How do eating disorder specialist clinicians apply DSM-IV diagnostic criteria in routine clinical practice? Implications for enhancing clinical utility in DSM-5.

The clinical utility of the DSM-IV eating disorder (ED) diagnostic criteria among practicing clinicians has not been formally evaluated, despite the considerable diagnostic challenges these disorders present. This study evaluated inter-rater reliability between research and clinical diagnoses, identified discrepantly rated diagnostic criteria, and evaluated ED subtype use in a naturalistic treatment setting. Seventy-six adolescent and young adult female patients consecutively admitted to a residential ED program were evaluated independently by clinicians (unstructured clinical interview) and research assessors (Structured Clinical Interview for DSM-IV). Clinicians and research assessors conferred concordant ED diagnoses in 80.3% of cases (kappa=0.70), thus highlighting the clinical utility of the extant DSM-IV diagnostic scheme in this specialty ED treatment setting. All but two discordant cases included a diagnosis of ED not otherwise specified (EDNOS). Clinicians applied ED subtypes in just 20.4% of eligible cases, and were significantly more likely to apply subtypes to major depressive disorder. Although clinical and research interviews yielded substantial reliability, EDNOS had the lowest reliability among the ED diagnoses. Moreover, infrequent subtype application on this specialty unit raises questions about the clinical utility of DSM-IV anorexia nervosa and bulimia nervosa subtypes, even in the context of clinically useful overarching categories.

The combined effects of balloon valvuloplasty and surgical weight loss in treatment of aortic stenosis.

We report a case of a patient with a congenitally bicuspid aortic valve and extreme obesity who developed severe aortic stenosis. She dramatically improved after the combined use of balloon valvuloplasty and Roux en Y gastric bypass. Gastric bypass surgery has promise for patients with congenital cardiac disease whose treatment is complicated by extreme obesity.

Cost analysis of ligature versus stapling techniques of laparoscopic appendectomy in children.

BACKGROUND: Although longer operative times and specialized instrumentation render laparoscopic appendectomies (LA) more expensive to perform than open appendectomies, the documented advantages of the laparoscopic approach have led many surgeons to prefer it. LAs are currently performed using either the ligature or the stapling technique. The decision as to which technique to employ is currently based on the surgeon's personal preference rather than on a knowledge of comparative costs. In light of the pressures for cost containment, we evaluated data from both laparoscopic methods to determine which was more effective based on cost and patient outcomes. PATIENTS AND METHODS: We conducted a retrospective review of 55 pediatric patients who underwent LA by either the ligature or stapling technique at Cincinnati Children's Hospital Medical Center (Cincinnati, OH) between March 2000 and March 2001. Comparative data on operating room cost, operative time, length of hospital stay, and readmission owing to complications were obtained for all LA cases. RESULTS: The cost of LA performed using the stapling technique was significantly higher than the cost of LA using the ligature technique. Overall, a 37% reduction in operating room cost was seen for ligature versus stapling LA. There were no statistically significant differences in any of the other variables measured. CONCLUSIONS: The ligation technique has appeal in residency training situations owing to the greater skill set that is needed for tissue handling and manipulation when using this technique. Our data suggest that LA performed using a ligation technique may also be less costly than the stapling technique and, therefore, should be considered as an appropriate surgical option.