Childhood obesity treatment: telephone coaching is as good as usual care in maintaining weight loss - a randomized controlled trial.

There is a need for more flexible treatment strategies to help patients reach relevant treatment outcomes and adhere better to treatment. The aim of this study was to evaluate the long-term efficacy, in terms of patients' weight status, of replacing usual care (UC) physical visits with more frequent but shorter telephone coaching (TC) sessions as part of a structured childhood obesity treatment. In this controlled study, patients aged 5-14 years from the Södertälje outpatient clinic, Sweden were randomized to either UC or TC over an 18-month period after participating in an initial standard obesity treatment programme. The patients were followed for a mean of 3.7 years. In total, 37 children (UC, n = 18 and TC, n = 19) were included, with a mean (standard deviation, SD) age of 9.5 (2.6) years and a body mass index standard deviation score (BMI SDS) of 2.9 (0.7). The change in BMI SDS did not differ between the groups during the study (P = 0.8). Both groups had similar changes in BMI SDS 3.7 years after the first visit to the clinic, TC = - 0.42 and UC = 0.52 BMI SDS units (P = 0.6 between groups). There were no gender differences. Furthermore, the average time clinicians spent with each patient during the study did not differ between the groups (P = 0.5). No patients were lost to follow-up during the study. In conclusion, the use of TC may offer greater flexibility in the treatment of paediatric obesity as it was non-inferior for both treatment efficacy and the time spent on treatment by healthcare personnel.

Association between impaired fasting glycaemia in pediatric obesity and type 2 diabetes in young adulthood.

OBJECTIVES: In adults, impaired fasting glycemia (IFG) increases the risk for type 2 diabetes mellitus (T2DM). This study aimed to investigate to which extent children with obesity develop T2DM during early adulthood, and to determine whether IFG and elevated hemoglobin A1c (HbA1c) in obese children are risk markers for early development of T2DM. METHODS: In this prospective cohort study, 1620 subjects from the Swedish Childhood Obesity Treatment Registry - BORIS who were ⩾18 years at follow-up and 8046 individuals in a population-based comparison group, matched on gender age and living area, were included. IFG was defined according to both ADA (cut-off 5.6 mmol l(-1)) and WHO (6.1 mmol l(-1)). Elevated HbA1c was defined according to ADA (cut-off 39 mmol l(-1)). Main outcome was T2DM medication, as a proxy for T2DM. Data on medications were retrieved from a national registry. RESULTS: The childhood obesity cohort were 24 times more likely to receive T2DM medications in early adulthood compared with the comparison group (95% confidence interval (CI): 12.52-46). WHO-defined IFG predicted future use of T2DM medication with an adjusted hazard ratio (HR) of 3.73 (95% CI: 1.87-7.45) compared with those who had fasting glucose levels <5.6 mmol l(-1). A fasting glucose level of 5.6-6.0 mmol l(-1), that is, the IFG-interval added by American Diabetes Association (ADA), did not increase the use of T2DM medication more than pediatric obesity itself, adjusted HR=1.72 (0.84-3.52). Elevated levels of HbA1c resulted in an adjusted HR=3.12 (1.50-6.52). More severe degree of obesity also increased the future T2DM risk. CONCLUSION: IFG according to WHO and elevated HbA1c (39-48 mmol l(-1)), but not the additional fasting glucose interval added by ADA (5.6-6.0 mmol l(-1)), can be considered as prediabetes in the obese pediatric population in Sweden.

Obese children without comorbidities have impaired microvascular endothelial function.

AIM: The aim was to test acetylcholine-induced endothelium-dependent vasodilatation in obese children without comorbidities, compared with normal weight controls, and to analyse associations between vasodilatation and other potential risk factors. METHODS: Endothelium-dependent vasodilatation was induced by transdermal iontophoresis of acetylcholine in 54 obese children (8.3-18.2 years old, 41% girls) and 44 normal weight controls (7.5-20.2 years old, 82% girls), and the subsequent change in perfusion was measured with laser Doppler flowmetry. In a subgroup of the obese children, associations between acetylcholine-induced vasodilatation and blood lipids, glucose/insulin metabolism, inflammation, 24-h ambulatory blood pressure (ABP), cardiovascular fitness and duration of obesity were evaluated. RESULTS: We found a lower endothelium-dependent vasodilatory response to acetylcholine in the obese children than the controls (p < 0.001). The peak perfusion response was 33% lower in obese children (p = 0.001). There was a trend towards lower vasodilatation in obese children with higher levels of triglycerides (p = 0.07). Children with the shortest duration of obesity exhibited the lowest vasodilatation (p = 0.03). No associations were found between 24-h ABP, cardiovascular fitness, inflammation and glucose/insulin metabolism. CONCLUSION: Obese children without comorbidities have significantly impaired microvascular endothelial function. The children who had been obese for a longer time seemed less affected.

Impaired fasting glucose prevalence in two nationwide cohorts of obese children and adolescents.

OBJECTIVE: Impaired fasting glucose (IFG), a pre-stage to type 2 diabetes in adults, is also present in obese children. A large variation of the occurrence has been recorded, but the true prevalence is unknown due to lack of larger representative cohort studies. This study was implemented to investigate the prevalence of IFG in two nationwide cohorts of obese children and to find factors that affect the risk of IFG. DESIGN: A cross-sectional study based on data collected from two nationwide registers of obese children in Germany and Sweden, respectively. SUBJECTS: Subjects included were 2-18 years old. 32,907 subjects with fasting glucose were eligible in Germany and 2726 in Sweden. Two cutoff limits for IFG were used: 5.6-6.9 mmol l(-1) according to the American Diabetes Association (ADA) and 6.1-6.9 mmol l(-1)according to the World Health Organization (WHO). Variables collected were gender, age and degree of obesity. Logistic regression was used to calculate odds ratios. RESULTS: The total prevalence of IFG among obese children in the German cohort according to the ADA was 5.7% and according to the WHO it was 1.1%. In Sweden, the corresponding prevalence was 17.1% and 3.9%, respectively. IFG risk was correlated with increasing age, male sex and degree of obesity. CONCLUSIONS: IFG is highly prevalent among obese children. Age and degree of obesity are positively correlated with the risk of having IFG. There are large regional differences. After adjustments, obese children in Sweden, due to unknown reasons, have a 3.4- to 3.7-fold higher risk of having IFG than obese children in Germany.

Nocturnal blood pressure non-dipping is prevalent in severely obese, prepubertal and early pubertal children.

AIM: To investigate the prevalence of nocturnal blood pressure dipping among obese prepubertal and early pubertal children and to analyse the relationship between dipping and measures of insulin-glucose metabolism or sleep-disordered breathing. METHODS: We studied 76 obese children (41% girls) under clinical care, with an average age of 10.4 ± 1.7 and a body mass index Z-score (BMI Z-score) of 6.2 ± 1.6. We performed a 24-h ambulatory blood pressure measurement. Non-dipping was defined as a nocturnal blood pressure reduction of <10%. We calculated measures of insulin-glucose metabolism from the performed frequently sampled intravenous glucose-tolerance test and from fasting blood samples. Overnight sleep polygraph recordings were performed to assess sleep-disordered breathing. RESULTS: Forty-two percent of the children were systolic non-dippers, and 17% were diastolic non-dippers. There were no associations between systolic or diastolic dipping and measures of insulin-glucose metabolism after adjustments for BMI Z-score, gender and pubertal status. There were no associations between dipping and measures of sleep-disordered breathing. CONCLUSION: Nocturnal non-dipping was two times higher among severely obese, prepubertal and early pubertal children, compared to previous reports among children in general. There were no associations between nocturnal dipping and insulin-glucose metabolism or measures of sleep-disordered breathing in this group.

Intragraft interleukin 2 mRNA expression during acute cellular rejection and left ventricular total wall thickness after heart transplantation.

OBJECTIVE: To assess whether diastolic graft function is influenced by intragraft interleukin 2 (IL-2) messenger RNA (mRNA) expression in rejecting cardiac allografts. DESIGN: 16 recipients of cardiac allografts were monitored during the first three months after transplantation. The presence of IL-2 mRNA in endomyocardial biopsies (n = 123) was measured by reverse transcriptase polymerase chain reaction. To determine heart function, concurrent M mode and two dimensional Doppler echocardiograms were analysed. RESULTS: Histological signs of acute rejection (International Society for Heart and Lung Transplantation (ISHLT) rejection grade > 2) were strongly associated with IL-2 mRNA expression (IL-2 mRNA was present in 12 of 20 endomyocardial biopsies (60%) with acute rejection and in 24 of 103 endomyocardial biopsies (23%) without acute rejection, p = 0.002). No significant relation was found between either histology or IL-2 mRNA expression alone and the studied echocardiographic parameters. However, stratification of the echocardiographic data into those of patients with and those without acute rejection showed that during acute rejection IL-2 mRNA expression was significantly associated with increased left ventricular total wall thickness (mean change in total wall thickness was +0.22 cm in patients with IL-2 mRNA expression versus -0.18 cm in patients without IL-2 mRNA expression, p = 0.048). CONCLUSIONS: An increase in left ventricular total wall thickness precedes IL-2 positive acute rejection after heart transplantation. Thus, cardiac allograft rejection accompanied by intragraft IL-2 mRNA expression may be indicative of more severe rejection episodes.

Patients, diagnoses and processes in general practice in the Nordic countries. An attempt to make data from computerised medical records available for comparable statistics.

OBJECTIVE: To try out a collection of a standard set of data from computerised medical records. DESIGN: Retrospective extraction of ordinary patient record information put into the computer by general practitioners. SETTING: Encounters in office hours in strategically selected practices or health centres in Denmark, Finland, Iceland, Norway and Sweden. SUBJECTS: 59 general practitioners and a total study population of 97475 persons. MAIN OUTCOME MEASURES: Proportions, crude and specific rates of encounters, diagnoses and processes. RESULTS: In a 4-week period there was a threefold difference in the office encounter rates between the participating sites in the Nordic countries. Gender and age patterns were similar despite these differences. An access to several different denominators revealed diverse patterns of referring to the specialist, prescribing, ordering blood tests, X-rays and physiotherapy. Data from computerised medical records agree well with earlier studies in the Nordic countries using other methods. CONCLUSIONS: This survey demonstrates that valid and reliable data for routine statistics are available from computerised medical records in general practice. The major obstacle extracting more epidemiological data from computerised medical records is caused by information in the databases not being uniquely linked to episodes of care.

Fluorescence correlation spectroscopy of enzymatic DNA polymerization.

We show that fluorescence correlation spectroscopy (FCS) can be used as a reliable, simple, and fast tool for detecting products of the polymerase chain reaction (PCR). By use of autocorrelation experiments, it is demonstrated that fluorescent 217-bp DNA fragments can be detected at very low initial ss M13mp18(+) DNA and tetramethylrhodamine-4-dUTP concentrations and that these polymers are cleaved by the chosen restriction enzymes. A FCS calibration curve is presented, where the translational diffusion times of different size DNA fragments are plotted versus the number of base pairs they contain. At zero and very low template concentrations a large "background" species emerges, which is a reflection of the experimental conditions chosen and the extremely high sensitivity of FCS. The relative amount of nonspecific product formation is less than 1%. The ease by which a FCS measurement can be performed (a few minutes at most) also enables the technique to be used as an effective screening method.

Comparison of the gonadotropin-releasing hormone agonist goserelin acetate alone versus goserelin combined with estrogen-progestogen add-back therapy in the treatment of endometriosis.

OBJECTIVE: To investigate whether the addition of low-dose estrogen-P combination hormone replacement therapy (HRT) to GnRH agonist (GnRH-a) treatment for endometriosis reduces the pharmacologic side effects of such treatment without reducing efficacy and to determine the endocrinologic changes during treatment. DESIGN: Prospective, randomized, double-blind, placebo-controlled, comparative study of two drug regimens: 3.6 mg goserelin acetate in a 28-day SC depot formulation once monthly for 6 months plus either a combination of 2 mg 17 beta-E2 and 1 mg norethisterone acetate (NET) 1 mg or matching placebo tablets once daily for 6 months. SETTING: Multicenter study in three tertiary referral centers at university teaching hospitals and two central hospitals. PATIENTS: Women with laparoscopically confirmed symptomatic endometriosis were included in the study. RESULTS: Of the total of 109 patients screened, 93 were recruited and 88 patients were randomized to either the HRT or the placebo group. Four women were withdrawn because of various medical reasons, and 76 patients were followed-up for a total of 12 months. In terms of efficacy, there was no difference between the two drug regimens for objective or subjective response. There were significantly less postmenopausal symptoms in the patients treated with goserelin plus HRT compared with those treated with goserelin plus placebo. CONCLUSION: Goserelin diminished significantly the symptoms and laparoscopic scores of endometriosis. The addition of HRT did not reduce the efficacy of goserelin but diminished the postmenopausal symptoms during treatment.

Change of central venous catheter dressings twice a week is superior to once a week in patients with haematological malignancies.

Thirty-two consecutive patients with haematological disorders, in need of a permanent central venous catheter (CVC) were randomly allocated to have their CVC bandages (Tegaderm) changed once (OAW, n = 20) or twice (TAW, n = 19) a week. The two randomization arms were balanced in respect of age, sex, and underlying disease. The exit site of the CVC was inspected daily through the transparent bandage and erythema was noted. If severe erythema occurred, daily wet gauze dressings were applied. Samples for bacterial cultures were taken from the exit site of the CVC at every change of bandages. There was no difference in complications leading to removal of the CVC between the two groups (7/20 OAW vs. 7/19 TAW) or in CVC survival-time (P = 0.4). However, the OAW group had more positive CVC tip cultures (OAW 11/14 vs. TAW 2/9; P < 0.05) and a tendency to: (i) more extra dressings (P = 0.08); (ii) more cultures from the exit skin site showing high numbers of colony forming units (P = 0.07); (iii) shorter time to first exit site infection (P = 0.09); and (iv) more Gram-positive septicaemias (P = 0.08). Both clinical and bacteriological data in this study indicate that changing transparent polyurethane CVC bandages twice a week is superior to once a week.

Priorities in primary health care. The views of patients, politicians and health care professionals.

A written inquiry was undertaken to explore the expectations towards primary care physicians (general practitioners), as expressed by patients, local health board members and health centre staff members. Treatment without delay was given top priority both by patients and board members, while continuity of care was considered most important by the health care professionals. Great similarity of opinions was expressed by patients and health board members, while staff members differed significantly in their views. A low degree of participation in the study by the politicians coincided with the authors' experience of lack of interest in the content of primary health care shown by health board members.