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Q. Dargoth, M.B. B.CH., M.B.B.Ch., Ph.D.

Assistant Professor, UTHealth John P. and Katherine G. McGovern Medical School

The symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. Major depressive episode includes affective/mood (green), behavioral/vegetative (orange), and cognitive (blue) symptoms. Other moodrelated symptoms of depression include weepiness-crying at the drop of a hat or for no apparent reason-and decreased sexual interest or desire. Behavioral and Physical Symptoms of Depression People who are depressed make more negative comments, make less eye contact, are less responsive, speak more softly, and speak in shorter sentences than people who are not depressed (Gotlib & Robinson, 1982; Segrin & Abramson, 1994). Depression is also evident behaviorally in one of two ways: psychomotor agitation or psychomotor retardation. Psychomotor agitation is an inability to sit still, evidenced by pacing, hand wringing, or rubbing or pulling the skin, clothes, or other objects. In contrast, psychomotor retardation is a slowing of motor functions indicated by slowed bodily movements and speech (in particular, longer pauses in answering) and lower volume, variety, or amount of speech. These two psychomotor symptoms, along with changes in appetite, weight, and sleep, are classified as vegetative signs of depression. Sleep changes can involve Psychomotor agitation An inability to sit still, evidenced by pacing, hand wringing, or rubbing or pulling the skin, clothes or other objects. Psychomotor retardation A slowing of motor functions indicated by slowed bodily movements and speech and lower volume, variety, or amount of speech. Vegetative signs (of depression) Psychomotor symptoms as well as changes in appetite, weight, and sleep. In fact, many people who are depressed had sleep disturbances up to a month before the depression began, which suggests that sleep irregularities may be a harbinger of a depressive episode (Perlis et al. In order to meet the diagnostic criteria, the vegetative signs should be observable by others, not just reported as subjective experiences. For instance, if a new patient reported difficulty getting to sleep, poor appetite, and feeling agitated, the clinician would ask the patient for more details before determining that these were vegetative signs of depression: How long does it actually take the patient to get to sleep? The clinician would also observe the patient for signs of psychomotor agitation, such as a leg constantly bobbing up and down or fingers tapping on the armrest. Cognitive Symptoms of Depression When in the grip of depression, people often feel worthless or guilt-ridden, may evaluate themselves negatively for no objective reason, and tend to ruminate over their past failings (which they may exaggerate). They may misinterpret ambiguous statements made by other people as evidence of their worthlessness. Depressed patients can also feel unwarranted responsibility for negative events, to the point of having delusions that revolve around a strong sense of guilt, deserved punishment, worthlessness, or personal responsibility for problems in the world. They blame themselves for their depression and for the fact that they cannot function well. During a depressive episode, people may also report difficulty thinking, remembering, concentrating, and making decisions, as author William Styron describes, in Case 6. Note, however, that depression is heterogeneous, which means that people with depression experience these symptoms in different combinations. The pain is unrelenting, and what makes the condition intolerable is the foreknowledge that no remedy will come-not in a day, an hour, a month, or a minute. So the decision-making of daily life involves not, as in normal affairs, shifting from one annoying situation to another less annoying-or from discomfort to relative comfort, or from boredom to activity-but moving from pain to pain. The more severe the depression, the longer the episode is likely to last (Melartin et al. In addition, someone who is truly depressed has severe symptoms for a relatively long period of time and is unable to function effectively at home, school, or work. Moreover, pervasive hopelessness and loss of pleasure are usually absent in normal sadness. Normal bereavement has characteristics that are similar to symptoms of a major depressive episode: sad thoughts and feelings, problems in concentrating, and changes in appetite and sleep. However, bereaved people are not generally overcome with feelings of hopelessness or anhedonia. Some people have increasingly frequent episodes over time, others have clusters of episodes, and still others have isolated depressive episodes followed by several years without symptoms (American Psychiatric Association, 2000; McGrath et al. Unfortunately, the documented rate of depression in the United States in increasing (Lewinsohn et al. By 2020, depression will probably be ranked second among disabling diseases in the United States (right after heart disease; Schrof & Schultz, 1999); it is currently associated with more than $30 billion dollars of lost productivity among U. Evidence also suggests that the risk of developing depression is increasing for each age cohort, a group of people born in a particular range of years.

The review included meta-analyses, randomized controlled trials, cohort studies, case reports, and expert opinions. Prior weight loss attempts, tanner stage and bone age should not be considered when referring patients for bariatric surgery. Extreme obesity and co-morbidities persist despite compliance with a formal program of lifestyle modification, with or without pharmacotherapy. Psychological evaluation confirms the stability and competence of the family unit (psychological distress due to impaired quality of life from obesity may be present, but the patient does not have an underlying untreated psychiatric illness). Patient has access to an experienced surgeon in a pediatric bariatric surgery center of excellence providing the necessary infrastructure for patient care, including a team capable of long-term follow-up of the metabolic and psychosocial needs of the patient and family. The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits. The Society noted that procedures should only be carried out in those mature pubertal individuals with severe comorbidities of obesity in the presence of a motivated and compliant patient and family and only in the hands of an experienced surgeon with a dedicated and experienced support team. Page 41 of 84 Medical Coverage Policy: 0051 the Task Force recommended against bariatric surgery for preadolescent children, for pregnant or breastfeeding adolescents, and for those planning to become pregnant within two years of surgery and in any patient who has not mastered the principles of healthy dietary and activity habits; and/or has unresolved substance abuse, eating disorder or untreated psychiatric disorder. In addition, centers should offer this procedure only if surgeons are experienced in bariatric surgery and a team of specialists is capable of long-term follow-up care of the metabolic and psychosocial needs of the patient and family" (Spear, et al. Only a surgeon with extensive experience with bariatric surgery should perform gastric bypass surgery. Finally, adolescents undergoing gastric bypass require lifelong medical and nutritional surveillance, especially during pregnancy (Baker, et al. Systematic Reviews on Bariatric Surgery Cochrane Reviews: A systematic review and meta-analysis by Colquitt et al. Most studies followed participants for 12, 24 or 36 months; the longest follow-up was 10 years. Serious adverse events, reported in four studies, ranged from 0% to 37% in the surgery groups and 0% to 25% in the no surgery groups. Between 2% and 13% of participants required reoperations in the five studies that reported these data. Based on one trial, sleeve gastrectomy led to better weight-loss outcomes than adjustable gastric banding after three years follow-up. Weight-related outcomes were similar between laparoscopic gastric imbrication and laparoscopic sleeve gastrectomy in one trial. Across all studies adverse event rates and reoperation rates were generally poorly reported. It was noted that due to the small number of studies included in the meta-analyses, only limited conclusions can be drawn from them. Also, the long-term effects of surgery remain unclear because the followup period in most trials was only one or two years. Pooled data for all procedures showed a mean excess weight loss in the range of 5467% with no evidence of loss of effect at 10 years. It was concluded that all current bariatric operations lead Page 42 of 84 Medical Coverage Policy: 0051 to major weight loss in the medium term. Of the 126 eligible studies, 83 described safety and efficacy of bariatric surgery, and 43 described predictors of body weight loss or absolute body weight following surgery. There were few direct (head-to-head) comparisons between different surgical procedures with sufficient evidence in nonrandomized studies and none for endoscopic procedures. Studies were primarily observational in design and very few utilized an appropriate design and/or analytical approach that could yield unbiased estimates of causal treatment effects including weight loss and non-weight-loss outcomes. Bariatric Surgery Impact on Health Outcomes the potential benefits of bariatric surgery on health outcomes include the following: the increase in reported morbidity associated with obesity is thought to be mediated primarily by insulin resistance, diabetes, hypertension and lipid disturbances (Sjцstrom, et al. Diet therapy alone in the absence of surgery is relatively ineffective in treating obesity over the long term (Buchwald, et al. Severely obese patients who undergo bariatric surgery achieve greater short-, intermediate- and longterm. Bariatric surgery reverses, eliminates or significantly improves risk factors of diabetes, hyperlipidemia, hypertension and obstructive sleep apnea (Buchwald, et al. Severely obese diabetic individuals treated with bariatric surgery have shown an 80% reduction in mortality (Sjцstrom, et al. Weight-loss surgery has been reported to reduce the relative risk of death by 89% with an absolute mortality reduction of 5.

Parasitic diseases Leishmaniosis has been reported in the Peten Region with a seroprevalence of 28% in dogs [549]. In a study performed on dogs from the coastal areas of El Puerto de La Libertad (La Libertad), prevalences ranging between 11­19%, depending on the type of methods used, were detected [527]. Guyana (British Guyana) the information on vector-borne pathogens in Guyana is extremely scarce or non-existent. Maggi and Krдmer Parasites Vectors (2019) 12:145 Page 15 of 37 Parasitic diseases Dirofilariosis by D. Leishmaniosis in people has been described frequently [553­555], but no published data on dogs or cats are available. Honduras Parasitic diseases Dirofilariosis has been detected and reported in dogs from Roatбn, Islas de la Bahнa, at a prevalence of 30% (Knotts test) [556]. Visceral and cutaneous leishmaniosis have been reported in humans in Honduras for some time with L. Although official reports on trypanosomosis in dogs are not available, apart from a single described canine isolate by Acosta et al. A prevalence of 19% of visceral leishmaniosis has been reported also in dogs from Chiapas [571]. Bacterial diseases Lyme borreliosis in form of seropositivity has been detected in cats at 25% prevalence [557]. Mexico Parasitic diseases Babesiosis has been described in 3 of 22 sick dogs from Morelos (13. Ehrlichia canis was also detected in a large countrywide screening at seroprevalences of 2. Maggi and Krдmer Parasites Vectors (2019) 12:145 Page 16 of 37 Nicaragua Parasitic diseases Bacterial diseases Babesiosis in form of Babesia spp. Additionally, in the same study in single dogs microfilariae were detected by microscopy and D. Leishmaniosis in different clinical scenarios and caused by different species has been reported in man [600, 601], but no prevalence data in dogs or cats could be found. Anaplasma phagocytophilum has been identified in ticks collected from a cow [613]. Paraguay the information on vector-borne pathogens in Paraguay is extremely scarce or non-existent. Ehrlichiosis in dogs has been found at a molecular prevalence of 56% [598] and at a seroprevalence of 63% for E. Panama Parasitic diseases Babesiosis in domestic dogs has been detected at an overall prevalence of 6% from 384 animals surveyed from Asunciуn, with B. Bacterial diseases Anaplasmosis has been detected in a larger population of dogs (n = 384) sampled from Asunciуn; A. Ehrlichiosis has been reported in the same population of dogs (n = 384) from Asunciуn with E. Peru Parasitic diseases Leishmaniosis was detected in dogs by microscopic examination at prevalences ranging between 3. A seroprevalence as high as 47% in dogs has also been reported in endemic regions [610]. Leishmaniosis has been reported in Peru at molecular prevalences ranging between 5. Prevalence was highly dependent on the detection method [631], as well as on the type of sample and the molecular target used for testing [632, 635]. Maggi and Krдmer Parasites Vectors (2019) 12:145 Page 17 of 37 Trypanosomosis due to T. Caution should be enforced due to potential cross-reactivity of the used test with A. Anaplasma platys infection as suggested by inclusion bodies in platelets, was identified in 29. Infection with Bartonella species in cats has been reported [642], but no prevalence values are available. Furthermore, potential vectors have been detected [643], but information is scarce.

Syndromes

• Hepatitis A vaccine
• Irritability
• Upper endoscopy (EGD)
• From another part of your body (usually around your pelvic bone). This is called an autograft. Your surgeon will make a small cut over your hip and remove some bone from the back of the rim of the pelvis.
• Make sure your pets receive the proper immunizations. Ask your veterinarian.
• Nausea and vomiting
• Is it present all of the time or only sometimes?

Perhaps marijuana use leads to schizophrenic symptoms only in those who were likely to develop the disorder anyway, or some aspect of a predisposition to develop schizophrenia also might make drug use attractive. It is also possible that marijuana "tips the scales" in those who are vulnerable but who would not develop schizophrenia if they did not use the drug. Or, perhaps some other factor affects both substance abuse and subsequent schizophrenia (Bowers et al. Researchers do not yet know enough to be able to choose among these possibilities, and true experiments designed to investigate them would obviously be unethical. One study may be able to shed some light on the relationship between using marijuana and later developing schizophrenia: the study compared marijuana use by those who have a "predisposition" toward psychosis. The researchers began the study before any of the participants had developed the disorder, and thus they were able to examine marijuana use prior to emergence of the symptoms. The study not only found that marijuana use was associated with later development of psychosis, but also that it had a greater effect on those who were predisposed to develop schizophrenia. Moreover, the more extensively marijuana was used, the more likely psychosis was to develop. Finally, this study did not support the notion that those who are predisposed to develop schizophrenia use marijuana in an attempt to medicate themselves: Those who were predisposed were not more likely to use marijuana 4 years later. Why might people with, or at risk for, schizophrenia be drawn to use marijuana at all? Glimmers of an answer come from a neuropsychological study of people with schizophrenia who used marijuana with varying frequencies. Although Green attributes his illness to his drug abuse, researchers cannot yet definitively state that such abuse causes schizophrenia in people who might not otherwise develop the disorder. In the premorbid phase, before symptoms develop, some people may display personality characteristics that later evolve into negative symptoms. During the prodromal phase, which occurs before the onset of a psychological disorder, symptoms may develop gradually but do not meet all the criteria for the disorder. In the active phase, a person has full-blown positive and negative symptoms that meet all of the criteria for the disorder. Over time, the individual may fully recover, may have intermittent episodes, or may develop chronic symptoms that interfere with normal functioning. Premorbid Phase In the premorbid phase, a person who later goes on to develop schizophrenia may appear odd or eccentric and may have diffi culty interacting with other people appropriately. This was the case for the Genain quads; during the premorbid phase, the sisters, with the possible exception of Myra, were seen as odd, and lacked the skills to make and sustain relationships with nonfamily members. However, it is important to note that most people who are odd or have eccentric tendencies do not develop schizophrenia. In addition, many people who develop schizophrenia, and particularly those who develop schizoaffective disorder, did not have odd or eccentric characteristics before the illness emerged. Prodromal Phase the prodromal phase, which may last from months to years, is marked by signs of suspiciousness, some disorganized thinking or behavior, poor hygiene, angry outbursts, and social withdrawal. These behaviors can be seen as precursors of the symptoms of schizophrenia, but they have not reached the level of positive and negative symptoms necessary for a diagnosis of schizophrenia (Heinssen et al. Hester may have begun her prodromal phase as early as age 11, when her cognitive functioning was sufficiently impaired that she could no longer keep up in school and was held back. Moreover, even in elementary school, she was described as socially inept (Rosenthal, 1963; Mirsky et al. By 11th grade, her symptoms progressed to the point that she could no longer function well enough to attend school. The tongue clicking and sighing continued for months, and she became destructive, breaking things. Instead of attending 12th grade, she stayed home, helping her mother around the house. Hester dressed and fed herself, but she was very slow at these tasks and would sometimes simply sit and stare into space. However, after 1 year of working there, she began to have crying spells and increasing agitation. After that, she became increasingly agitated and disorganized until she quit her job several months later. Her illness progressed to the active phase; she developed Prodromal phase the phase that precedes the onset of a psychological disorder (such as schizophrenia) when symptoms do not yet meet all the criteria for the disorder.