Aesthetic outcomes after surgical repair of pectus excavatum in females: Differences between patients and professional evaluators.

BACKGROUND: Pectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients' versus medical professionals' evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients' self-perception. METHODS: Of 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared. RESULTS: Patients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients' self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education. CONCLUSIONS: Surgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient's self-perception.

Consolidation of working hours and work-life balance in anaesthesiologists - A cross-sectional national survey.

Currently, healthcare management fosters a maximization of performance despite a relative shortage of specialists. We evaluated anaesthesiologists' workload, physical health, emotional well-being, job satisfaction and working conditions under increased pressure from consolidated working hours. A nationwide cross-sectional survey was performed in Austrian anaesthesiologists (overall response rate 41.0%). Three hundred and ninety four anaesthesiologists (280 specialists, 114 anaesthesiology trainees) participated. Anaesthesiologists reported frequently working under time pressure (95%CI: 65.6-74.6), at high working speed (95%CI: 57.6-67.1), with delayed or cancelled breaks (95%CI: 54.5-64.1), and with frequent overtime (95%CI: 42.6-52.4). Perceived work climate correlated with task conduct (manner of work accomplishment, the way in which tasks were completed), participation (decision-making power in joint consultation and teamwork), psychosocial resources, uncertainty, task variability and time tolerance (authority in time management and control over operating speed) (all P <0.001). Having not enough time for oneself (95%CI: 47.6-57.4), for sleep (95%CI: 45.6-55.4) or for one's partner and children (95%CI: 21.8-30.4) was common. One-third of the participants reported frequent feelings of being unsettled (95%CI: 33.4-43.0) and difficulty talking about their emotions (95%CI: 27.3-36.5). Frequent dissatisfaction with life was reported by 11.4% (95%CI: 8.7-14.9) of the respondents. Strong time pressure and little decision-making authority during work along with long working hours and frequent work interruptions constitute the basis for occupational stress in anaesthesiologists. We conclude that increased pressure to perform during work hours contributes to emotional exhaustion and poor work-life balance. Changes in the work schedule of anaesthesiologists are required to avoid negative effects on health and emotional well-being.

Obesity Management Task Force of the European Association for the Study of Obesity Released "Practical Recommendations for the Post-Bariatric Surgery Medical Management".

Bariatric patients may face specific clinical problems after surgery, and multidisciplinary long-term follow-up is usually provided in specialized centers. However, physicians, obstetricians, dieticians, nurses, clinical pharmacists, midwives, and physical therapists not specifically trained in bariatric medicine may encounter post-bariatric patients with specific problems in their professional activity. This creates a growing need for dissemination of first level knowledge in the management of bariatric patients. Therefore, the Obesity Management Task Force (OMTF) of the European Association for the Study of Obesity (EASO) decided to produce and disseminate a document containing practical recommendations for the management of post-bariatric patients. The list of practical recommendations included in the EASO/OMTF document is reported in this brief communication.

Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management.

Bariatric surgery is today the most effective long-term therapy for the management of patients with severe obesity, and its use is recommended by the relevant guidelines of the management of obesity in adults. Bariatric surgery is in general safe and effective, but it can cause new clinical problems and is associated with specific diagnostic, preventive and therapeutic needs. For clinicians, the acquisition of special knowledge and skills is required in order to deliver appropriate and effective care to the post-bariatric patient. In the present recommendations, the basic notions needed to provide first-level adequate medical care to post-bariatric patients are summarised. Basic information about nutrition, management of co-morbidities, pregnancy, psychological issues as well as weight regain prevention and management is derived from current evidences and existing guidelines. A short list of clinical practical recommendations is included for each item. It remains clear that referral to a bariatric multidisciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations.

[Psychiatric and psychosomatic day hospitals in Austria]. / Psychiatrische und psychosomatische Tageskliniken in Österreich.

This paper on psychiatric and psychosomatic day hospitals in Austria first looks at the overall situation of Austrian day clinics then, in a second step, compares psychiatric and psychosomatic day hospitals. For this purpose, a questionnaire was developed and sent to all psychiatric and psychosomatic day hospitals in Austria. The first part consisted of closed questions and was used to gather and evaluate the categories: general conditions for treatment in day hospitals, tasks of day hospitals, therapeutic paradigms, indication and contraindication, diagnostics, day hospital organisation, interdisciplinary cooperation and the offering in day hospitals. The second section consisted of open questions which were used to gather and evaluate active factors, difficulties, specifics and requests for future treatment in day hospitals. The results show that there is a trend towards more day hospitals. Psychosomatic day hospitals are a rather new phenomenon. Furthermore, the distinction between psychiatric and psychosomatic day hospitals is important in order to offer patients distinguishable treatment options in future. The results show that psychiatric and psychosomatic day hospitals both have a strong focus on psychotherapy and both fulfill the active factors for psychotherapy by Grawe.

[Obesity: stigmatization, discrimination, body image]. / Adipositas: Stigmatisierung, Diskrimination, Körperimage.

Obesity is a heterogeneous condition with multifactorial genesis (genetic predisposition, life-style, psychosocial situation), but there is a relatively homogeneous negative stereotype of obese individuals, because overweight and obesity are seen as self-inflicted disorders caused by physical inactivity and disorderd eating behavior. Obese individuals are confronted with far-reaching stigmatization and discrimination. Typical stereotypes are laziness, unattractiveness, work refusal. This negative image by the environment contributes to negative self-awareness and self-stigmatization, accompanied by a poor self-esteem and feelings of poor self-control and reduced self-efficacy, resulting in poor constructive coping strategies for overweight reduction. In addition, a disturbed body image combined with deep dissatisfaction with their own body is often found in many obese individuals. There is not always a close connection between body weight and body dissatisfaction. Young women and individuals with a binge eating disorder often show an increased body dissatisfaction as well.

Long-term quality-of-life improvement in gastric banding patients from body-contouring surgery.

Following my prior study of long-term results after laparoscopic gastric banding concerning operative outcome and complications involving the gastric band itself, I now focus on long-term quality-of-life improvement in the same study group after body-contouring surgery. As determined from our electronic patient data system, 72 patients from the former study group subsequently sought body-contouring surgery at our hospital after successful weight loss. Patients were enrolled in a telephone interview and asked about their expectations and body image before and after postbariatric aesthetic surgery and how it altered their well-being in addition to the weight loss achieved with the gastric band. All patients undergoing postbariatric aesthetic surgery felt extremely uneasy with the hanging skin resulting from weight reduction. Patients cannot imagine the degree of dissatisfaction they will experience from the sagging skin that comes with weight loss. Hardly any patient expected fewer scars than he ultimately had after body-contouring surgery and reported an extreme improvement in body image. Gastric banding should not be performed without informing patients about the need for postbariatric body-contouring surgery, because most patients not forewarned suffer greatly from their body image after weight loss.

Prevalence of eating disorders in middle-aged women.

OBJECTIVE: Little is known about the prevalence and correlates of eating disorders (ED) in middle-aged women. METHOD: We mailed anonymous questionnaires to 1,500 Austrian women aged 40-60 years, assessing ED (defined by DSM-IV), subthreshold ED, body image, and quality of life. We broadly defined "subthreshold ED" by the presence of either (1) binge eating with loss of control or (2) purging behavior, without requiring any of the other usual DSM-IV criteria for frequency or severity of these symptoms. RESULTS: Of the 715 (48%) responders, 33 [4.6%; 95% confidence interval (CI): 3.3-6.4%] reported symptoms meeting full DSM-IV criteria for an ED [bulimia nervosa = 10; binge eating disorder = 11; eating disorder not otherwise specified (EDNOS) = 12]. None displayed anorexia nervosa. Another 34 women (4.8%; CI: 3.4-6.6%) displayed subthreshold ED. These women showed levels of associated psychopathology virtually equal to the women with full-syndrome diagnoses. DISCUSSION: ED appear common in middle-aged women, with a preponderance of binge eating disorder and EDNOS diagnoses as compared to the "classical" diagnoses of anorexia and bulimia nervosa. Interestingly, middle-aged women with even very broadly defined subthreshold ED showed distress and impairment comparable to women with full-scale ED.

Psychosocial state after bariatric surgery is associated with the serotonin-transporter promoter polymorphism.

BACKGROUND: Bariatric surgery is the method of choice in the treatment of morbid obesity. Different genotypes of the serotonin transporter gene (5-HTT) are known to impact the prevalence of psychiatric disorders and the psychosocial state in obese individuals. In this study, we examined the influence of the 5-HTTLPR polymorphism on physiologic and psychosocial measures in morbidly obese women after bariatric surgery. METHODS: We investigated women 1-5 years after bariatric surgery using a semi-structured interview and the Beck Depression Inventory, the Moorhead-Ardelt Quality of life questionnaire, the NEO-Five Factor Inventory and a Resilience scale. The 5-HTTLPR polymorphism (s/s, s/l, l/l) was genotyped using mouth swabs. The influence of genotype on outcome variables was analyzed by independent t test and analysis of covariance corrected for possible confounders. RESULTS: 64 women were enrolled in this study between January 2004 and September 2009. Significantly lower quality of life and higher depression, neuroticism and resilience scores were found in homozygous s-allele carriers of the 5-HTTLPR polymorphism than in l-allele carriers. Except for neuroticism, other factors (age, education, year of surgery, weight before surgery and method of surgery) did not affect the results. We found no influence of genotype on weight loss, current weight or weight before surgery. CONCLUSION: Quality of life, mood, and resilience but not weight loss after bariatric surgery are negatively influenced by the s-allele of the 5-HTTLPR polymorphism.

The menopausal transition--a possible window of vulnerability for eating pathology.

OBJECTIVE: No published studies, to our knowledge, have examined the association of menopausal status with eating disorders and body image in women. We assessed these associations in a large sample of middle-aged women. METHOD: We administered an anonymous questionnaire to a randomly selected nonclinical sample of women aged 40-60 in Innsbruck, Austria. The questionnaire covered demographic items, menopausal status, weight history, measures of body image, and current eating disorders as diagnosed by DSM-IV criteria. Using modified WHO criteria, we classified the respondents' current stage of menopausal transition as premenopausal (N = 192), perimenopausal (N = 110), or naturally postmenopausal (N = 134). In a separate analysis, we also examined the small group of women with surgically induced menopause (N = 12). RESULTS: The three groups were similar in all demographic features except age, and did not differ significantly on current body mass index (BMI), weight-control behaviors, or dieting history after age adjustment. However, perimenopausal women reported a significantly greater prevalence of eating disorders as compared to premenopausal women. Perimenopausal women also reported significantly higher self-ratings of "feeling fat" and higher Body Shape Questionnaire scores than premenopausal women. Women with surgically induced menopause also showed an elevated prevalence of eating and body image pathology. DISCUSSION: Our data suggest that the menopausal transition is associated with an increased prevalence of eating disorders and negative body image. Menopause, like puberty, may perhaps represent a window of vulnerability to these conditions, likely because of changes in hormonal function, body composition, and conceptions of womanhood.

The impact of abdominoplasty after massive weight loss: a qualitative study.

A sharp increase in bariatric surgery has resulted in a spike in the population of patients seeking plastic surgery after massive weight loss. This study was undertaken to determine how patients experience plastic surgical removal of an overlap flap and how they benefit from the surgery. A content analysis of interviews with 10 patients who underwent abdominoplasty was carried out approximately 12 months after the procedure. All interviews were audio-taped, transcribed, and analyzed using inductive reasoning. The data were then organized into categories that reflected emerging themes. All patients reported benefits in areas such as mental health, quality of life, or body image. Plastic surgery after weight loss improves psychosocial well-being. These results will influence the indication for a reconstructive operation in future and underline the need for reconstructive surgery in a multidisciplinary care program after weight loss surgery in morbidly obese patients.

[Morbidly obese patients: psychopathology and eating disorders. Results of a preoperative evaluation]. / Morbid adipöse Patienten: Psychopathologie und Essstörungen. Ergebnisse einer präoperativen Evaluation.

BACKGROUND: The prevalence of individuals who are overweight or obese has increased dramatically over the past decades, especially in high-income countries. However, the success rates of conservative therapies in morbidly obese patients are poor. Consequently, bariatric surgery is the treatment of choice for morbid obesity. Because many obese individuals who seek professional help show a high co-morbidity of mental disorders, including eating disorders, and psychosocial problems, a psychological evaluation before bariatric surgery is deemed. METHODS: The patient cohort included 547 morbidly obese subjects (389 females, 158 males). All patients were recruited from the Department of Surgery, Medical University of Innsbruck. An exact psychological evaluation, using a semi-structured interview and the Structured Clinical Interview for Mental Diseases (SCID), was carried out at the Department of Psychosomatic Medicine. RESULTS: The results of the preoperative psychiatric-psychotherapeutic evaluation of the morbidly obese patients revealed that more than half suffered from one or more mental disorders; these included in particular depression and adjustment disorders, as well as personality disorders, in particular Cluster C personality disorders. A majority of the patients showed one or more disordered eating patterns. Females showed a markedly higher rate of a "binge-eating"-disorder than males, while males tended to be classified as "overeaters" in many cases. CONCLUSIONS: An exact preoperative psychological evaluation can make an important contribution in identifying those patients who, on one hand, are not ideal candidates for bariatric surgery, or, on the other hand, need additional psychiatric and/or psychotherapeutic treatment to cope with the new demands postoperatively.

Diabetes mellitus and comorbid depression: improvement of both diseases with milnacipran. A replication study (results of the Austrian Major Depression Diabetes Mellitus study group).

Comorbid depression is common in patients with type 2 diabetes mellitus and is associated with greater mortality risk and a higher incidence of diabetic complications and decreased quality of life. In an earlier pilot study, we found that treatment with the serotonin norepinephrine reuptake inhibitor antidepressant, milnacipran, significantly improved metabolic parameters in diabetic patients with comorbid depression who had an antidepressant response. We sought to replicate these results in a larger cohort (n = 135). Patients received milnacipran and metformin for 6 months and metabolic parameters and depressive symptoms were measured at baseline and after 3 and 6 months. At the end of the study, 72.6% of patients had an antidepressant response (≥50% reduction of baseline Beck Depression Inventory score). Overall, there was significant improvement in the metabolic and anthropometric parameters measured. The number of patients with glycated hemoglobin > 8% (>63.9 mmol/mol), an indicator of poor metabolic control requiring intensive therapeutic intervention, decreased from 31.9% at baseline to 11.9% during the study. As found in the pilot study, levels of total cholesterol and triglycerides were only significantly decreased in antidepressant responders. Body weight was significantly reduced in both responders and nonresponders but the effect size was significantly greater in the responder group. In contrast to the pilot study, fasting blood glucose and glycated hemoglobin were significantly decreased to a similar extent in both antidepressant-responders and nonresponders. The present study thus replicates some of the original findings. The main difference between the present and the pilot study is that in the larger cohort significant reductions in fasting blood glucose and glycated hemoglobin were found in all patients irrespective of whether or not they responded to antidepressant treatment. The present data underline the importance of diagnosis and treatment of comorbid depression in patients with type 2 diabetes mellitus with milnacipran.

[Are eating disorders addictions?]. / Sind Essstörungen Suchterkrankungen?

The various eating disorders, anorexia nervosa, bulimia nervosa, and binge-eating disorder, are characterized by severe disturbances in eating behavior and are seen as typical "psychosomatic disorders". The subdivision of anorexia nervosa into two subtypes, namely "anorexia nervosa restricting type" and "anorexia nervosa bulimic type" has proved to be very good. It is to be assumed that eating disorders are not a homogeneous group, and that the various subtypes of eating disorders are also heterogeneous at several levels. Co-morbid psychiatric disorders, especially affective disorders, anxiety disorders, substance-related disorders, and personality disorders, are often found in eating- disordered patients. Many anorectics of the restrictive type and orthorectics show co-morbid psychiatric disorders such as anxiety disorders, obsessive-compulsive disorders, and avoidant or obsessive-compulsive personality disorders, while a co-morbidity of affective disorders, addiction, personality disorders, especially multi-impulsivity and borderline personality disorder, is frequently found in anorectics of bulimic type, bulimics, and binge eaters. Addictive behavior manifests itself in permanent preoccupation with food and eating, withdrawal symptoms, continuation of disturbed eating behavior in spite of negative consequences, loss of control, and frequent relapse. There are some indications that there is a basic psychological disturbance common to eating disorders, especially bulimia nervosa, and to substance-related disorders, namely a personality disorder with an emotional instability and multi-impulsivity. The possible associations between eating disorders and mental disorders, particularly addictions, will be discussed.

Long-term results and complications following adjustable gastric banding.

This study was performed to assess our long-term results with laparoscopic gastric banding in patients with an observation period of at least 9 years calculated from the date of operation. Between January 1996 and December 2000, a total of 276 patients (83% female) underwent laparoscopic gastric banding at our institution. Mean preoperative body mass index (BMI) was 44 +/- 6 kg/m(2). BMI after 1, 5, 7, 9, and 10 years was 33 +/- 6, 30 +/- 6, 31 +/- 6, 32 +/- 7, and 31 +/- 7 kg/m(2), respectively. Mean excess weight loss after 1 year was 57.1 +/- 23.0% and after 5, 7, 9, and 10 years 73.2 +/- 29.6%, 65.9 +/- 29.3%, 61.8 +/- 32.8%, and 64.0 +/- 32.1%, respectively. Median completeness of follow-up was 80%. Of the study population, 146 (52.9%) patients had at least one complication requiring reoperation. Presently, only 148 (53.6%) patients still have their original band, 49 (17.8%) had their original band replaced with a new one, and 79 (28.6%) had their band removed. Thirty-three patients had no second bariatric operation, a Roux-en-Y gastric bypass was done in 39 patients, and six patients underwent sleeve gastrectomy. Our long-term results are good with regard to weight loss in those patients who still have their band in situ. This is accompanied by a high complication rate and a 29% band loss rate.

[Major depressive disorder, antidepressants and sexual dysfunction]. / Depression und Antidepressiva: Auswirkungen auf die Sexualität.

Depression and antidepressant therapy have been associated with sexual dysfunction. Studies report wide discrepancies with regard to frequency, gender, and quality of sexual dysfunction. Although sexual side effects are a common reason for non-compliance with medication, information on impairment of sexuality in psychiatric patients is rare. The impact of antidepressant- induced sexual dysfunction is substantial and negatively affects quality of life, self-esteem, mood, and relationship with partner. Sexual side effects resulting from serotonin specific reuptake inhibitors use may be mediated by a number of central and peripheral mechanisms. Some antidepressants such as Bupropion, mirtazapine, and moclobemide have a sexual tolerability profile significantly better than SSRIs, especially escitalopram, paroxetine, venlafaxine, sertraline, or fluoxetine. There are some possibilities for treatment of anti-depressant induced sexual dysfunctions such as waiting for spontaneous remission, reducing the dosage level, substituting the offending drug with other antidepressants, drug holidays, or administration of a phosphodiesterase- 5-inhibitor. These side-effects are increasingly used therapeutically in the context of the common male sexual dysfunction ejaculatio praecox. For this indication short-acting SSRI;s are available.

Correlation between avalanche emergencies and avalanche danger forecast in the alpine region of Tyrol.

OBJECTIVE: We investigated whether frequency of avalanche accidents corresponds with the danger assessment given in avalanche hazard tables and with topographic factors of the avalanche origin. METHODS: A retrospective review of official avalanche surveillance data and of medical reports from helicopter-based emergency medical systems was conducted. RESULTS: Most victims involved in avalanche accidents are ski tourers and off-piste skiers, about 90% are male, and age ranges from 10 to more than 70 years. Sixty-seven percent of accidents occurred when moderate and considerable danger was forecast. In 94.0% of accidents avalanches were triggered by victims themselves or by nearby recreationists; 32.6% of avalanche slides occurred on extremely steep slopes at gradients exceeding 40 degrees . Overall incidence of accidents before noon was 25.0%. Professional stand-by avalanche parties significantly contributed to rescuing avalanche victims, but the chance of survival is diminished when arrival was delayed. All patients who were able to free themselves from avalanche burial survived. Of those rescued by companions, 78.0% survived compared with only 10.0% of those rescued by organized rescue teams (P<0.001). CONCLUSION: Frequency of avalanche emergencies associated with outdoor leisure activities does not correspond with the danger forecast in avalanche hazard bulletins. There is need of a modified and regionally adjusted grading that makes allowance for experience and individual behavior of recreationists going in for backcountry leisure activities.

Psychosocial impact of abdominoplasty.

BACKGROUND: The number of patients desiring reconstructive surgery after a huge weight loss achieved with gastric banding is increasing. This study was undertaken to determine whether plastic surgical removal of an overlap flap has a psychosocial effect on patients. METHODS: Thirty-women and four men who underwent overlap flap surgery were interviewed 1 day before, and again 3 and approximately 12 months after the procedure using a series of instruments: Strauss and Appelt's Questionnaire for assessing one's body, the Body Perception Questionnaire by Paulus, the questionnaire for satisfaction of life by Fahrenberg, Myrtek, Schumacher, and Brähler, the Hospital Anxiety and Depression Scale (German version) by Herrmann, Buss, and Snaith, and the authors' general questionnaire after surgery. The same clinical parameters were also investigated in a control group of persons who did not undergo plastic surgery. Comparisons were made before and after surgery between and in both groups. RESULTS: In contrast to the control group, surgical patients reported a highly significant increase in self-confidence and the feeling of being attractive (p