Nourishing Conversations: Using Motivational Interviewing in a Community Teaching Kitchen to Promote Healthy Eating via a Food as Medicine Intervention.

It is well known that dietary choices impact both individual and global health. However, there are numerous challenges at the personal and systemic level to fostering sustainable healthy eating patterns. There is a need for innovative ways to navigate these barriers. Food as Medicine (FM) and Culinary Medicine (CM) are approaches to helping individuals achieve healthier diets that also recognize the potential to alleviate the burden of chronic diseases through healthy eating. Teaching kitchens, which offer an interactive environment for learning nutrition and cooking skills, are valuable educational tools for FM and CM interventions. Motivational interviewing (MI), a type of person-centered counseling, facilitates behavior change and may enhance FM and CM programs involving teaching kitchens. In this commentary, we share our experience with using MI in a community-based CM program at a teaching kitchen. In demonstrating our application of MI principles, we hope to offer an additional strategy for improving dietary quality and delivering nutrition education.

Therapeutic Drug Monitoring in Patients with Systemic Lupus Erythematosus: Utility and Gaps.

Despite advances in the treatment of patients with systemic lupus erythematous (SLE), outcomes have remained suboptimal. Persistent disease activity, patient comorbidities and drug toxicities contribute to the accrual of progressive irreversible damage and high rates of morbidity and mortality. Currently, similar drug doses and regimens are promulgated in the treatment guidelines for all SLE patients, despite the vast differences in patient and environmental factors that affect the drugs' metabolism and blood concentrations. This causes a disconnect between drug dosing and drug blood concentrations, which can then result in unpredictability in drug toxicities and therapeutic effects. In this review, we discuss commonly used oral immunosuppressive medications in SLE, their pharmacogenomics, and factors affecting their metabolism and blood concentrations. Further, we highlight the role of therapeutic drug monitoring in SLE, which is the first accessible step to individualising therapy.

Phosphorus Content of Commonly Prescribed Medications Among Patients With Chronic Kidney Disease.

OBJECTIVES: This study aimed to build a brand-specific library of phosphorus content in medications and to determine the median daily phosphorus intake from medications among chronic kidney disease (CKD) patients in Singapore. METHODS: This is a single-center, cross-sectional study conducted in 200 patients with CKD Stages 3-5D. Package inserts of medications commonly used by the CKD patients were reviewed to identify brands containing phosphorus. Drug manufacturers were contacted to obtain phosphorus content of products. The median daily phosphorus intake from medications of the 200 patients was then calculated using the information. RESULTS: A total of 399 formulations of 204 medications and supplements were reviewed (March 2020). Fifty-eight (15%) formulations were found to contain phosphorus. Forty-three (11%) formulations had missing information regarding the phosphorus content. Based on available information, the median daily phosphorus intake from medications was 1.28 mg (interquartile range = 0.006-16.08) across the CKD stages. Patients with CKD Stage 5D had a higher median intake of 4.09 mg (P = .009). A dose-independent variation in phosphorus content of excipients between generic and branded formulations was noted in this study. We have developed a library of phosphorus content in medications. CONCLUSIONS: The inorganic phosphorous content in frequently prescribed medications for CKD patients is generally low, with excipients (as opposed to the active ingredient or counterions) being the main source of phosphorus. Although this may seem almost negligible in comparison to the recommended dietary intake, prescribers should still exercise care, given the wide range of phosphorus content possible between different brands of the same medication, and the unpredictable absorption of inorganic phosphate in CKD patients.

Changes of Drug Pharmacokinetics in Patients with Short Bowel Syndrome: A Systematic Review.

BACKGROUND AND OBJECTIVES: Short bowel syndrome is a clinical condition defined by malabsorption of nutrients and micronutrients, most commonly following extensive intestinal resection. Due to a loss of absorptive surfaces, the absorption of orally administered drugs is also often affected. The purpose of this study was to systematically review the published literature and examine the effects of short bowel syndrome on drug pharmacokinetics and clinical outcomes. METHODS: Studies were identified through searches of databases MEDLINE, EMBASE, Web of Science, and SCOPUS, in addition to hand searches of studies' reference lists. Two reviewers independently assessed studies for inclusion, yielding 50 studies involving 37 different drugs in patients with short bowel syndrome. RESULTS: Evidence of decreased drug absorption was observed in 29 out of 37 drugs, 6 of which lost therapeutic effect, and 14 of which continued to demonstrate clinical benefit through drug monitoring. CONCLUSIONS: The influence of short bowel syndrome on drug absorption appears to be drug-specific and dependent on the location and extent of resection. The presence of a colon in continuity may also influence drug bioavailability as it can contribute significantly to the absorption of drugs (e.g., metoprolol); likewise, drugs that have a wide absorption window or are known to be absorbed in the colon are least likely to be malabsorbed. Individualized dosing may be necessary to achieve therapeutic efficacy, and therapeutic drug monitoring, where available, should be considered in short bowel syndrome patients, especially for drugs with narrow therapeutic indices.

Direct Measurement of Creatinine Clearance over a Short Interval in Intensive Care Settings.

BACKGROUND: The definition of acute kidney injury (AKI), based on serum creatinine and urine output, bears significant limitations in intensive care units (ICUs). Serum creatinine has significant lag-time as it needs to be accumulated and stabilized at a new level whereas urine output is affected by diuresis, antidiuresis, and antinatriuresis. Direct measurement of creatinine clearance (CrCldirect = urine creatinine × urine flow rate/serum creatinine) over a short interval (3-6 hours) was explored to identify patients with AKI. MATERIALS AND METHODS: We reanalyzed a previous published dataset. We included 11 patients who had serial daily urine collections over 0 to 3 days of stay in ICU and baseline (day -1) serum creatinine levels. RESULT: The ratio of CrCldirect on day 0 to baseline creatinine clearance predicted the progression of AKI over the subsequent 1 to 3 days of ICU stay [area under receiver operating characteristic curve = 0.933 and 95% confidence interval (CI) = 0.780-1.000]. DISCUSSION: CrCldirect over a short interval may be an alternative marker of kidney function. Future studies may explore its use to identify patients with AKI who may benefit from early renal replacement therapy. HOW TO CITE THIS ARTICLE: Law LSC, Lo EAG, Yeoh SF. Direct Measurement of Creatinine Clearance over a Short Interval in Intensive Care Settings. Indian J Crit Care Med 2021;25(7):800-802.

Neurologic and cognitive outcomes associated with the clinical use of xenon: a systematic review and meta-analysis of randomized-controlled trials.

BACKGROUND: Xenon has been shown to have positive neurologic effects in various pre-clinical models. This study systematically reviewed the randomized-controlled trials (RCTs) investigating neurologic and cognitive outcomes associated with the clinical use of xenon. METHODS: We searched PubMed, CENTRAL, EMBASE, CINAHL, elibrary.ru (for Russian studies), Google Scholar (for Russian studies), and Wanfang (for Chinese studies) for appropriate RCTs comparing neurologic or cognitive outcomes after clinical use of xenon with control treatment or with other anesthetic agents. RESULTS: Seventeen RCTs met the inclusion criteria. Two studies investigated the effects of xenon plus therapeutic hypothermia to treat neonatal asphyxia or out-of-hospital cardiac arrest. Compared with therapeutic hypothermia alone, xenon and therapeutic hypothermia reduced cerebral white matter abnormalities after cardiac arrest but had no effect on neurocognitive outcome and mortality. Xenon had no added value when used to treat neonatal asphyxia. Thirteen RCTs compared neurocognitive effects of xenon with other anesthetic agents in surgical patients. While xenon may be associated with improved short-term (< three hours) cognitive outcome, no medium-term (six hours to three months) advantage was observed, and longer-term data are lacking. No differences in biochemical (S-100ß, neuron-specific enolase) and neuropsychologic (attentional performance) outcomes were found with xenon compared with other anesthetic drugs. Finally, two studies suggest that brief, intermittent administration of sub-anesthetic doses of xenon to patients during the acute phase of substance withdrawal may improve neurocognitive outcomes. CONCLUSIONS: Despite promising pre-clinical results, the evidence for positive clinical neurologic and cognitive outcomes associated with xenon administration is modest. Nevertheless, there is some evidence to suggest that xenon may be associated with better neurologic outcomes compared with the standard of care therapy in certain specific clinical situations. More clinical trials are needed to determine any potential benefit linked to xenon administration.

Risk of Herpes Zoster in Individuals on Biologics, Disease-Modifying Antirheumatic Drugs, and/or Corticosteroids for Autoimmune Diseases: A Systematic Review and Meta-Analysis.

BACKGROUND: Studies examining the risk of herpes zoster (HZ) associated with immunosuppressants, such as biologics, nonbiological disease-modifying antirheumatic drugs (nbDMARDs), or corticosteroids, have generated conflicting results. METHODS: We conducted a systematic literature search from January 1946 to February 2016. Search terms related to HZ, rheumatoid arthritis, psoriasis, psoriatic arthritis, systemic lupus erythematous, or inflammatory bowel disease, biologics, nbDMARDS, and corticosteroids were used. We included randomized controlled trials (RCTs) and observational studies reporting associations between immunosuppressants and HZ outcomes in adults. For RCTs, we used the Mantel-Haenszel fixed-effects model to estimate pooled odds ratios (ORs) and 95% confidence intervals (CIs) for HZ risk. For observational studies, adjusted ORs were pooled separately using random-effects inverse variance models. RESULTS: Data were pooled from 40 eligible RCTs (20136 patients) and 19 observational studies (810939 patients). Biologics were associated with a greater risk of HZ than control (RCTs: OR = 1.71, 95% CI = 1.11-2.64; observational studies: OR = 1.58, 95% CI = 1.39-1.81). In RCTs, the OR of non-tumor necrosis factor (TNF) blockers was 2.19 (95% CI 1.20-4.02), but that of TNF blockers was not significantly different from control. Increased risks of HZ with nbDMARDs (OR = 1.21; 95% CI = 1.15-1.28) and corticosteroids (OR = 1.73; 95% CI = 1.57-1.89) were observed in observational studies, but few RCTs examined these comparisons. CONCLUSIONS: Immunocompromised patients receiving biologics were associated with an increased risk of HZ. The risk is also increased with corticosteroids and nbDMARDs. These findings raise the issue of prophylaxis with zoster vaccine in patients initiating immunosuppressive therapy for autoimmune diseases.

Xenon Anesthesia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: Xenon anesthesia has been studied for decades. However, no meta-analysis of randomized controlled trials (RCTs) on xenon anesthesia has been conducted. The aim of this study was to systematically review all available evidence from RCTs comparing xenon and other inhaled and IV anesthetics on anesthetic outcomes. Our meta-analysis attempted to quantify the effects of xenon anesthesia on clinical outcomes in relation to other anesthetics. METHODS: We found 43 RCTs from PubMed, MEDLINE, CENTRAL, EMBASE, and CINAHL (until January 2015). A total of 31 studies comparing xenon (841 patients) with other inhaled agents (836 patients) and 12 studies comparing xenon (373 patients) with propofol (360 patients) were found. We evaluated clinical outcomes, such as intraoperative hemodynamics, emergence, and postoperative nausea and vomiting (PONV). RESULTS: Patients undergoing xenon anesthesia had a lower heart rate and higher mean arterial pressure (MAP) intraoperatively than those receiving volatile anesthesia (mean difference = -6 min⁻¹ [99% confidence interval {99% CI} -10.0 to -2.3]; mean difference = 9 mm Hg [99% CI 3.1-14.4]) and propofol anesthesia (mean difference = -10 min⁻¹ [99% CI -12.4 to -6.6]; mean difference = 7 mm Hg [99% CI 0.85-13.2]). Compared with baseline, intraoperative MAP remained relatively stable (change < 5.5%, 99% CI within ±20% of the baseline) under xenon anesthesia, but MAP decreased by ≥15% under volatile (mean difference = -17 mm Hg [99% CI -29.5 to - 4.9], percentage change = -17.5%) and propofol (mean difference = -14 mm Hg [99% CI -26.1 to -2.5], percentage change = -15.0%) anesthesia. Patients had faster emergence from xenon than from volatile anesthesia: eyes opening (versus all volatile agents: mean 4 vs 7 minutes, percentage change = -49.8% [99% CI -55.1% to -44.0%]), tracheal extubation (versus all volatile agents: mean 4 vs 8 minutes percentage change = -44.6% [99% CI -57.3% to -28.1%]), orientation (versus sevoflurane: mean 5 vs 10 minutes, percentage change = -45.1% [99% CI -58.5% to -28.1%]), countdown (versus sevoflurane: mean 6 vs 10 minutes, percentage change = -41.7% [99% CI -50.3% to -31.6%]; versus isoflurane: mean 6 vs 14 minutes, percentage change = -57.7% [99% CI -65.7% to -48.3%]), and reaction on demand (versus sevoflurane: mean 4 vs 8 minutes, percentage change = -53.2% [99% CI -65.7% to -35.6%]). However, xenon anesthesia increased the risks of PONV (incidence 34.4% vs 19.9%; risk ratio = 1.72 [99% CI 1.10-2.69], risk difference = 0.19 [99% CI 0.04-0.33]). CONCLUSIONS: Xenon anesthesia provides relatively more stable intraoperative blood pressure, lower heart rate, and faster emergence from anesthesia than volatile and propofol anesthesia. However, xenon is associated with a higher incidence of PONV.

A mixed-methods study on the acceptability of using eHealth for HIV prevention and sexual health care among men who have sex with men in China.

BACKGROUND: Human immunodeficiency virus (HIV) infection disproportionately affects men who have sex with men (MSM). Over half of all HIV-positive MSM in China may not know their HIV status. Mobile phones and Web interventions (eHealth) are underutilized resources that show promise for supporting HIV education, testing, and linkage to care. OBJECTIVE: This mixed-methods study among MSM in China assessed technology utilization and eHealth acceptability for sexual health care. METHODS: We conducted in-depth interviews and an online survey. Qualitative analyses informed the development of the Internet survey, which was administered through two popular MSM websites. Bivariate and multivariate analysis assessed characteristics of MSM interested in eHealth for sexual health care. RESULTS: The qualitative sample included MSM across a range of ages, education, marital status, sexuality, and HIV testing experience. Qualitative findings included the importance of the Internet as the primary source of information about sexual health, HIV and other sexually transmitted diseases (STDs), use of the Internet to enable HIV testing opportunities by facilitating connections with both the gay community and health care providers, and mixed perceptions regarding the confidentiality of eHealth tools for sexual health. Among the Internet sample (N=1342), the average age was 30.6 years old, 82.81% (1098/1342) were single, and 53.42% (711/1331) had completed college. In the past 3 months, 38.66% (382/988) had condomless sex and 60.53% (805/1330) self-reported having ever tested for HIV. The majority of men owned computers (94.14%, 1220/1296) and mobile phones (92.32%, 1239/1342), which many had used to search for HIV/STD information and testing sites. In multivariate analysis, interest in using computers or mobile phones to support their sexual health care was associated with being a student, prior use of computers or mobile phones to search for general health information, prior use of computers or mobile phones to search for HIV/STD information, and confidentiality concerns. CONCLUSIONS: MSM in this sample had high utilization of technology and interest in eHealth despite confidentiality concerns. Future eHealth interventions can thoughtfully and creatively address these concerns as a priority for successful implementation.

HIV and syphilis testing preferences among men who have sex with men in South China: a qualitative analysis to inform sexual health services.

BACKGROUND: Health services for men who have sex with men (MSM) are inadequate in many areas around the world. HIV and syphilis test uptake remain suboptimal among MSM in China and many other regions. To inform the development of more comprehensive sexually transmitted disease (STD) testing programs among MSM, we collected descriptive data on MSM testing practices and preferences. METHODS: MSM in two large urban Chinese cities were recruited through community-based organizations and clinics to participate in semi-structured interviews. We purposively sampled MSM across a range of sociodemographic characteristics and testing history, and assessed preferences for HIV and syphilis testing in the context of facilitators and barriers to testing and previous testing experiences. Each interview transcript was coded and thematically analyzed using Atlas.ti 7.0. RESULTS: 35 MSM were interviewed. Confidentiality and privacy were the most important factors influencing participants' decisions about whether and where to get tested. Men preferred rapid testing (results available within 30 minutes) compared to conventional tests where results take several hours or days to return. Participants described concerns about quality and accuracy of rapid tests offered in non-clinical settings such as community-based organizations. Men preferred testing service providers who were MSM-friendly, non-discriminatory, and medically trained. Preferred service center environments included: convenient but discrete location, MSM-friendly atmosphere, and clean/standard medical facilities. CONCLUSION: Our data highlight the need for HIV/syphilis testing services that are confidential and inclusive of MSM. Rapid testing in decentralized (i.e. peripheral health facilities and community-level, non-clinical venues) settings provides an opportunity to reach individuals who have not been tested before, but must be accompanied by quality assurance systems and technical competence. Implementation research could further evaluate HIV/syphilis testing programs responsive to MSM preferences. SHORT SUMMARY: A qualitative study of MSM in South China found that men preferred rapid STD testing at MSM-focused test centers, but were concerned about test quality assurance and confidentiality.

Use of proton pump inhibitors in the management of gastroesophageal varices: a systematic review.

OBJECTIVE: To review the efficacy and safety of proton pump inhibitors (PPIs) in gastroesophageal varices (GEVs). DATA SOURCES: MEDLINE (1946 to September 2014), EMBASE (1974 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), Cochrane Central Register of Controlled Trials (1991 to September 2014), Google, and Google Scholar were searched using the following terms: esophageal varices, gastroesophageal varices, variceal hemorrhage, variceal bleeding, banding ligation, endoscopic variceal ligation, sclerotherapy, proton pump inhibitor, PPI, omeprazole, pantoprazole, lansoprazole, dexlansoprazole, rabeprazole, and esomeprazole. STUDY SELECTION AND DATA EXTRACTION: Published and unpublished studies evaluating the clinical outcomes of PPI use for GEVs were included regardless of study design. Non-English and nonhuman studies were excluded. DATA SYNTHESIS: Of 1156 studies, 20 were included after assessment. There was wide methodological heterogeneity and moderately high risk of bias among studies. Level I evidence suggests that PPIs reduce esophageal ulcer size post-elective esophageal ligation; the clinical importance of such findings is not known given the self-limiting nature of esophageal ulcer. Available evidence does not support a role of PPIs for long-term prophylaxis of portal hypertension-related bleeding and high-dose infusion for acute management of GEV hemorrhage. Retrospective data demonstrate a potential increase in the incidence of spontaneous bacterial peritonitis in patients with cirrhosis receiving PPIs. CONCLUSIONS: The best available evidence supports the use of short-course (10 days) PPI post-endoscopic variceal ligation to reduce ulcer size if ulcer healing is a concern. Practices such as high-dose infusion and prolonged use should be discouraged until evidence of benefit becomes available.

Organizational characteristics of HIV/syphilis testing services for men who have sex with men in South China: a social entrepreneurship analysis and implications for creating sustainable service models.

BACKGROUND: UNAIDS has called for greater HIV/syphilis testing worldwide just as local HIV/syphilis testing programs are cut or altered. New models are needed to make HIV/syphilis testing services sustainable while retaining their essential public health function. Social entrepreneurship, using business principles to promote a social cause, provides a framework to pilot programs that sustainably expand testing. Drawing on fieldwork in two South Chinese cities, we examined organizational and financial characteristics of current HIV/syphilis testing systems for men who have sex with men (MSM) in addition to new pilot programs focused on revenue-generation for sustainability. METHODS: We undertook a qualitative study to explore organizational and financial characteristics of HIV/syphilis testing for MSM. Data were collected from men who have sex with men and policy stakeholders in Guangzhou and Hong Kong. Framework analysis was used to identify themes and then code the data. RESULTS: Our qualitative research study included MSM and policy stakeholders (n = 84). HIV/syphilis testing services were implemented at a wide range of organizations which we grouped broadly as independent community-based organizations (CBOs), independent clinics, and hybrid CBO-clinic sites. From an organizational perspective, hybrid CBO-clinic sites offered the inclusive environment of an MSM CBO linked to the technical capacity and trained staff of a clinic. From a financial perspective, stakeholders expressed concern about the sustainability and effectiveness of sexual health services reliant on external funding. We identified four hybrid CBO-clinic organizations that launched pilot testing programs in order to generate revenue while expanding HIV testing. CONCLUSION: Many MSM CBOs are searching for new organizational models to account for decreased external support. Hybrid CBO-clinic organizations create a strong foundation to increase HIV/syphilis testing using social entrepreneurship models in China.