Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes.

Aims: The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations. Patients and Methods: A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction. Results: Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001). Conclusion: Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468-74.

Beliefs and expectations regarding etiology, treatment and outcome in bulimia nervosa.

OBJECTIVE: To examine pretreatment client beliefs and expectations about the causes of bulimia nervosa (BN), and helpfulness of treatment. The association between outcome expectations, pretreatment characteristics, and treatment outcome was also tested. METHOD: 76 BN clients completed a questionnaire assessing beliefs and expectations before participating in a randomized treatment trial. RESULTS: Clients attributed their BN to problems of dysphoria, low self-esteem, perfectionism, and weight preoccupation. They also anticipated a wide array of therapeutic modalities to be helpful, and expected to make changes within 7 weeks of treatment. Surprisingly, outcome expectations were not related to treatment response. Clients who were identified as treatment optimists were more likely to be older, have a longer duration of illness, and greater pretreatment depression and BN symptomatology. DISCUSSION: These results are discussed in the context of the transtheoretical model, suggesting that veteran BN clients who experience greater complications are less ambivalent and more hopeful about change.

Comparisons of men with full or partial eating disorders, men without eating disorders, and women with eating disorders in the community.

OBJECTIVE: The authors compared 62 men who met all or most of the DSM-III-R criteria for eating disorders with 212 women who had similar eating disorders and 3,769 men who had no eating disorders on a wide variety of clinical and historical variables. METHOD: The groups of subjects were derived from a community epidemiologic survey performed in the province of Ontario that used the World Health Organization's Composite International Diagnostic Interview. RESULTS: Men with eating disorders were very similar to women with eating disorders on most variables. Men with eating disorders showed higher rates of psychiatric comorbidity and more psychosocial morbidity than men without eating disorders. CONCLUSIONS: These results confirm the clinical similarities between men with eating disorders and women with eating disorders. They also reveal that both groups suffer similar psychosocial morbidity. Men with eating disorders show a wide range of differences from men without eating disorders; the extent to which these differences are effects of the illness or possible risk factors for the occurrence of these illnesses in men is not clear.

Pilot study of televideo psychiatric assessments in an underserviced community.

OBJECTIVE: The goal of this study was to evaluate patient and physician acceptance of televideo interviews for general psychiatric assessments. METHOD: DSM-III-R diagnoses for axes I and II were made for 40 patients by using the Structured Clinical Interview for DSM-III-R. The patients were then randomly assigned to face-to-face or televideo interviews for general psychiatric assessments conducted by psychiatrists. After each interview the patient and psychiatrist completed measures evaluating perceived rapport and level of satisfaction with the interview. RESULTS: The patients gave high ratings to both satisfaction and ability to develop rapport for both the televideo and face-to-face interviews. The psychiatrists expressed significantly less satisfaction with the televideo interviews, but their actual ratings were positive. CONCLUSIONS: Despite geographic distance, televideo interviews allow a sense of connection between patient and psychiatrist. Lower-cost technology may increase the use of televideo to extend psychiatric service to geographically isolated communities.

A randomized controlled trial of fluoxetine and cognitive behavioral therapy for bulimia nervosa: short-term outcome.

This study compared and combined fluoxetine and individual cognitive behavioral therapy in the treatment of bulimia nervosa. Participants were 76 women who sought treatment at the Eating Disorders Program of the Toronto Hospital and who met DSM-III-R criteria for bulimia nervosa. Subjects were randomly assigned to receive fluoxetine alone, cognitive behavior therapy alone, or the two in combination and were treated over 16 weeks. Short-term outcome revealed that all three treatment conditions were associated with clinical improvement across a wide range of parameters. The combination of pharmacotherapy and psychotherapy was superior to pharmacotherapy alone on specific parameters and there was no statistically significant advantage to the combination over psychotherapy alone. Limitations to the study include the absence of a placebo pill group and a waiting list control group as well as a substantial dropout rate across all three treatment conditions.

The early Canadian history of anorexia nervosa.

OBJECTIVE: To examine several early Canadian descriptions of anorexia nervosa (AN) in light of modern understanding of the disorder. METHOD: Two clinical reports of AN from the late 19th century and early 20th century in Canada are cited and summarized. These original case descriptions are then compared with late 20th century knowledge of the disorder. RESULTS: Both of these early descriptions contain many astute and prescient observations on the etiology and sequelae of AN and reveal a compassionate approach to patient care. CONCLUSIONS: Canadian contributions to the medical literature on AN prior to 1970 merit both careful scrutiny and appreciation in the world literature on this disorder.

Rediscovering general psychiatry: creation of an academic division.

OBJECTIVE: To describe the rationale, origins, and goals of a newly created academic division of general psychiatry within a university setting. METHOD: Literature review, observation, and description. RESULTS: Within 2 years of its inception, the General Psychiatry Division of the University of Toronto has begun to realize some of its goals and further elucidate specific objectives. CONCLUSIONS: In an era of increasing academic subspecialization, the preservation of core skills in psychiatry and the recognition of the continuing public need for psychiatric generalists must be enshrined within academic training programs.

Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa.

OBJECTIVES: This study was undertaken to determine whether the increased cerebrospinal fluid (CSF) volumes found in anorexia nervosa (AN) are the result of differences in gray matter or white matter volumes or both. METHODS: Thirteen adolescent girls with AN who were receiving inpatient care at a tertiary-care university children's hospital and eight healthy female control subjects were studied by using magnetic resonance imaging. Images were processed by means of software developed to classify all pixels as either CSF, gray matter, or white matter. Pixels of each class were then summed across all sections. RESULTS: The AN group had larger total CSF volumes in association with deficits in both total gray matter and total white matter volumes. Lowest reported body mass index was inversely correlated with total CSF volume and positively correlated with total gray matter volume. Urinary free cortisol levels were positively correlated with total CSF volume and inversely correlated with central gray matter volume. CONCLUSIONS: These findings add support to the view that the brain abnormalities found in AN are in large part the result of the effects of the illness. The extent to which these differences in gray matter and white matter volumes are reversible with recovery remains to be established.

Purging and nonpurging forms of bulimia nervosa in a community sample.

OBJECTIVE: Recent consensus on the subclassification of the eating disorder bulimia nervosa into purging and nonpurging forms is examined in the context of a large psychiatric epidemiological survey in Ontario, Canada. METHOD: Among a sample of 8,116 individuals, 62 met criteria for bulimia nervosa. Of these, the 17 who were of the purging subtype could be distinguished from the nonpurging group on a variety of parameters of comorbidity, family history, and childhood environment. RESULTS: The purging subtype was distinguishable on the basis of early age of onset, and high rates of affective disorders and anxiety and alcoholism, sexual abuse, and parental discord. DISCUSSION: The data support the taxonomy and point to the need for better understanding of the meaning of purging behavior.

Psychiatric practice for the coming decade.

OBJECTIVE: To identify important trends and themes that will affect psychiatric training and practice. METHOD: Selective literature review and reflections by the authors. RESULTS: Three principal themes are elucidated relating to empiricism and integration, accountability and collaboration, and training and the public trust. CONCLUSIONS: There must be debate and action on these and other themes to maintain the relevance of psychiatry to its changing context.

Should amenorrhoea be necessary for the diagnosis of anorexia nervosa? Evidence from a Canadian community sample.

BACKGROUND: This study compares the characteristics of women with anorexia nervosa with those of women who have all the diagnostic features of that disorder except amenorrhoea. METHOD: The study uses data from a large community epidemiological survey of the mental health status of household residents in Ontario, Canada. A multi-stage stratified sampling design generated a sample of 4285 females aged 15-64. DSM-III-R diagnoses were made using the Composite International Diagnostic interview. RESULTS: Eighty-four out of 4285 female respondents met full or partial-syndrome criteria for anorexia nervosa. Comparison of these two groups revealed few statistically significant differences in terms of demographics, psychiatric comorbidity, family history or early experiences. CONCLUSIONS: Amenorrhoea did not discriminate between women with anorexia nervosa and women with all the features except amenorrhoea across a number of relevant variables. The authors question the utility of amenorrhoea as a diagnostic criterion.

The hormonal response to intravenous 5-hydroxytryptophan in bulimia nervosa.

In recent years evidence has accumulated to implicate a disturbance in serotonin function in the eating disorder bulimia nervosa. This study employs a neuroendocrine technique to assess the effect of intravenous 5-hydroxytryptophan, the immediate precursor to serotonin, on peripheral hormones in bulimia nervosa subjects and controls. Blunted prolactin and growth hormone responses were observed among bulimia nervosa subjects; the possible pathophysiology and implications of the findings are discussed.

Bulimia nervosa in a Canadian community sample: prevalence and comparison of subgroups.

OBJECTIVE: Previous epidemiological studies of bulimia nervosa have generated differing estimates of the incidence and prevalence of the disorder. These differences are attributable, in part, to varying definitions of the illness and a range of methodologies. The authors sought to define the prevalence of bulimia nervosa in a nonclinical community sample, examine the clinical significance of DSM-III-R threshold criteria, and examine comorbidity. METHOD: Subjects across Ontario (N = 8,116) were assessed with a structured interview, the World Health Organization Composite International Diagnostic Interview, with specific questions added for bulimia nervosa. Subjects who met DSM-III-R criteria for bulimia nervosa were compared with those who were missing only the frequency criterion (two or more binge-eating episodes per week for 3 months). RESULTS: In this sample, the lifetime prevalence of bulimia nervosa was 1.1% for female subjects and 0.1% for male subjects. The subjects with full- and partial-syndrome bulimia nervosa showed significant vulnerability for mood and anxiety disorders. Lifetime rates of alcohol dependence were high in the full-syndrome group. Rates of parental psychopathologies were high in both bulimic groups but tended to be higher in the subjects with full-syndrome bulimia nervosa. Both bulimic groups were significantly more likely to experience childhood sexual abuse than a normal female comparison group. CONCLUSIONS: This study confirms other prevalence estimates of bulimia nervosa and its comorbid diagnoses from studies that were based on sound methodologies. It also points to the arbitrary aspects of the frequency of binge eating as a diagnostic threshold criterion for the disorder.

Correlations of plasma and urinary phenylacetic acid and phenylethylamine concentrations with eating behavior and mood rating scores in brofaromine-treated women with bulimia nervosa.

Women with bulimia nervosa undergoing treatment with the reversible monoamine oxidase type A inhibitor, brofaromine, were rated for mood and eating behaviour and their plasma and urine were assessed for phenylacetic acid (unconjugated and total) and unconjugated phenylethylamine prior to and after four weeks of drug treatment. Changes in plasma unconjugated phenylacetic acid concentrations were significantly and negatively correlated with the corresponding changes in Hamilton Depression scores but not with eating behavior measures. There were no significant correlations between changes in phenylethylamine levels and changes in rating scores. Patients diagnosed as suffering concurrently from severe depression (Hamilton Depression score of 17 or higher) had lower plasma and urinary phenylacetic acid levels than did those whose depression was not severe (Hamilton score less than 17). Phenylethylamine concentrations were not different between the severely and mildly depressed subgroups. The results confirm earlier studies on the relationship between phenylacetic acid and depression while showing that a similar relationship does not pertain to phenylacetic acid and eating behavior in bulimia nervosa.