Of nannies and nudges: the current state of U.S. obesity policymaking.

In the sprawling American political debates over obesity, which date back a decade and a half, 'nanny state' has been a rhetorical cudgel used to oppose those seeking even modest state action to address rising obesity rates. This essay explores obesity policy through the prism of state involvement, focusing on four possible types of response to what virtually all those involved--physicians and nutritional scientists, public-health advocacy groups, even food industry executives--agree is a serious threat to individual and collective health.

Child and adolescent fast-food choice and the influence of calorie labeling: a natural experiment.

OBJECTIVE: Obesity is an enormous public health problem and children have been particularly highlighted for intervention. Of notable concern is the fast-food consumption of children . However, we know very little about how children or their parents make fast-food choices, including how they respond to mandatory calorie labeling. We examined children's and adolescents' fast-food choice and the influence of calorie labels in low-income communities in New York City (NYC) and in a comparison city (Newark, NJ). DESIGN: Natural experiment: Survey and receipt data were collected from low-income areas in NYC, and Newark, NJ (as a comparison city), before and after mandatory labeling began in NYC. Study restaurants included four of the largest chains located in NYC and Newark: McDonald's, Burger King, Wendy's and Kentucky Fried Chicken. SUBJECTS: A total of 349 children and adolescents aged 1-17 years, who visited the restaurants with their parents (69%) or alone (31%) before or after labeling was introduced. In total, 90% were from racial or ethnic minority groups. RESULTS: We found no statistically significant differences in calories purchased before and after labeling; many adolescents reported noticing calorie labels after their introduction (57% in NYC) and a few considered the information when ordering (9%). Approximately 35% of adolescents ate fast food six or more times per week and 72% of adolescents reported that taste was the most important factor in their meal selection. Adolescents in our sample reported that parents have some influence on their meal selection. CONCLUSIONS: Adolescents in low-income communities notice calorie information at similar rates as adults, although they report being slightly less responsive to it than adults. We did not find evidence that labeling influenced adolescent food choice or parental food choices for children in this population.

Can additional experienced staff reduce emergency medical admissions?

BACKGROUND: Increases in emergency medical admissions are placing a strain upon hospitals throughout the world. The aim of the study was to evaluate the effect of a new post, the "A&E physician", upon emergency medical admissions to a hospital. METHODS: For six months the A&E physician workload was audited and a randomised controlled comparison undertaken. Days were randomised to "A&E physician present" or "A&E physician absent". The A&E physician recorded details of all patients referred for medical admission, any intervention made, and their disposal from A&E. Routine hospital data compared the mean daily number of medical admissions, non-medical admissions, and referrals to other hospitals. RESULTS: 124 days were randomised: 59 to A&E physician present, 65 to A&E physician absent. The A&E physician received 581 referrals and intervened in the management of 142 (24%). Of these, 80 were discharged home, apparently saving 1.4 admissions per day. However, randomised comparison showed that presence of the A&E physician was associated with a reduction of only 0.7 medical admissions per day (95% CI -1.7 to 3.2, p = 0.561), and an increase of 1.1 non-medical admissions (95% CI -0.2 to 2.3, p = 0.09) and 0.3 transfers to other hospitals per day (95% CI zero to 0.6, p = 0.09). Overall, hospital admissions were increased by 0.9 per day when the A&E physician was present (95% CI -1.8 to 3.6, p = 0.5). CONCLUSION: Despite receiving many referrals and discharging a substantial proportion of these patients home, the A&E physician did not significantly change emergency medical admissions and may have increased admissions to other specialties.

Prevention of microvascular thrombosis with short-term infusion of human tissue-type plasminogen activator.

A locally active thrombolytic agent, human tissue-type plasminogen activator (t-PA), given over a finite time period (24 hours) by local infusion, maintains long-term microvascular patency (7 days) in a proven thrombosis model using an arterial inversion graft in the rabbit model. Thirteen rabbits in the control group and 16 rabbits in the experimental group underwent an arterial inversion graft followed by continuous infusion (24 hours) with human tissue-type plasminogen activator (experimental) or normal saline (control). No significant clinical bleeding or alteration of coagulation parameters was noted in hematologic studies in both experimental and control groups. Scanning electron microscopy of the postoperative human tissue-type plasminogen activator-perfused arteries suggests an interaction of the human tissue-type plasminogen activator with specific platelet receptors in reversing microvascular thrombosis by decreasing or preventing further platelet aggregation and adhesion. Human tissue-type plasminogen activator infused locally for a finite period (24 hours) allows adequate time for platelet metamorphosis to occur in converting a thrombogenic to a nonthrombogenic vessel surface. The clinical ramifications in preventing or reversing microvascular thrombosis in free-tissue transfers and replantation surgery are apparent. Further study in this area will enhance our understanding of the pathogenesis and prevention of microvascular thrombosis.

Microvascular surgical experimental thrombosis model: rationale and design.

The rationale for the design of surgical models of microvascular thrombosis is discussed, and a new model, the arterial inversion graft (AIG), is described and evaluated in the New Zealand white rabbit. Femoral artery segments of predetermined length are excised, gently turned inside-out, and resutured into their native position. Blood flow is restored, and at varying time intervals, vessel patency is assessed through the direct "milking test." In this study, three groups of 20 arterial inversion grafts of 2, 5, and 10 mm in length are created and evaluated for patency at 1 hour and again at 7 days. The incidence of femoral artery occlusion in this model appears to be an increasing function of arterial inversion graft length both at 1 hour--30 percent (2 mm), 80 percent (5 mm), and 100 percent (10 mm)--and at 7 days--65 percent (2 mm), 90 percent (5 mm), and 100 percent (10 mm). This proportionality suggests the arterial inversion graft may be adjusted in length to provide an incidence of vessel occlusion best suited to the needs of any particular experiment.

Human recombinant tissue type plasminogen activator and its effect on microvascular thrombosis in the rabbit.

A new potent thrombolytic agent, human tissue type plasminogen activator (t-PA), has become available for study through recombinant DNA technology. In this series of experiments, we have tested t-PA in a reliable microvascular thrombosis model previously developed in our laboratory. Its action in preventing thrombus formation and lysing fresh clot by direct local infusion and systemic infusion was tested. The results revealed that t-PA was able to keep locally infused vessels open for 4 hours and reopen them after they were allowed to clot in 100 percent of the animals tested. Those vessels exposed only to systemic levels of t-PA achieved by the same local infusion remained thrombosed and were unaffected. Laboratory studies showed no evidence of activation of the systemic lytic state or alteration in coagulation parameters. t-PA has proved to be a protein with characteristics that make it attractive for use in microvascular surgery. The results suggest that further research may lead the way toward clinical use.

Carcinoma of the female urethra: combined iridium Ir 192 interstitial and external beam radiotherapy.

Three female patients (mean age 55) with carcinoma of the urethra were treated with combined external beam irradiation (4,000 to 5,000 rads) and interstitial irradiation with iridium Ir 192 (2,700 to 3,000 rads) applied with a modified Syed-Neblett template. Two patients are alive with no evidence of disease at 27 and 37 months. One patient died of a second primary tumor at 30 months, without histologic evidence of the original urethral neoplasm. No patient had significant complications of therapy. This treatment regimen is effective for selected women with urethral carcinoma.

Late results following surgical management of vascular graft infection.

Ninety-two patients underwent surgical treatment for 59 prosthetic graft infections and 33 secondary aortoenteric fistulas. Definitive treatment was accomplished with a low perioperative mortality rate (14%). Long-term follow-up confirmed that most patients were cured of their infection or fistula, and 88% of the patients who survived the perioperative period (67 of 76) had no further evidence of infection when followed up from 10 months to 12 1/2 years postoperatively. The 12% late mortality rate (9 of 76) was secondary to persistent infection and aortic stump disruption. When perioperative and late deaths in both groups are combined, 67 of 92 patients (73%) were cured of their prosthetic graft infection. Factors associated with a favorable prognosis for survival and cure of infection were autogenous reconstruction and possibly staged operative repair. Poor prognosis for survival and cure of infection resulted from aortic stump disruption, persistent infection, and retained graft material. Significant morbidity (amputation and multiple operative procedures) was related to the severity of underlying vascular disease, the inadequacy of extra-anatomic reconstruction, and in some cases progression of vascular disease. The major challenges in the treatment of graft infection at present are the preoperative identification of limited graft infection and the successful management of the interrupted aorta. Complex and innovative reconstructive procedures continue to be necessary to ensure limb salvage and remain a considerable technical challenge. Nonetheless, the prospects for cure as reported in this series justify an aggressive operative approach. A successful outcome following definitive treatment of these devastating complications is possible for the majority of affected patients.

Intracoronary thrombus in nontransmural myocardial infarction and in unstable angina pectoris.

Although intracoronary thrombus formation plays a major role in acute transmural myocardial infarction (MI), its occurrence in unstable angina (UA) and nontransmural MI has not clearly been established. To determine whether intracoronary thrombus does occur in these syndromes, coronary arteriography was performed before, during, and after intracoronary nitroglycerin and streptokinase infusion in 17 patients. None of the 8 patients with nontransmural MI and 1 of the 9 patients with UA responded to intracoronary nitroglycerin. Seven of 8 patients with nontransmural MI and 4 of 9 patients with UA responded to streptokinase infusion with opening of an occluded vessel, an increase in stenotic diameter, dissolution of an intracoronary filling defect, or a combination of these. Serial opening and closing of ischemia-related vessels occurred spontaneously and in response to streptokinase in some patients in whom thrombolysis was demonstrated. Evidence of thrombolysis was not seen in any patient studied longer than 1 week from the onset of the rest pain syndrome. The finding of thrombolysis in several patients with nontransmural MI and UA suggests that intracoronary thrombus formation plays a pathogenetic role in some patients with these ischemic syndromes.