Mental health in adolescents with obesity: conflicting views among physicians, a qualitative study.

Mental health issues in adolescents with obesity are multifold, with no explicit screening recommendations. The aim of this research is to explore how this screening is performed by physicians and, thus, how it impacts adolescents' care pathways, offering insights into how to improve it through a qualitative study using interpretative phenomenological analysis. Twenty physicians (non-psychiatrist physicians and child and adolescent psychiatrists) involved at various stages in the care pathway were interviewed with semi-structured questionnaires. The findings connect 2 meta-themes. Non-psychiatrist physicians perceive widespread but ill-defined suffering in adolescents with obesity. Non-psychiatrist physicians see screening for mental conditions as mandatory. Unlike child and adolescent psychiatrists, they are not experts in distinguishing psychosocial suffering from psychiatric disorders. Screening is clinical. Adolescents' demand to lose weight in a context of shaming and alexithymia limits their access to psychiatric care. Child and adolescent psychiatrists then redefine the medical response to polymorphous symptoms. Psychiatric diagnoses mainly involve anxiety and depression symptoms, seldom eating disorders.    Conclusion: Physicians have overtly conflicting perspectives over the intensity of mental conditions. Non-psychiatrists, sensitive to perceived distress, seek to have it quickly appraised if they detect a significant suffering. Child and adolescent psychiatrists find appraisal complex to perform in the absence of means, interest, and/or experience. Improving screening requires training health professionals and using multidisciplinary assessment means. What is Known: • Mental health and eating disorders are contributing factors of obesity but their relationship remains complex between cause and consequence. • Mental health conditions and psychosocial suffering are the main complications among adolescents suffering from obesity with guilt, sadness, or stigma. What is New: • Non-psychiatric physicians express their need of a specialized diagnosis to define this suffering, but the lack of availability of psychiatrists and the necessity of time and of a multidisciplinary team lead to a delayed assessment. • For psychiatrists, this suffering is often not a psychiatric condition. Though requiring attention, this can lead to a misunderstanding between professionals.

["Somatic symptom disorders" in adolescence. A systematic review of the recent literature]. / « Troubles à symptomatologie somatique ¼ chez les adolescents. Une revue systématique.

OBJECTIVES: Body expression of mental disorders is common in adolescence. Only two literature reviews over the last five years have been identified about somatoform disorders in children., The present article provides a systematic review of articles in English, which concern "Somatic Symptom and Related Disorders" according to the DSM-5 (Diagnostic and Statistical Manual - 5th Edition) among adolescents. METHODS: The article search was made on Medline, Psychinfo, Google Scholar, BiomedCentral, Central and tripdatabase (for grey literature) according to PRISMA criteria and with the items "somatoform disorders" or "somatic symptom disorders". An age filter was applied for "adolescents", and a selection was done from the last five years. All articles concerning adolescents (often associated with children) were initially included, except for articles concerning eating disorders, dysmorphic disorders or adult population. Comments, editorials, opinion or descriptive articles were also excluded. The authors then carried out an analysis of the main topics, themes and questions covered in the selected publications and presented a descriptive synthesis. RESULTS: A total of seventy-seven publications were included in the analysis, from three hundred and seventy-two publications. First, the terms used to refer to these "somatic symptom disorders" were varied, such as "somatization", "somatic complaints/symptoms", "functional disorder", "unexplained symptoms" and "somatoform disorders". Then, studies related just to adolescents were limited: most of studies included children and adolescents in their methodologies; and some of them questioned somatic symptoms from a developmental perspective. Case reports were the most represented articles among all medical specialties, with clinical descriptions about "functional neurological symptom disorder", "factitious disorder" and "somatic symptom disorder" with a medical disease, among children and adolescents. We sometimes observed a controversial borderline between psychological and somatic disorders. Various explanatory models appeared, especially the trauma path; familial and social environment was also pointed out, with a possible peer group effect; neurocognitive theories were finally described. The literature highlights the effectiveness of psychosocial therapies (especially the cognitive-behavioral therapy) and the importance of multidisciplinary management. Finally, a few studies with a qualitative methodology are represented. CONCLUSIONS: Only nine articles included "somatic symptom disorder" in their titles, despite a terminology valued by many authors (compared to "somatoform disorders" from the DSM-IV). The heterogeneity of terminologies, case reports and explanatory models witness a lack of connexions between medical specialties. This could explain in part the wandering of adolescents and their families in the health care system. It could also contribute to the delay before diagnosis, especially when neurological symptoms exist, and a late referral for psychiatric consultation. Further studies are needed to understand difficulties to use a clinical pathway among medical specialties, when the benefit of amultidisciplinary approach seems to be unanimous.

Checklist for follow-up of adolescents with chronic illness. A monitoring tool to help prepare the transition from pediatric to adult care.

Adolescence can be a particularly challenging period for individuals with a chronic illness. To help the specialized healthcare teams, an expert panel drafted a checklist of topics to be addressed throughout adolescence that are often not covered in subspecialty clinic visits such as peers, coping, adherence, understanding of illness, sexuality, etc., since these topics apply to youth with special healthcare needs. Each member of the specialized team can discuss one of the themes according to their role with the adolescent as a doctor, educator, nurse, dietician, etc. The coherence of the team enables a comprehensive approach and will facilitate the transition to adult medical care.

Research in adolescent healthcare: The value of qualitative methods.

BACKGROUND: The vast majority of publications about adolescent healthcare use a quantitative methodology that often involves long and expensive research protocols with results that do not always provide answers adequate to the complexity of the questions being asked. The qualitative method is sometimes a more effective alternative for exploring some of these. This method can be defined from its objective, which is to generate theoretical hypotheses, its mandatory consideration of the researcher's subjectivity, and the importance it ascribes to the context of the participants' experience. Among the many techniques of qualitative research, the use of phenomenological methods, in particular, interpretative phenomenological analysis (IPA), is highly developed in medical research. OBJECTIVES: To define the qualitative method and describe the principal stages of a phenomenological qualitative study. RESULTS: The three stages of a qualitative study are data collection (population and sampling, data collection methods), data analysis, and writing up the results. Purposive sampling makes it possible to include participants who can describe in detail, and as experts, their experience during semi-structured interviews. The analysis takes place in two stages, the first very descriptive, the second more interpretative. The results are written-up in a narrative form, including both direct quotations from the interviews and the researchers' interpretation. DISCUSSION: The issues of health promotion and healthcare associated with the management of chronic symptoms or diseases in adolescents involve an extremely rich and complex context. Qualitative methods make it possible to approach these questions and to understand them better by generating hypotheses from a rigorous scientific procedure appropriate to the context and objectives. In addition to being used on their own, they can be used on an exploratory basis early in a quantitative study to help define it better, for explanatory purposes, to help understand complex quantitative results, or combined with a quantitative study. The qualitative and quantitative results will then be integrated.

A platform for x-ray Thomson scattering measurements of radiation hydrodynamics experiments on the NIF.

We present an experimental design for a radiation hydrodynamics experiment at the National Ignition Facility that measures the electron temperature of a shocked region using the x-ray Thomson scattering technique. Previous National Ignition Facility experiments indicate a reduction in Rayleigh-Taylor instability growth due to high energy fluxes, compared to the shocked energy flux, from radiation and electron heat conduction. In order to better quantify the effects of these energy fluxes, we modified the previous experiment to allow for non-collective x-ray Thomson scattering to measure the electron temperature. Photometric calculations combined with synthetic scattering spectra demonstrate an estimated noise.

A qualitative exploration of the work of embodiment in adolescent girls with obesity.

Social representations generally associate obesity, especially in adolescent girls, with sedentariness, lack of self-control and laziness. These girls thus have substantial problems of self-esteem. Dietary, lifestyle and behavioural approaches alone cannot address this issue, for they do not apprehend all of the complexity of obesity. This qualitative study is based on a dual observation: that the work performed by adolescents is unrecognized and that the body is not considered as a subject of analysis. It raises the question of the corporality of these teens through an original perspective: that of the perspective of their organization of actions on, to and by the body, in specific situations. The objective is to have access to the corporal experience of young girls with obesity, so that we can understand and support them better. The data come from semi-directive interviews with 10 adolescent girls with obesity. The content was analysed in terms of concepts of professional didactics (a branch of educational psychology) and enaction. Five situations were identified from these interviews: the first, shopping with friends, concerns actions by the subjects towards their bodies; the other four are enacted actions: conduct towards a normal-weight person, conduct in public transportation, performing physical activity, and eating. The results show the work of these young women with obesity, the means they mobilize to live in their bodies and their considerable efforts of embodiment. Recognition of this work should help to enhance their self-esteem. Treatment and support may take this dimension of work into account and help them to become aware of the efforts they make every day.

Demonstration of x-ray fluorescence imaging of a high-energy-density plasma.

Experiments at the Trident Laser Facility have successfully demonstrated the use of x-ray fluorescence imaging (XRFI) to diagnose shocked carbonized resorcinol formaldehyde (CRF) foams doped with Ti. One laser beam created a shock wave in the doped foam. A second laser beam produced a flux of vanadium He-α x-rays, which in turn induced Ti K-shell fluorescence within the foam. Spectrally resolved 1D imaging of the x-ray fluorescence provided shock location and compression measurements. Additionally, experiments using a collimator demonstrated that one can probe specific regions within a target. These results show that XRFI is a capable alternative to path-integrated measurements for diagnosing hydrodynamic experiments at high energy density.

Qualitative studies among obese children and adolescents: a systematic review of the literature.

Childhood obesity is a complex condition involving medical, social, moral and cultural issues. Qualitative approaches are of great value in understanding this complexity. This meta-synthesis of 45 qualitative studies deals specifically with the issue of obesity in children and adolescents from different perspectives--those of obese children and adolescents, of parents, and of health professionals providing support to the family. Our aim was to obtain a coherent view of child and adolescent obesity, focused on clinical and personal experience. The themes derived from the synthesis process fall under three main axes: 'Seeing others, seeing oneself', 'Understanding others, understanding oneself', and 'Treating others, treating oneself'. It emerges that participants in all three groups had equal difficulty in perceiving and labelling obesity, mainly because of their lack of any real common ground. The insufficiency of shared representations destabilizes the therapeutic relationship and its construction: an important issue in the doctor-child-parent relationship in this context is the need to exchange their viewpoints of obesity. Health workers may also expand their understanding of obesity by incorporating the personal experiences of obese children and their parents in order to match treatment plans to their needs and expectations.

[Initial descriptive analysis of 200 obese adolescents in an adolescent care unit]. / Qui sont les adolescents consultant pour demande de prise en charge d'une obésité dans une Maison des adolescents ? Phénotypes d'une cohorte de 200 patients.

Common obesity is a frequent reason for outpatient visits to adolescent clinics. Its high risk of persistence or progression into adulthood is well known. This article is a study of 200 clinical charts of obese adolescents that visited our clinic. The physical, metabolic, psychological, and social characteristics of these patients when they first started their follow-up are described. Body image disturbance and the everyday psychosocial impact of obesity were the most frequent reasons for the first visit. Two-thirds of the adolescent girls had already had unsuccessful follow-ups by other teams or doctors. The average age was 14.5 years and the average body mass index z-score was above 7.4. They suffered from musculoskeletal or respiratory disorders but had few metabolic complications at that stage. Various personal or family psychological and social characteristics were frequently observed as well as certain types of eating disorders. This data may be useful in establishing different profiles that could be used to adapt obese patient care for adolescents.

[Nonalcoholic fatty liver disease in a severely obese adolescent. An arguable liver biopsy]. / Stéatohépatite non alcoolique chez une adolescente obèse: une biopsie hépatique discutable.

The growing epidemic of juvenile obesity has prompted pediatricians to investigate obesity-related conditions in obese teenagers. We report a clinical case of severe hepatic fibrosis in an adolescent with severe and recent obesity. Because of elevated serum aminotransferase levels, abnormal hepatic ultrasonography and insulin resistance (impaired glucose tolerance), we suspected nonalcoholic steatohepatitis (NASH). Disease activity and fibrosis were confirmed on liver biopsy. Considering the risk of progression toward cirrhosis and its complications, and the pathological liver lesions, we started long-term medical monitoring and drug therapy to control weight loss. At present, although biopsy is the only validated way to establish the diagnosis of NASH, there is no consensus on its indication when NASH is suspected. Noninvasive strategies are attractive but require validation in children.

[Gender differences in premature mortality and avoidable deaths]. / Disparités de mortalité "prématurée" selon le sexe et causes de décès "évitables"

OBJECTIVE: This paper aims to describe and to analyse disparities between men and women for "premature" mortality rates (deaths before 65 year-old). The study is particularly focused on "avoidable" causes of death. These types of deaths are greatly related to risk behaviours such as alcohol abuse, tobacco abuse or dangerous driving. Taking account of these indicators ("premature" and "avoidable" mortality) enables to study health status discrepancies by gender and to characterize specific public health issues in France including high rates of "premature" mortality and risk behaviours. METHODS: The analysis is based on exhaustive mortality data from 1980 to 1999 supplied by the Centre for epidemiology of medical causes of death (CepiDc-INSERM). Specific causes of death closely related to risk behaviours are classified as "avoidable": lung and upper airways cancers, cirrhosis, alcoholic psychosis, traffic accidents, aids and suicide. The contribution of these categories in the global male overmortality was assessed according to different demographic and geographic characteristics. RESULTS: Within "premature" mortality, males experience greater burden of "avoidable" mortality (sex-ratio: 4 versus 2). The gender differences are mainly due to injuries and suicides in the younger age groups and to tobacco and alcohol-related cancers (lung and upper airways) in the 45-64 years age group. The recent decline in "premature" mortality sex-ratio is explained by an increase of these two cancers for females. Among european countries, the French male overmortality is especially marked and mainly attributable to "avoidable" causes of death. CONCLUSION: "Avoidable" and "premature" mortality provide useful tools for the follow-up of health status in France particularly because of high risk behaviours and prevention inadequacy. Reducing gender discrepancies will depend mainly on public health policies in terms of primary prevention.

[Diagnosis, treatment, and prognosis of lung cancer in the Manche (France) (1997-1999) according to patients socioeconomic characteristics]. / Diagnostic, traitement et pronostic des cancers bronchiques dans le département de la Manche (1997-1999) en fonction du statut socio-économique des malades.

BACKGROUND: In France, data on social environment influence on cancer management and prognosis are rare and no study has been conducted on lung cancer. This study was designed to investigate the associations between place of residence and occupation class, and diagnosis, treatment and prognosis of lung cancer. METHODS: The study population consisted of the 585 cases of lung cancer collected by the cancer registry of the Manche department (France) over a three-year period (1997-1999). Distribution of qualitative variables was tested using chi(2) test. Multivariate analysis were conducted using logistic regressions. Differences in actuarial survival were tested using log-rank test. RESULTS: Difference in diagnostic conditions did not demonstrate any prominence by social characteristics. People living in rural areas did however have a higher probability of therapeutic abstention than people living in urban areas (adjusted odds ratio=2.20 [1.18-4.10]). Similarly, people without any occupational activity had a probability of therapeutic abstention higher than people with an occupational activity (adjusted odds ratio=3.40 [1.99-5.80]). Moreover, occupational class and place of residence had a significant influence on the place of diagnosis and treatment, lower class and rural people being less often managed in university hospitals. Regarding prognosis, our results do not give prominence to difference in survival according to social characteristics. CONCLUSION: This study suggests that the type of center providing patient care and the nature of treatment given could be associated with the socioeconomic status of the patient. Nevertheless, due to the small sample size, further studies in a larger series would be required to make any formal conclusion.

[Influence of social and occupational class and area of residence on management and survival in patients with digestive tract cancer: a population study in the Calvados area (France)]. / Influence du groupe socioprofessionnel et du lieu de résidence sur la prise en charge et la survie des cancers digestifs. Etude en population--département du Calvados.

Several studies have shown socio-economic differences in cancer survival, low socio-economic level being associated with poor prognosis of cancer. The aim of the study was to investigate the influence of social environment on care procedures for treatment in cancer and to determine to what extent well-established socio-economic differences in cancer prognosis can be explained by such an influence. A retrospective analysis was conducted on patients having had a digestive cancer in the department of Calvados (France) between 1978 and 1990 collected by the local digestive cancer registry (1534 males and 1060 females). Jobless male and female farmers visited private specialists and were treated in specialized care centres at a rate two-fold lower than people in higher social classes. However, our results suggest that these variations do not explain all the influence of social environment on cancer survival either in males and females.

Stage of extension and treatment for colorectal cancer after a negative test and among non-responders in mass screening with guaiac faecal occult blood test: a French experience.

Despite its proven efficacy in three randomized trials, the relevance of mass screening for colorectal cancer using the guaiac faecal occult blood test is still debated. The low sensitivity of the test and the poor participation rate, especially in France, are major obstacles to its effectiveness. The aim of our study was to characterize cancers occurring after a negative test and among non-participants in the screening programme organized in the French department of Calvados. Cancers in the negative test group had a later stage of extension than subjects testing positively but an earlier stage of extension than cancers in the reference group, which were not different from those of non-responders. The proportion of resection for non-responders was significantly lower than that for participants, whatever the test result (P < 0.001), and lower than that for reference subjects (P < 0.05). There was no difference in treatment between negative and positive responders. Negative responders did not have a delayed cancer diagnosis or a worse condition of treatment than people who were not screened. Low sensitivity reduced the efficacy of colorectal cancer screening but did not seem to increase the potential to do harm.

Caught in the trio trap? Potential selection bias inherent to association studies using parent-offspring trios.

During the last years, the validity of classic case control studies in psychiatric genetic research has been increasingly under question due to the risk of population stratification problems inherent to this type of association study. By consequence, the application of family-based association studies using parent-offspring trios has been strongly advocated. Recently, however, in a study comparing clinical characteristics between index patients from parent-offspring trios and singleton patients with bipolar affective disorder, the question was raised whether a systematic neglect of case control association studies could lead to a selection bias of susceptibility genes. In a similar approach, we compared demographic and clinical characteristics of 122 singleton bipolar patients with those of 54 bipolar patients derived from parent-offspring trios. The singleton patients did not only present with a higher age of onset, but also with a higher frequency of suicidal behavior and a higher familial loading for suicidality. These findings suggest that the genetic mechanism for disease might be different between trio-based and classic case control samples, where patients are examined whose parents are not available for genetic studies. Thus, giving up case control designs for the sake of family-based association studies could be at the risk of selecting against several genetically determined factors.

Oral insulin administration and residual beta-cell function in recent-onset type 1 diabetes: a multicentre randomised controlled trial. Diabète Insuline Orale group.

BACKGROUND: Oral administration of autoantigens can slow the progression of beta-cell destruction in non-obese diabetic mice. We investigated whether oral administration of recombinant human insulin could protect residual beta-cell function in recent-onset type 1 diabetes. METHODS: We enrolled 131 autoantibody-positive diabetic patients aged 7-40 years within 2 weeks of diagnosis (no ketoacidosis at diagnosis, weight loss <10%, polyuria for <6 weeks). They were randomly assigned 2.5 mg or 7.5 mg oral insulin daily or placebo for 1 year, in addition to subcutaneous insulin therapy. Serum C-peptide concentrations were measured in the fasting state and after stimulation, to assess beta-cell function. Autoantibodies to beta-cell antigens were assayed. Analyses were by intention to treat. FINDINGS: Baseline C-peptide and haemoglobin A1c concentrations were similar in the three groups. During follow-up, there were no differences between the groups assigned 2.5 mg or 7.5 mg oral insulin or placebo in subcutaneous insulin requirements, haemoglobin A1c concentrations, or measurements of fasting (mean at 12 months 0.18 [SD 0.17], 0.17 [0.17], and 0.17 [0.12] nmol/L) or stimulated C-peptide concentrations (glucagon-stimulated 0.39 [0.38], 0.37 [0.39], and 0.33 [0.24] nmol/L; meal-stimulated 0.72 [0.60], 0.49 [0.49], and 0.57 [0.51 nmol/L]. Neither age nor C-peptide concentration at entry influenced treatment effects. No differences were seen in the time-course or titres of antibodies to insulin, glutamic acid decarboxylase, or islet antigen 2. INTERPRETATION: At the doses used in this trial, oral administration of insulin initiated at clinical onset of type 1 diabetes did not prevent the deterioration of beta-cell function.