In this retrospective cohort study, we determined the long-term mortality (from 1984 to 2002) among 9949 patients who had undergone gastric bypass surgery and 9628 severely obese persons who applied for driver’s licenses. From these subjects, 7925 surgical patients and 7925 severely obese control subjects were matched for age, sex, and body-mass index. We determined the rates of death from any cause and from specific causes with the use of the National Death Index. Results During a mean follow-up of 7.1 years, adjusted long-term mortality from any cause in the surgery group decreased by 40%, as compared with that in the control group (37.6 vs. 57.1 deaths per 10,000 person-years, P<0.001); cause-specific mortality in the surgery group decreased by 56% for coronary artery disease (2.6 vs. 5.9 per 10,000 person-years, P = 0.006), by 92% for diabetes (0.4 vs. 3.4 per 10,000 person-years, P = 0.005), and by 60% for cancer (5.5 vs. 13.3 per 10,000 person-years, P<0.001). However, rates of death not caused by disease, such as accidents and suicide, were 58% higher in the surgery group than in the control group (11.1 vs. 6.4 per 10,000 person-years, P = 0.04). Conclusions Long-term total mortality after gastric bypass surgery was significantly reduced, particularly deaths from diabetes, heart disease, and cancer. However, the rate of death from causes other than disease was higher in the surgery group than in the control group.

Long-Term Mortality after Gastric Bypass Surgery

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

https://onlinelibrary.wiley.com/doi/pdf/10.1002/oby.20461

Clinical Practice Guidelines for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient—2013 Update: Cosponsored by American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery

ContextThe optimal management of fibromyalgia syndrome (FMS) is unclear and
comprehensive evidence-based guidelines have not been reported.ObjectiveTo provide up-to-date evidence-based guidelines for the optimal treatment
of FMS.Data Sources, Selection, and ExtractionA search of all human trials (randomized controlled trials and meta-analyses
of randomized controlled trials) of FMS was made using Cochrane Collaboration
Reviews (1993-2004), MEDLINE (1966-2004), CINAHL (1982-2004), EMBASE (1988-2004),
PubMed (1966-2004), Healthstar (1975-2000), Current Contents (2000-2004),
Web of Science (1980-2004), PsychInfo (1887-2004), and Science Citation Indexes
(1996-2004). The literature review was performed by an interdisciplinary panel,
composed of 13 experts in various pain management disciplines, selected by
the American Pain Society (APS), and supplemented by selected literature reviews
by APS staff members and the Utah Drug Information Service. A total of 505
articles were reviewed.Data SynthesisThere are major limitations to the FMS literature, with many treatment
trials compromised by short duration and lack of masking. There are no medical
therapies that have been specifically approved by the US Food and Drug Administration
for management of FMS. Nonetheless, current evidence suggests efficacy of
low-dose tricyclic antidepressants, cardiovascular exercise, cognitive behavioral
therapy, and patient education. A number of other commonly used FMS therapies,
such as trigger point injections, have not been adequately evaluated.ConclusionsDespite the chronicity and complexity of FMS, there are pharmacological
and nonpharmacological interventions available that have clinical benefit.
Based on current evidence, a stepwise program emphasizing education, certain
medications, exercise, cognitive therapy, or all 4 should be recommended.

/pdf/management-of-fibromyalgia-syndrome-4oxrb77sem.pdf

Management of Fibromyalgia Syndrome

‘‘Gentlemen don’t need mistletoe’’ said the Christmas whiskey billboard I saw recently in Florida, a garish reminder of how much mistletoe lore is embedded in western society. Mistletoe The Genus Viscum, one in the series of medicinal and aromatic plants for industry and academic researchers, centers on the mistletoe in this advertisement, the common European mistletoe,Viscum album. There are helpful discussions on African, Asian, and Argentine mistletoes and their uses but the corpus of the book deals with V. album. Viscum album, considered sacred by the Druids, is no doubt the most widely used parasitic angiosperm for various health concoctions. As a result, much has been learned about its biochemistry and pharmaceutical potential. A great deal of the work on the culture and utilization ofV. album has been done by investigators at Institute Hiscia Center for Cancer Research in Switzerland where votaries of Rudolf Steiner’s distinct form of homeopathy have used mistletoe extracts (‘‘Iscador’’) for many years in cancer treatment. Mistletoe collected from less common hosts are considered to have greater efficacy in preparation of Iscador. As a result, there is a helpful chapter on culturing V. album which is not as difficult as might be imagined for an obligate parasite. Most of the chapters deal with the medicinal aspects of mistletoe including toxicology, clinical aspects, chemistry, and biochemistry emphasizing the lectins which are one of the more desirable compounds produced by the parasite. I found the treatment by Bu ̈ssing (Biological and pharmacological properties of Viscum album L.) helpful because it reviews the link between folk and modern medicine. However, several relevant papers were omitted which are included in a recent excellent review of mistletoes (Watson 2001). Like many books with a diversity of authors, the quality of chapters varies. Obviously produced as a reference volume, Mistletoe lacks an extensive index. Especially aggravating is the lack of an author’s index, limiting the value of the book for anyone looking for specific papers. These days, $70 for a hardbound monograph is reasonable. Color images are well-produced but some of the black and white figures are blurry in my copy. This volume will be of value to ethnobotanists, anyone interested in alternative medicines, and students of mistletoes and parasitic plants. LITERATURE CITED

Genetic Data Analysis II. Methods for Discrete Population Genentic Data

Background
Fibromyalgia (FM) is a syndrome expressed by chronic widespread body pain which leads to reduced physical function and frequent use of health care services. Exercise training is commonly recommended as a treatment. This is an update of a review published in Issue 2, 2002.

Objectives
The primary objective of this systematic review was to evaluate the effects of exercise training including cardiorespiratory (aerobic), muscle strengthening, and/or flexibility exercise on global well-being, selected signs and symptoms, and physical function in individuals with FM.

Search methods
We searched MEDLINE, EMBASE, CINAHL, SportDiscus, PubMed, PEDro, and the Cochrane Central Register for Controlled Trials (CENTRAL, Issue 3, 2005) up to and including July 2005. We also reviewed reference lists from reviews and meta-analyses of treatment studies.

Selection criteria
Randomized trials that were selected focused on cardiorespiratory endurance, muscle strength and/or flexibility as treatment for FM.

Data collection and analysis
Two of four reviewers independently extracted data for each study. All discrepancies were rechecked and consensus was achieved by discussion. Methodological quality was assessed by two instruments: the van Tulder and the Jadad methodological quality criteria. We used the American College of Sport Medicine (ACSM) guidelines to evaluate whether interventions had provided a training stimulus that would effect changes in physical fitness. Due to significant clinical heterogeneity among the studies we were only able to meta-analyze six aerobic-only studies and two strength-only studies.

Main results
There were a total of 2276 subjects across the 34 included studies; 1264 subjects were assigned to exercise interventions. The 34 studies comprised 47 interventions that included exercise. Effects of several disparate interventions on global well-being, selected FM signs and symptoms, and physical function in individuals with FM were summarized using standardized mean differences (SMD). There is moderate quality evidence that aerobic-only exercise training at recommended intensity levels has positive effects global well-being (SMD 0.49, 95% CI: 0.23 to 0.75) and physical function (SMD 0.66, 95% CI: 0.41 to 0.92) and possibly on pain (SMD 0.65, 95% CI: -0.09 to 1.39) and tender points (SMD 0.23, 95% CI: -0.18 to 0.65). Strength and flexibility remain under-evaluated.

Authors' conclusions
There is 'gold' level evidence (www.cochranemsk.org) that supervised aerobic exercise training has beneficial effects on physical capacity and FM symptoms. Strength training may also have benefits on some FM symptoms. Further studies on muscle strengthening and flexibility are needed. Research on the long-term benefit of exercise for FM is needed.

Exercise for treating fibromyalgia syndrome.

OBJECTIVE To test the hypothesis that acupuncture improves symptoms of fibromyalgia. PATIENTS AND METHODS We conducted a prospective, partially blinded, controlled, randomized clinical trial of patients receiving true acupuncture compared with a control group of patients who received simulated acupuncture. All patients met American College of Rheumatology criteria for fibromyalgia and had tried conservative symptomatic treatments other than acupuncture. We measured symptoms with the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory at baseline, immediately after treatment, and at 1 month and 7 months after treatment. The trial was conducted from May 28, 2002, to August 18, 2003. RESULTS Fifty patients participated in the study: 25 in the acupuncture group and 25 in the control group. Total fibromyalgia symptoms, as measured by the FIQ, were significantly improved in the acupuncture group compared with the control group during the study period (P=.01). The largest difference in mean FIQ total scores was observed at 1 month (42.2 vs 34.8 in the control and acupuncture groups, respectively; P=.007). Fatigue and anxiety were the most significantly improved symptoms during the follow-up period. However, activity and physical function levels did not change. Acupuncture was well tolerated, with minimal adverse effects. CONCLUSION This study paradigm allows for controlled and blinded clinical trials of acupuncture. We found that acupuncture significantly improved symptoms of fibromyalgia. Symptomatic improvement was not restricted to pain relief and was most significant for fatigue and anxiety.

https://www.mayoclinicproceedings.org/article/S0025-6196(11)61729-1/pdf

Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial.

Background: How psychosocial factors may impact on weight loss after bariatric surgery is not well understood. This lack of knowledge is problematic, because there is a high prevalence of psychosocial distress in patients seeking treatment for obesity in hospital-based programs. The purpose of this study was to examine the relationship between preoperative psychosocial factors and eventual weight loss. Method: Between 1987 and 1998, all individuals undergoing Roux-en-Y gastric bypass for weight loss in our institution had psychologic preoperative evaluations. Patients who were followed prospectively were studied. The relation of having received mental health treatment to percentage of excess weight loss at 2 years is examined using t-tests. Results: 62 women and 18 men completed a 2-year follow-up. Patients who had received treatment for either substance abuse (n=10) or psychiatric co-morbidity (n=39) lost more weight compared with those without such histories (P<0.05, P <0.001 respectively). Conclusion: Given these results, it is plausible that a history of having received either psychiatric treatment for a disorder or counseling for substance abuse should not be a contraindication to bariatric surgery, and, in fact, may be prognostic of favorable outcome. Further research examining psychosocial factors and outcome from bariatric surgery is clearly warranted.

Psychosocial factors and 2-year outcome following bariatric surgery for weight loss.

Objective. This study of patients with a diagnosis of fibromyalgia (FM) was conducted to test the hypothesis that immediate posttreatment measures of psychosocial functioning, health attributes, negative pain-related emotions, and depressive symptoms improve significantly during multidisciplinary pain rehabilitation while concurrently withdrawing analgesic medications.



Design.  Prospective case series.



Setting.  Multidisciplinary pain rehabilitation center at a tertiary referral medical center.



Patients.  In total, 159 consecutive patients with a diagnosis of FM admitted to the pain rehabilitation program from January 2002 to December 2003.



Interventions.  A 3-week outpatient multidisciplinary pain rehabilitation program based on a cognitive–behavioral model that incorporates analgesic medication withdrawal.



Outcome Measures.  Multidimensional Pain Inventory (MPI), Short Form-36 Health Status Questionnaire (SF-36), Coping Strategies Questionnaire-Catastrophizing subscale (CSQ-C), and the Center for Epidemiologic Studies-Depression scale (CES-D) were administered at admission and dismissal and the mean differences in scores were compared using paired t-tests. The number of patients using opioid analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), benzodiazepines, and muscle relaxants at admission and dismissal were compared using chi-squared analyses.



Results.  The difference in admission and dismissal scores from the MPI, SF-36, CSQ-C, and CES-D demonstrated a favorable response to treatment (P < 0.001). Compared with admission, the number of patients using opioids (P < 0.001), NSAIDs (P < 0.001), benzodiazepines (P < 0.001), and muscle relaxants (P < 0.01) at program dismissal was significantly reduced.



Conclusion.  The results of this study support the hypothesis that immediate posttreatment measures of physical and emotional functioning are favorable for patients with FM following multidisciplinary pain rehabilitation that incorporates withdrawal of analgesic medications.

/pdf/treatment-outcomes-after-multidisciplinary-pain-1cayhpef9p.pdf

Treatment Outcomes after Multidisciplinary Pain Rehabilitation with Analgesic Medication Withdrawal for Patients with Fibromyalgia

• Objectives: To evaluate the efficacy of a brief, intense treatment program for fibromyalgia and to determine which patient characteristics are associated with a better treatment response. • Patients and Methods: Two self-report measures, the Fibromyalgia Impact Questionnaire (FIQ) and the Multidimensional Pain Inventory (MPI), were administered before patients completed treatment and 1 month after participating in the program. The main outcome measure was the difference in FIQ score and MPI scale before and after program participation. • Results: Of 139 patients who met the American College of Rheumatology criteria for fibromyalgia, 100 chose to participate in the 1 1 /2-day Fibromyalgia Treatment Program at the Mayo Clinic, Rochester, Minn. Of these 100 patients, 74 completed the follow-up surveys. Patients were less affected by fibromyalgia after participation in the treatment program. This was demonstrated by a posttreatment improvement in the total FIQ score (P<.001), the MPI pain severity score (P<.001), and the MPI interference score (P=.01). The 1 patient characteristic found to be significantly associated (P<.001) with a better response to treatment was a high pretreatment level of impairment from fibromyalgia, as measured by the pretreatment FIQ score. • Conclusions: A brief interdisciplinary program for treating fibromyalgia reduced some associated symptoms. Patients more severely affected by fibromyalgia may benefit most from this approach. Clinicians may apply these findings to develop beneficial and convenient treatment programs for patients with fibromyalgia. Mayo Clin Proc. 2001;76:384-390

Treating fibromyalgia with a brief interdisciplinary program: initial outcomes and predictors of response.

Objective To study differences in treatment outcomes between patients with chronic noncancer pain taking vs those not taking maintenance opioids at admission to a pain rehabilitation program. Patients and Methods A nonrandomized 2-group prepost design was used to compare 356 patients admitted to the Mayo Comprehensive Pain Rehabilitation Center from January 2002 to December 2002 at admission and discharge by opioid status at admission. Measures of pain severity, interference due to pain, perceived life control, affective distress, activity level, depression, and catastrophizing (an exaggerated negative mental set associated with actual or anticipated pain experiences) were used to compare opioid and nonopioid groups. The patients entered a 3-week intensive outpatient multidisciplinary pain rehabilitation program designed to improve adaptation to chronic noncancer pain. The program uses a cognitive-behavioral model and incorporates opioid withdrawal. Results More than one third of patients (135/356) were taking opioids daily at admission. At completion of the program, all but 3 of the 135 patients had successfully discontinued opioid treatment. No significant pretreatment differences were found between the opioid and nonopioid group regarding demographics, pain duration, treatment completion, or all outcome variables, including pain severity. Significant improvement was noted at discharge for all outcome variables assessed regardless of opioid status at admission. Conclusion Patients with symptomatically severe and disabling pain while taking maintenance opioid therapy can experience significant improvement in physical and emotional functioning while participating in a pain rehabilitation program that incorporates opioid withdrawal.

https://www.mayoclinicproceedings.org/article/S0025-6196(11)62628-1/pdf

Christopher D. Sletten

Papers

Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial.

Psychosocial factors and 2-year outcome following bariatric surgery for weight loss.

Treatment Outcomes after Multidisciplinary Pain Rehabilitation with Analgesic Medication Withdrawal for Patients with Fibromyalgia

Treating fibromyalgia with a brief interdisciplinary program: initial outcomes and predictors of response.

Chronic Noncancer Pain Rehabilitation With Opioid Withdrawal: Comparison of Treatment Outcomes Based on Opioid Use Status at Admission