemer, Salters, Raffa, & Orsillo, 2005). The purpose of the present study was to extend previous findings to explore the role of experiential avoidance and distress about emotions in a treatment-seeking sample with a principal diagnosis of GAD compared with demographically matched non-anxious controls, and to explore their shared relationship with two putative psychopathological processes in GAD: intolerance of uncertainty and worry. Patients with GAD reported significantly higher levels of experiential avoidance and distress about emotions compared to non-clinical controls while controlling for depressive symptoms, and measures of these constructs significantly predicted GAD status. Additionally, experiential avoidance and distress about anxious, positive, and angry emotions shared unique variance with intolerance of uncertainty when negative affect was partialled out, while only experiential avoidance and distress about anxious emotions shared unique variance with worry. Discussion focuses on implications for treatment as well as future directions for research.

Research has highlighted the role of emotion regulation as a common factor underlying emotional disorders. The current study examined the relationship of emotion regulation skills to obsessive-compulsive disorder (OCD) symptoms. Seven participants with a principal diagnosis of OCD in a multiple-baseline across subjects design were taught the skill of prevention of emotional avoidance in the context of emotion provocation procedures to clinically irrelevant (nonspecific) cues prior to practicing this skill with clinically relevant (OCD-specific) cues. Results suggested successful acquisition of emotion regulation skills (as evidenced by decreased thought suppression and increased acceptance of thoughts and feelings) in clinically irrelevant contexts. Acquisition of this skill was associated with decreases in obsessive-compulsive symptoms, even though clinically relevant cues were not introduced during this phase. Implementation of skills in clinically relevant contexts was associated with greater reductions in OCD symptoms. Discussion focuses on implications for emotion regulatory processes in the maintenance and treatment of emotional disorders.

A 47-year-old woman with athetoid cerebral palsy (ACP) experienced isolated right-sided spasticity. Imaging revealed cord edema, a herniated disc, and anterolisthesis (figure, A, B, D). The patient underwent discectomy with spinal fusion (figure, F), and reported improved activities of daily living. Figure C-spine T2 …

We present a patient with a large spontaneous splenorenal shunt secondary to isolated splenic vein thrombosis who developed severe bleeding from fundal gastric varices. The patient was managed emergently with splenic artery embolization and balloon occlusion retrograde embolization of the varices with alcohol. We discuss the clinical presentation, embolization techniques, and a potential complication of the use of alcohol for this purpose.

Small bowel obstruction (SBO) is a complication of previous abdominal surgeries, hernias, and other pathologies. Patients can be managed non-operatively or operatively, thus patients are admitted to medical and surgical services. The purpose of this study was to compare characteristics and outcomes associated with admitting service. A retrospective medical record review was conducted of SBO admissions via the emergency department to an academic medical center in 2012. Patients were identified using discharge diagnosis codes in an administrative database. Patients with ileus without mechanical obstruction, lack of obstructive symptoms, and previous abdominal surgery within 30 days were excluded (103 patients with 107 admissions). Univariate and bivariate frequencies were used to describe the population. Chi-square and Wilcoxon rank sums tests were used to examine differences by admission service. 251 patients with 292 admissions were included in the analysis. Approximately half (n=134; 46%) were admitted to medical services; there was no difference in age, sex, race, insurance status, or comorbidities between patients admitted to medicine vs. surgery. The most common etiologies were adhesive disease (60%) and hernias (16%). 205 admissions (70%) were managed non-operatively; 113 (55%) were admitted to medical and 92 (45%) were admitted to surgical services. There was no difference in time to bowel function, use of total parenteral nutrition (TPN), 30-day readmission rates, or mortality for patients managed on medical vs. surgical services (Table 1). Non-operative surgical admissions were associated with lower cost despite equivalent hospital length of stay (LOS). 87 admissions (30%) were managed operatively; 21 (24%) were admitted to medical and 66 (76%) were admitted to surgical services. Time from admission to operation was shorter for patients admitted to surgery (median, 0.9 days; IQR, 0.4-3.6) than medicine (median, 4.6 days; IQR 2.2-8.3; p=0.0002); this held true when excluding patients that were operated on within 24 hours of admission (median, 3.7 days vs. 5.0; p=0.08). Operative intervention in patients admitted to medical services was more likely to require a bowel resection (n= 13; 62%) than surgical admissions (n=18; 27%; p=0.004). Major complications and mortality were also more frequent in medical (n=8; 42%) than surgical admissions (n=7; 15%; p= 0.02). Surgical admissions were associated with shorter hospital and post-operative LOS, less TPN use, lower mortality, and lower cost (Table 2). Patients admitted with SBO were managed more efficiently when admitted to surgical services regardless of whether surgical interventionwas required. Furthermore, patients admitted to themedical service that required surgical intervention had worse outcomes. These data support routine admission to surgical services for patients presenting with SBO. Table 1. Outcomes of Non-Operative Management by Admit Service

Objective: To assess the safety, tolerability and efficacy of armodafinil therapy for hypersomnia associated with dementia with Lewy bodies (DLB). Background Recent analyses have demonstrated hypersomnia is often associated with DLB, but no data has been gathered on the safety, tolerability and efficacy of wake-promoting agents for hypersomnia in DLB. Design/Methods: We conducted an open-label pilot study using armodafinil 250 mg taken orally every morning in patients with hypersomnia associated with DLB. Subjects underwent assessment of cognition (Mini-Mental State Exam-MMSE), visual hallucinations (NPI-VH), apathy (NPI-A), daytime sleepiness (Epworth Sleepiness Scale-ESS), and quality of life (QOL) at baseline and after 1, 2, and 3 months of therapy. The Maintenance of Wakefulness Test (MWT) was also conducted at baseline and at 3 months, in which the mean initial sleep latencies (ISL) across 4 naps were analyzed. Safety and tolerability were assessed by clinical evaluations, laboratory studies and electrocardiogram (ECG). Results: Fifteen subjects (12 male, median age 74 years, range 67-84 years) have completed most or all the 3 month protocol thus far, with 1 discontinuing near completion due to worsening disease and 1 expiring from community-acquired pneumonia. Of the 13 subjects with baseline and 3 month MWTs, 11 subjects improved (median value 11 minutes, range 1-22 minutes). Improvement on the ESS occurred in 14 subjects (median 6 points, range 1-15). MMSE scores were relatively stable (+/- 4 points) compared to baseline except for a 6 point improvement in 1 subject. Scores improved on the NPI-VH in 6 and on the NPI-A in 10. QOL was rated as improved in 7 subjects and in 7 caregivers. No clinically significant side-effects, laboratory abnormalities, or ECG abnormalities occurred except for prolongation of the QTc interval in 1 subject. Conclusions: These pilot data suggest reasonable safety, tolerability and efficacy of armodafinil therapy in hypersomnolent DLB subjects. Supported by: Funded by Cephalon, Inc. Disclosure: Dr. Kuntz has received research support from Cephalon, Inc. Dr. Boeve has nothing to disclose. Dr. Drubach has received research support from Allon Therapeutics. Dr. Allen has nothing to disclose. Dr. Drubach has received research support from Allon Therapeutics.