How adolescents decide on bariatric surgery: an interpretative phenomenological analysis.

The National Institute of Clinical Excellence states that bariatric surgery may be considered for adolescents with severe obesity in 'exceptional circumstances'. However, it is not clear what is deemed to be exceptional, and there is a lack of long-term outcomes data or research, which would inform patient selection. This is an in-depth qualitative study involving five adolescents who had previously undergone bariatric surgery (between 1 and 3 years postoperatively) and four who were being assessed for the treatment. All patients were from one tertiary NHS weight management service offering bariatric surgery to adolescents. Participants were interviewed to explore how young people decide whether bariatric surgery is an appropriate intervention for them. Of the nine adolescents recruited, four were male and five female, aged between 17 and 20 years at the time of interview. Participants who had already undergone surgery did so between the ages of 16 and 18. The data were analysed using interpretative phenomenological analysis, and key themes were identified, such as (i) wanting a different future, (ii) experiences of uncertainty, (iii) managing the dilemmas and (iv) surgery as the last resort. The findings suggest that young people are prepared to accept a surgical solution for obesity despite numerous dilemmas. Young people choose this intervention as a way of 'normalizing' when they perceive there is nothing better available. It is argued that these findings may have implications for the counselling of young people living with overweight and obesity and for government policy.

Systematic review of psychological and social outcomes of adolescents undergoing bariatric surgery, and predictors of success.

The psychological and social outcomes of bariatric surgery in adolescents, together with psychological and social predictors of success, were systematically reviewed. PubMed, EMBASE, ISI Web of Science and PsychInfo were searched on July 2014. Existing data were sparse; 15 were suitable for qualitative review and six for meta-analysis (four quality of life [QOL], two depression). One study was a randomized controlled trial. A total of 139 subjects underwent Roux-en-Y gastric bypass, 202 underwent adjustable gastric band and 64 underwent sleeve gastrectomy. Overall QOL improved after bariatric surgery, regardless of surgical type with peak improvement at 6-12 months. Meta-analysis of four studies showed changed in overall QOL at latest follow-up of 2.80 standard deviation (SD) (95% confidence interval [CI] 1.23-4.37). Depression improved across all studies, regardless of procedure (effect size -0.47 SD [95% CI -0.76, -0.18] at 4-6 months). Two cohorts reported changes in both overall QOL and depression following a quadratic trajectory, with overall improvement over 2 years and deterioration in the second post-operative year. There were limited data on other psychological and social outcomes. There were insufficient data on psychosocial predictors of outcome to form evidence-based recommendations for patient selection for bariatric surgery at this time.

'For the cases we've had I don't think anybody has had enormous confidence'--exploring 'uncertainty' in adolescent bariatric teams: an interpretative phenomenological analysis.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Bariatric surgery is more effective for weight loss in severe obesity than lifestyle interventions. The number of bariatric surgery procedures carried out in England in adults has almost doubled between 2008 and 2011. Bariatric surgery is increasingly being offered to adolescents with severe obesity. WHAT THIS STUDY ADDS: A predominant theme of 'uncertainty' around adolescent bariatric surgery emerged from the interviews. In the absence of empirical data, professionals bracket away this uncertainty by a variety of means, including the acceptance of surgery as inevitable. This study has implications for the effective counselling of adolescents and their families around bariatric surgery. Evidence suggests that bariatric surgery is increasingly being offered to adolescents with severe obesity despite the lack of long-term outcome data or research to guide patient selection. This is a qualitative study in which nine clinicians were interviewed to investigate the process of decision-making around adolescent bariatric surgery. The interviews revealed a pervasive 'uncertainty', with sources of uncertainty relating to (i) the lack of research in this area, (ii) the perception of bariatric surgery as a treatment option unlike others, (iii) the view that adolescence is a complex developmental period and (iv) the perception that bariatric in adolescents is controversial to the public. Professionals manage this uncertainty in a variety of ways, which are described. It is argued here that shedding light on this process of professional decision-making has implications for policy and practice and for the counselling of patients considering these sorts of treatments.

Cause of death and clinical grading criteria in a cohort of amyotrophic lateral sclerosis cases undergoing autopsy from the Scottish Motor Neurone Disease Register.

BACKGROUND: The Scottish Motor Neurone Disease Register is a population based register of amyotrophic lateral sclerosis/motor neurone disease (ALS/MND) in Scotland, with high case ascertainment levels. OBJECTIVE: To investigate the cause of death by autopsy and assess grading criteria in a cohort of cases of ALS from the Scottish MND Register. METHODS: The records of 44 patients undergoing autopsy were reviewed to determine the cause of death, clinical assessment (El Escorial and modified World Federation of Neurology criteria) during life and neuropathological autopsy findings. RESULTS: In a cohort of 44 cases undergoing autopsy between 1989 and 1998, the cause of death could be directly or indirectly (bronchopneumonia, aspiration/pneumonia and respiratory failure) attributed to MND in 32/44 (73%) cases. The clinical diagnosis of MND was confirmed at autopsy in 44/44 (100%) cases, 3/44 (7%) cases showed coexistent neurodegenerative disease and 5/44 (11%) were familial MND cases. CONCLUSIONS: Within our cohort, MND contributes to death in the majority of cases and there is excellent clinicopathological correlation, irrespective of the clinical grading criteria used. However, the autopsy rate is low (4%) and further larger studies are required to identify heterogeneity within the disease.

Unexpected decline in survival from amyotrophic lateral sclerosis/motor neurone disease.

OBJECTIVES: To describe survival of 1226 Scottish adults with amyotrophic lateral sclerosis/motor neurone disease (ALS/MND). METHODS: Ten year, prospective, population based disease register. Cox time dependent proportional hazards modelling for multivariate survival analyses. RESULTS: Median survival from onset was 25 months (interquartile range 16-34 months). In multivariate models we found an increased hazard with more recently diagnosed cases-that is, there was an unexpected decline in survival over the 10 year period (hazard ratio (HR) 1.06 (95% CI 1.04 to 1.09). Positive effects on survival were demonstrated for longer time from onset to diagnosis (HR 0.38 (95% CI 0.33 to 0.42), assessment by a neurological specialist (HR 0.56 (95% CI 0.40 to 0.77), and treatment with riluzole (HR 0.24 (95% CI 0.14 to 0.42). Poor prognosis was associated with bulbar onset (HR 1.25 (95% CI 1.09 to 1.46) and a mixed lower and upper motor neurone syndrome (HR 1.23 (95% CI 1.01-1.49) and increasing age. CONCLUSIONS: We found an unexpected decline in survival over the 10 year period, despite controlling for potential confounding variables. We would be cautious about over-interpreting these observations and suggest that further research is required to confirm or refute these findings.

Are the El Escorial and Revised El Escorial criteria for ALS reproducible? A study of inter-observer agreement.

INTRODUCTION: For accurate diagnosis, inter-observer agreement of criteria is important. METHODS: Using case records, the reproducibility of the original and revised El Escorial diagnostic criteria for amyotrophic lateral sclerosis were tested in a consecutive series of people referred to the Scottish Motor Neuron Disease Register. RESULTS: Agreement between independent observers was similar (weighted kappa: 0.783, 95% CI 0.656 to 0.911 (original criteria), 0.681, 95% CI 0.485 to 0.878 (revised)). CONCLUSIONS: Serious errors are unlikely, but the revised criteria may be less reproducible as they include more diagnostic categories. Revisions of diagnostic criteria should be tested for reproducibility and validity prior to widespread adoption.

Molecular genetic analysis of the APEX nuclease gene in amyotrophic lateral sclerosis.

We analyzed genomic DNA from ALS patients for mutations in the apurinic/apyrimidinic endonuclease (APEX nuclease) gene. We identified three rare polymorphisms in the untranslated region of the gene and one common two-allele polymorphism (D148E). The allelic frequency D148E was significantly different in sporadic ALS patients compared with controls. A conserved amino acid change and a 4-base pair deletion were also identified in sporadic ALS patients. These data suggest that APEX nuclease may contribute to the etiology of ALS.