Should Europe follow the US and declare obesity a disease?: a discussion of the so-called utilitarian argument.

In 2013, the American Medical Association (AMA) decided to recognize obesity as a disease. One of the main arguments presented in favor of this was broadly 'utilitarian': the disease label would, it was claimed, provide more benefits than harms and thereby serve the general good. Several individuals and groups have argued that this reasoning is just as powerful in the European context. Drawing mainly on a review of relevant social science research, we discuss the validity of this argument. Our conclusion is that in a Western European welfare state, defining obesity as a disease will not on balance serve the general good, and that it is therefore more appropriate to continue to treat obesity as a risk factor. The main reasons presented in favor of this conclusion are: It is debatable whether a disease label would lead to better access to care and preventive measures and provide better legal protection in Europe. Medicalization and overtreatment are possible negative effects of a disease label. There is no evidence to support the claim that declaring obesity a disease would reduce discrimination or stigmatization. In fact, the contrary is more likely, since a disease label would categorically define the obese body as deviant.

Patients' strategies for eating after gastric bypass surgery: a qualitative study.

BACKGROUND/OBJECTIVES: There is considerable variation in the amount of weight patients lose after gastric bypass surgery, and this may be related to the way they adjust to the operation in their daily eating practices. Little is known about how this varies. On the basis of a qualitative research design, this study therefore explores how patients deal with gastric bypass surgery in their daily lives. SUBJECTS/METHODS: The study is based on interviews with 24 men and women in Denmark diagnosed with morbid obesity who have had, Roux-en-Y gastric bypass surgery. The interviews were transcribed, coded and analysed using 'grounded theory' methodology. RESULTS: Three strategies used by patients to cope with postoperative changes were identified. In the first strategy, patients treat surgery as time-out, using the operation to facilitate a change in their ordinary habits of daily life, but not as a solution to overweight in itself. Patients adopting the second strategy of surgery as solution would expect their smaller stomach to hinder excess food intake automatically. The third strategy of abstaining was adopted by patients who were afraid to experience negative side effects, or who believed they might 'ruin the operation'. CONCLUSIONS: Patients adjust to their postoperative condition in very different ways. The variation in the ways patients comprehend and cope with the operation and in its effects on their eating routines and practices needs to be further investigated and compared more systematically with the outcomes of the operation in terms of weight loss and overall well-being.

Implementation of a trauma system in Norway: a national survey.

BACKGROUND: Trauma systems have improved outcomes for injured patients, but might be challenging to implement. We assessed the implementation of a trauma system in Norway after recommendations for a national trauma system were published in 2007, with a focus on elements in acute care hospitals. METHODS: All hospitals in Norway, except for the four regional trauma centres, admitting injured patients at the time of the study were included in a telephone survey. The questionnaire was administered during May 2013 by the regional trauma coordinators who interviewed the local trauma coordinator and/or the local doctor responsible for trauma care in all the acute care hospitals. The main categories were availability of the trauma team and team training, written procedures, preparedness and training of personnel. The compliance to a set of 17 predefined trauma system criteria was evaluated at each institution. RESULTS: Of the 35 acute care hospitals in Norway admitting trauma patients at the time of the survey, all were included. The median number of fulfilled criteria was 14. Major deficiencies were found in fulfilling competence criteria, maintaining a local trauma registry, and trauma audits. The number of fulfilled criteria correlated strongly with the size of the hospital and the frequency of trauma team activation. CONCLUSIONS: Shortcomings in requirements for lower-level trauma care hospitals correlate to hospital size and frequency with which the trauma team is activated. In order to fulfill the minimum requirements, smaller hospitals should receive more attention.

The nuclear receptors NUR77, NURR1 and NOR1 in obesity and during fat loss.

BACKGROUND: Adipose tissue is critical for systemic metabolic health. Identifying key factors regulating adipose tissue function is a research priority. The NR4A subfamily of nuclear receptors (NRs) (NR4A1/NUR77, NR4A2/NURR1 and NR4A3/NOR1) has emerged as important proteins in different disease states and in the regulation of metabolic tissues, particularly in liver and muscle. However, the expression of the NR4A members in human adipose tissue has not previously been described, and their target genes are largely unknown. OBJECTIVE: To determine whether the NR4As are differentially expressed in human adipose tissue in obesity, and identify potential NR4A target genes. DESIGN: Prospective analysis of s.c. adipose tissue before and 1 year after fat loss, and during in vitro differentiation of primary human preadipocytes. Case-control comparison of omental (OM) adipose tissue. SUBJECTS: A total of 13 extremely obese patients undergoing biliopancreatic diversion with duodenal switch for fat loss, 12 extremely obese patients undergoing laparoscopic sleeve gastrectomy and 37 lean individuals undergoing hernia repair or laparotomy were included in the study. Measurements were done by quantitative PCR gene expression analysis of the NR4A members and in silico promoter analysis based on microarray data. RESULTS: There was a strong upregulation of the NR4As in extreme obesity and normalization after fat loss. The NR4As were expressed at the highest level in stromal-vascular fraction compared with adipocytes, but were downregulated in both fractions after fat loss. Their expression levels were also significantly higher in OM compared with s.c. adipocytes in obesity. The NR4As were downregulated during differentiation of primary human preadipocytes. Moreover, the NR4As were strongly induced within 30 min of tissue incubation. Finally, promoter analysis revealed potential NR4A target genes involved in stress response, immune response, development and other functions. Our data show altered adipose tissue expression of the NR4As in obesity, suggesting that these stress responsive nuclear receptors may modulate pathogenic potential in humans.

History of the development of antiemetic guidelines at Mayo Clinic Rochester.

This article describes the historic experience of the development of antiemetic guidelines for patients taking chemotherapy drugs at Mayo Clinic Rochester. The initial guidelines for the use of serotonin (5-hydroxytryptamine3) receptor antagonists for the prevention of chemotherapy-induced nausea and vomiting were developed in early 1995 and implemented in September 1995. In February 1997, the guidelines were reviewed and modified. In the spring of 1998, major changes were made based on new data from the literature and discussions with antiemetic authorities in the United States. These guidelines were implemented in July 1998. The guidelines were again reviewed and modified in December 1998. In addition, we compared costs associated with the 1997 guidelines and the December 1998 guidelines. The developed guidelines, utilizing clinically available agents, seem to provide high-quality patient care at a reasonable cost.

Venlafaxine in management of hot flashes in survivors of breast cancer: a randomised controlled trial.

BACKGROUND: Hot flashes can be troublesome, especially when hormonal therapy is contraindicated. Preliminary data have suggested that newer antidepressants, such as venlafaxine, can diminish hot flashes. We undertook a double-blind, placebo-controlled, randomised trial to assess the efficacy of venlafaxine in women with a history of breast cancer or reluctance to take hormonal treatment because of fear of breast cancer. METHODS: Participants were assigned placebo (n=56) or venlafaxine 37.5 mg daily (n=56), 75 mg daily (n=55), or 150 mg daily (n=54). After a baseline assessment week, patients took the study medication for 4 weeks. All venlafaxine treatment started at 37.5 mg daily and gradually increased in the 75 mg and 150 mg groups. Patients completed daily hot-flash questionnaire diaries. The primary endpoint was average daily hot-flash activity (number of flashes and a score combining number and severity). Analyses were based on the women who provided data throughout the baseline and study weeks. FINDINGS: 191 patients had evaluable data for the whole study period (50 placebo, 49 venlafaxine 37.5 mg, 43 venlafaxine 75 mg, 49 venlafaxine 150 mg). After week 4 of treatment, median hot flash scores were reduced from baseline by 27% (95% CI 11-34), 37% (26-54), 61% (50-68), and 61% (48-75) in the four groups. Frequencies of some side-effects (mouth dryness, decreased appetite, nausea, and constipation) were significantly higher in the venlafaxine 75 mg and 150 mg groups than in the placebo group. INTERPRETATION: Venlafaxine is an effective non-hormonal treatment for hot flashes, though the efficacy must be balanced against the drug's side-effects. Confirmation of the results of this 4-week study awaits the completion of three ongoing randomised studies to assess the effects of other related antidepressants for the treatment of hot flashes.

Randomized comparison of megestrol acetate versus dexamethasone versus fluoxymesterone for the treatment of cancer anorexia/cachexia.

PURPOSE: Previous double-blind, placebo-controlled, randomized clinical trials have demonstrated that both corticosteroids and progestational agents do partially alleviate cancer anorexia/cachexia. Pilot information suggested that an anabolic corticosteroid might also improve appetite in patients with cancer anorexia/cachexia. The current trial was developed to compare and contrast a progestational agent, a corticosteroid, and an anabolic corticosteroid for the treatment of cancer anorexia/cachexia. PATIENTS AND METHODS: Patients suffering from cancer anorexia/cachexia were randomized to receive either dexamethasone 0. 75 mg qid, megestrol acetate 800 mg orally every day, or fluoxymesterone 10 mg orally bid. Patients were observed at monthly intervals to evaluate weight changes and drug toxicity. Patients also completed questionnaires at baseline and at monthly intervals to evaluate appetite and drug toxicities. RESULTS: Fluoxymesterone resulted in significantly less appetite enhancement and did not have a favorable toxicity profile. Megestrol acetate and dexamethasone caused a similar degree of appetite enhancement and similar changes in nonfluid weight status, with nonsignificant trends favoring megestrol acetate for both of these parameters. Dexamethasone was observed to have more corticosteroid-type toxicity and a higher rate of drug discontinuation because of toxicity and/or patient refusal than megestrol acetate (36% v 25%; P =.03). Megestrol acetate had a higher rate of deep venous thrombosis than dexamethasone (5% v 1%; P =.06). CONCLUSION: Whereas fluoxymesterone clearly seems to be an inferior choice for treating cancer anorexia/cachexia, megestrol acetate and dexamethasone have similar appetite stimulating efficacy but differing toxicity profiles.

Laparoscopic appendectomy: comparison with open appendectomy in 720 patients.

We conducted a review of laparoscopic appendectomies (LA) and open appendectomies (OA) over a 3-year period, including 720 patients (253 LA, 467 OA) who underwent appendectomy during the study period. Computer records were reviewed with respect to demographics, length of stay, operating room time, operating room cost, hospital cost, and morbidity. All patients were sent surveys to assess their posthospitalization recovery. The LA patients had significant shorter hospital stays (2.06 days vs. 3.44 days, p < .001), lower morbidity rates (5 vs 14%, p < .02), and comparable overall hospital costs ($4,800 vs. $4,950). The LA patients also reported less postoperative pain and were able to return to work sooner. Our results show that LA can significantly decrease morbidity and hospital stay with a comparable hospital cost and result in quicker patient recovery.

Laparoscopic Nissen fundoplication: cost, morbidity, and outcome compared with open surgery.

We report a retrospective review of all patients undergoing both open and laparoscopic Nissen fundoplication from January 1990 through December 1993. Computer data were reviewed to determine the length of hospital stay, hospital costs, and perioperative complications. Questionnaires were sent to patients undergoing Nissen fundoplication. During the study period, 232 patients underwent Nissen fundoplication, and 72 patients underwent laparoscopic Nissen fundoplication. The open group had an average hospital stay of 6.1 days, the laparoscopy group, 1.5 days (p < < 0.001). Total hospital costs for the open group averaged $8,616 versus $4,331 for the group that underwent laparoscopic procedure (p < 0.001). Operating room time averaged 10 min longer for the laparoscopic procedure (p value, nonsignificant). In-hospital morbidity was significantly greater for the open group. In follow-up questionnaires, the laparoscopy group experienced an earlier return to "general health" (p < 0.005) and an earlier return to work.

Optometric prescription writing.

A clearly written prescription is an important part of good optometric patient care. There are seven parts of a well-written prescription, and each of these should be considered individually. This article discusses these seven parts, and also other important aspects of prescription writing.