Amudha S. Poobalan

A review of chronic pain after inguinal herniorrhaphy.

BackgroundChronic pain was believed to be a recognized but infrequent complication after inguinal hernia repair. Evidence suggests that patients with chronic pain place a considerable burden on health services. However, few scientific data on chronic pain after this common elective operation are available. ObjectivesTo review the frequency of chronic pain and to discuss etiological theories and current treatment options for patients with chronic post herniorrhaphy pain. Materials and MethodsAll studies of postoperative pain after inguinal hernia repair with a minimum follow-up period of 3 months, published between 1987 and 2000, were critically reviewed. Results and DiscussionThe frequency of chronic pain after inguinal hernia repair was found to be as high as 54%, much more than previously reported. Quality of life of these patients is affected. Chronic pain is reported less often after laparoscopic and mesh repairs. Recurrent hernia repair, preoperative pain, day case surgery, delayed onset of symptoms, and high pain scores in the first week after surgery, however, were identified to be risk factors for the development of chronic pain. Definition of chronic pain was not explicit in the majority of the reviewed studies. Accurate evaluation of the frequency of chronic pain will require standardization of definition and methods of assessment. Prospective studies are required to define the role of risk factors identified in this review.

Obesity as an independent risk factor for elective and emergency caesarean delivery in nulliparous women - systematic review and meta-analysis of cohort studies

The objective of the study was to investigate the association between increasing maternal body mass index (BMI) and elective/emergency caesarean delivery rates. Systematic review and meta‐analysis of published cohort studies were used. The bibliographic databases, MEDLINE, EMBASE, CINAHL, were searched systematically, with no language restrictions, from 1996 to May 2007. MeSH terms and key words for ‘pregnancy’, ‘obesity’, ‘overweight,’‘body mass index’ and ‘caesarean section’ were combined with the Cochrane Collaboration strategy for identifying primary studies. Finally, 11 papers were considered eligible for inclusion in the review. Although all the papers were cohort studies, only three were prospective in nature. Compared with women with normal BMI (20–25 kg m−2), the crude pooled odds ratios (95% confidence intervals) for caesarean section in overweight (BMI 25–30 kg m−2), obese (BMI 30–35 kg m−2) and morbidly obese (BMI > 35 kg m−2) women were 1.53 (1.48, 1.58), 2.26 (2.04, 2.51) and 3.38 (2.49, 4.57) respectively. The pooled odds of having an emergency caesarean section were 1.64 (95% confidence intervals 1.55, 1.73) in overweight and 2.23 (2.07, 2.42) in obese women. Caesarean delivery risk is increased by 50% in overweight women and is more than double for obese women compared with women with normal BMI.

Effects of weight loss in overweight/obese individuals and long-term lipid outcomes--a systematic review.

This paper aims to review the evidence for long‐term effectiveness of weight loss on cholesterol, high‐density lipoprotein (HDL), low‐density lipoprotein (LDL) and triglycerides in overweight/obese people. Current evidence is mostly based on short‐term studies. A systematic review of long‐term lipid outcomes of weight loss in studies published between 1966 and 2001, was conducted. Inclusion criteria included all cohort studies and trials carried out on participants with body mass index of greater than or equal to 28 kg m−2. Studies had at least two weight change measurements and follow‐up of more than 2 years. Thirteen long‐term studies with a follow‐up of more than 2 years were included. Cholesterol has a significant positive linear relationship with weight change (r = 0.89) where change in weight explains about 80% of the cholesterol difference variation (Adj R2 = 0.80). For every 10 kg weight loss a drop of 0.23 mmol L−1 in cholesterol may be expected for a person suffering from obesity or are grossly overweight. Weight loss has long‐term beneficial effects especially on LDL and cholesterol. Weight loss in obese patients should be encouraged and sustained.

Effects of Weight Loss in Overweight/Obese Individuals and Long-Term Hypertension Outcomes A Systematic Review

Many studies have assessed short-term effects of weight loss on blood pressure, whereas little attention has been paid to long-term effects. We conducted a systematic review to evaluate the long-term effects of weight loss on hypertension outcome measures in adults using literature published from 1966 to 2001. All prospective studies and trials, performed on participants with body mass index of ≥28 kg/m2 with a follow-up of >2 years and weight changes recorded, were included. The data from these studies were used to model the long-term effects on blood pressure. Previous reviews on shorter-term studies indicate a 1:1 drop in blood pressure (mm Hg) with weight loss (kilograms). Our findings, based on studies with follow-up of ≥2 years, demonstrate blood pressure decreases less than this after weight loss. The surgical intervention studies exhibited huge weight losses with undramatic blood pressures changes. When surgical interventions are excluded, the models suggest that for 10 kg weight loss, decreases of 4.6 mm Hg and 6.0 mm Hg in diastolic and systolic blood pressure, respectively, may be expected, about half of that predicted from the short-term trials. Initial blood pressure, the length of follow-up, medication changes, and physiological restrictions may contribute to this reduced effect in the long-term studies. Extrapolation of short-term blood pressure changes with weight loss to the longer term is potentially misleading. The weight/hypertension relationship is complex and needs well-conducted studies with long-term follow-up to examine the effects of weight loss on hypertension outcomes.

The prevalence of chronic chest and leg pain following cardiac surgery: a historical cohort study.

&NA; Chronic pain after surgery is recognised as an important post‐operative complication; recent studies have shown up to 30% of patients reporting persistent pain following mastectomy and inguinal hernia repair. No large‐scale studies have investigated the epidemiology of chronic pain at two operative sites following coronary artery bypass grafting (CABG). This paper reports the follow‐up of a cohort of 1348 patients who underwent cardiac surgery between 1996 and 2000 at one cardiothoracic unit in northeast Scotland. Chronic pain was defined as pain in the location of surgery, different from that suffered pre‐operatively, arising post‐operatively and persisting beyond 3 months. The survey questionnaire consisted of the short‐form‐36 (SF‐36), Rose angina questionnaire, McGill pain questionnaire and the University of California and San Francisco (UCSF) pain service questionnaire. Of the 1080 responders, 130 reported chronic chest pain, 100 chronic post‐saphenectomy pain and 194 reported pain at both surgical sites. The cumulative prevalence of post‐cardiac surgery pain was 39.3% (CI95 36.4–42.2%) and mean time of 28 months since surgery (SD 15.3 months). Patients who reported pain at both sites had lower quality of life scores across all eight health domains compared to patients with pain at one site only and those who were pain‐free. Prevalence of chronic pain decreased with age, from 55% in those aged under 60 years to 34% in patients over 70 years. Patients with pre‐operative angina and those who were overweight or obese (BMI≥25) at the time of surgery were more likely to report chronic pain. Chronic pain following median sternotomy and saphenous vein harvesting is more common than hitherto reported and that patients undergoing CABG should be warned of this possibility.

Weight loss in obese diabetic and non-diabetic individuals and long-term diabetes outcomes - a systematic review

The aim was to review the evidence for the long‐term effects of weight loss on diabetes outcomes in obese people or for those at risk of developing type 2 diabetes. Current evidence is mostly based on short‐term studies. This is a systematic review of long‐term outcomes of weight loss in studies published between 1966 and 2001. Eleven long‐term studies with a follow up of more than 2 years were included. Results show that those with diabetes who lost weight intentionally significantly reduced their mortality risks by 25%. Additionally, weight loss of 9–13 kg was most protective. Patients with the risk of developing diabetes due to either family history of diabetes or impaired glucose tolerance, saw a reduction in this risk. Those with large weight losses achievable with surgical interventions reduced their risk by at least 63%. Metabolic handling of glucose improved in 80% of those already with type 2 diabetes who lost weight. Based on one large study, intentional weight loss in obese patients appears to have a beneficial effect on mortality risk for those with type 2 diabetes. Clearly, further studies are needed to endorse this. The risk of developing diabetes being reduced by weight loss was shown in seven studies. However, the results were from studies with different analytical adjustments and outcome indices, making it difficult to make direct comparisons and should be viewed with caution. More long‐term prospective studies need to be conducted with commitment to improving the methodological quality and standardization, in order to accurately assess the long‐term effects of weight loss for obese diabetic and non‐diabetic individuals.

Weight loss interventions in young people (18 to 25 year olds): a systematic review.

This systematic review assesses weight loss interventions in young adults (18–25 years), who are vulnerable to weight gain. This age group experience critical life course points (leaving home for higher studies or job, pregnancy, cohabitation) and develop/establish lifestyle and behavioural patterns making this an opportune intervention period. Medline, Embase, Cinahl, PsychINFO and Cochrane Library were searched (1980 to March 2008). All trials and cohort studies with control groups that assessed weight loss interventions in this specific age group were included finally identifying 14 studies. Before and after comparison of behavioural/motivational interventions (−2.40 kg; 95% CI −5.4 to 0.6) and combination interventions (−2.96; 95% CI −4.4 to −1.5) consistently showed weight loss. Behavioural/motivational interventions increased self‐efficacy, the desire to control weight, boosted self‐esteem, and increased satisfaction with body areas and appearance. Interventions also showed improvements in HDL cholesterol, insulin, glucose and maximum oxygen uptake. However, recruitment to participation in interventions was a barrier for this age group with small sample sizes and short‐term interventions. There may be gender differences in preference to participation in certain type of interventions. Further research to understand attitudes towards healthy lifestyle and preferences of interventions is needed to develop suitable interventions for this vulnerable age group.

Long‐term weight loss effects on all cause mortality in overweight/obese populations

This systematic review assesses the long‐term effectiveness of weight loss on all cause mortality in overweight/obese people. Medline, Embase and Cinahl were searched (1966–2005). Cohort studies and trials on participants with body mass index ≥25 kg m−2, with weight change and mortality with ≥2‐year follow‐up, were included finally identifying 11 papers based on eight studies. There may be gender differences in the benefits for all cause mortality. The impact of weight loss in men on mortality was not clear with some studies indicating weight loss to be detrimental, while a recent cohort study showed benefits, if it were a personal decision. Other studies with no gender separation had similarly mixed results. However, one study indicated that overweight/obese women with obesity‐related illness, who lost weight intentionally within 1 year, had significantly reduced mortality rates of 19–25%. In contrast, studies of overweight/obese diabetics irrespective of gender showed significant benefit of intentional weight loss on mortality in a meta‐analysis, hazard ratios = 0.75 (0.67–0.83). There is some evidence that intentional weight loss has long‐term benefits on all cause mortality for women and more so for diabetics. Long‐term effects especially for men are not clear and need further investigation.

Quantitative assessment of chronic postsurgical pain using the McGill Pain Questionnaire

ObjectivesThe McGill Pain Questionnaire (MPQ) provides a quantitative profile of 3 major psychologic dimensions of pain: sensory-discriminative, motivational-affective, and cognitive-evaluative. Although the MPQ is frequently used as a pain measurement tool, no studies to date have compared the characteristics of chronic post-surgical pain after different surgical procedures using a quantitative scoring method. MethodsThree separate questionnaire surveys were administered to patients who had undergone surgery at different time points between 1990 and 2000. Surgical procedures selected were mastectomy (n = 511 patients), inguinal hernia repair (n = 351 patients), and cardiac surgery via a central chest wound with or without saphenous vein harvesting (n = 1348 patients). A standard questionnaire format with the MPQ was used for each survey. The IASP definition of chronic pain, continuously or intermittently for longer than 3 months, was used with other criteria for pain location. The type of chronic pain was compared between the surgical populations using 3 different analytical methods: the Pain Rating Intensity score using scale values, (PRI-S); the Pain Rating Intensity using weighted rank values multiplied by scale value (PRI-R); and number of words chosen (NWC). ResultsThe prevalence of chronic pain after mastectomy, inguinal herniorrhaphy, and median sternotomy with or without saphenectomy was 43%, 30%, and 39% respectively. Chronic pain most frequently reported was sensory-discriminative in quality with similar proportions across different surgical sites. Average PRI-S values after mastectomy, hernia repair, sternotomy (without postoperative anginal symptoms), and saphenectomy were 14.06, 13.00, 12.03, and 8.06 respectively. Analysis was conducted on cardiac patients who reported anginal symptoms with chronic post-surgical pain (PRI-S value 14.28). Patients with moderate and severe pain were more likely to choose more than 10 pain descriptors, regardless of the operative site (P < 0.05). DiscussionThe prevalence and characteristics of chronic pain was remarkably similar across different operative groups. This study is the first to quantitatively compare chronic post-surgical pain using similar methodologies in heterogeneous post-surgical populations.

Physical activity attitudes, intentions and behaviour among 18–25 year olds: A mixed method study

BackgroundYoung people (18–25 years) during the adolescence/adulthood transition are vulnerable to weight gain and notoriously hard to reach. Despite increased levels of overweight/obesity in this age group, physical activity behaviour, a major contributor to obesity, is poorly understood. The purpose of this study was to explore physical activity (PA) behaviour among 18–25 year olds with influential factors including attitudes, motivators and barriers.MethodsAn explanatory mixed method study design, based on health Behaviour Change Theories was used. Those at university/college and in the community, including those Not in Education, Employment or Training (NEET) were included. An initial self reported quantitative questionnaire survey underpinned by the Theory of Planned Behaviour and Social Cognitive Theory was conducted. 1313 questionnaires were analysed. Results from this were incorporated into a qualitative phase also grounded in these theories. Seven focus groups were conducted among similar young people, varying in education and socioeconomic status. Exploratory univariate analysis was followed by multi staged modelling to analyse the quantitative data. ‘Framework Analysis’ was used to analyse the focus groups.ResultsOnly 28% of 18–25 year olds achieved recommended levels of PA which decreased with age. Self-reported overweight/obesity prevalence was 22%, increasing with age, particularly in males. Based on the statistical modelling, positive attitudes toward PA were strong predictors of physical activity associated with being physically active and less sedentary. However, strong intentions to do exercise, was not associated with actual behaviour. Interactive discussions through focus groups unravelled attitudes and barriers influencing PA behaviour. Doing PA to feel good and to enjoy themselves was more important for young people than the common assumptions of ‘winning’ and ‘pleasing others’. Further this age group saw traditional health promotion messages as ‘empty’ and ‘fear of their future health’ was not a motivating factor to change current behaviour.Conclusion18–25 year olds are a difficult group to reach and have low levels of PA. Factors such as, ‘enjoyment’, ‘appearance ‘and ‘feeling good’ were deemed important by this specific age group. A targeted intervention incorporating these crucial elements should be developed to improve and sustain PA levels.