Decision-making for older patients undergoing emergency laparotomy: defining patient and clinician values and priorities.

AIM: There remains limited knowledge on what patients value and prioritize in their decision to undergo emergency laparotomy (ELap) and during their subsequent recovery. The aim of this study was to explore factors in decision-making and to reach a consensus amongst patients on the 10 most important priorities in decision-making in ELap. METHODS: Patients aged over 65 years who had required an ELap decision within the preceding 12 months (regardless of management) were identified and invited to attend a modified Delphi process focus group. RESULTS: A total of 20 participants attended: eight patients, four relatives and eight perioperative specialists. The perioperative specialists group defined 12 important factors for perioperative decision-making. The patient group agreed that only six (50%) of these factors were important: independence, postoperative complications, readmission to hospital, requirement for stoma formation, delirium (including long-term cognition) and presence of an advocate (such as a friend or family member). Open discussion refined multiple themes. Agreement was reached by patients and relatives about 10 factors that they valued as most important in their ELap patient journey: return to independence, realistic expectations, postoperative complications, what to expect postoperatively, readmission to hospital, nutrition, postoperative communication, stoma, follow-up and delirium. CONCLUSION: Patients and clinicians have different values and priorities when discussing the risks and implications of undergoing ELap. Patients value quality of life outcomes, in particular, the formation of a stoma, returning to their own home and remaining independent. This work is the first to combine both perspectives to guide future ELap research outcomes.

The relationship between early weight loss and weight loss at 1 year with naltrexone ER/bupropion ER combination therapy.

BACKGROUND/OBJECTIVES: Weight management medications increase the likelihood that patients will achieve clinically meaningful improvements in cardiovascular, metabolic and other weight-related measures of health. However, the weight loss achieved with any weight management intervention can vary widely among individuals, and patients who do not respond to pharmacotherapy by achieving clinically meaningful weight loss should discontinue therapy. We characterized 1-year weight loss in the phase 3 clinical trial program of the weight management medication, naltrexone/bupropion 32/360 mg (NB), as well as the relationship between early weight loss and long-term weight loss, particularly with respect to participants who achieved the clinically recommended threshold of ⩾5% weight loss by Week 16. PARTICIPANTS/METHODS: Data from participants from each of the four phase 3, randomized, placebo-controlled, 56-week clinical trials with NB were pooled (modified intent-to-treat population; NB N=2043, Placebo N=1319). This exploratory analysis examined the relationship between participant achievement of various weight loss thresholds early in treatment (at Week 8, 12 or 16) and the associated weight loss at Week 56 (Completers population; NB N=1310, Placebo N=763). RESULTS: In the NB participants who completed 1 year of treatment, weight loss of at least 5% at Week 16 (n=873) was associated with least-squares mean weight loss of 11.7% at Week 56 and 85% of these participants had Week 56 weight loss of ⩾5%. Eighty percent (95% confidence interval: 78-82%) of the participants who would, and would not, achieve ⩾5% weight loss at Week 56 were correctly identified using the clinically recommended threshold of ⩾5% at Week 16. Safety and tolerability of NB was similar to previously published reports. CONCLUSIONS: Participants who meet the Week 16 threshold of ⩾5% weight loss are likely to maintain clinically significant weight loss after 1 year of treatment. Further evaluations are required to evaluate improvements in measures of cardiovascular and metabolic risk.

Factors associated with development of excessive fatness in children and adolescents: a review of prospective studies.

The purpose of this review was to examine the factors that predict the development of excessive fatness in children and adolescents. Medline, Web of Science and PubMed were searched to identify prospective cohort studies that evaluated the association between several variables (e.g. physical activity, sedentary behaviour, dietary intake and genetic, physiological, social cognitive, family and peer, school and community factors) and the development of excessive fatness in children and adolescents (5-18 years). Sixty-one studies met the eligibility criteria and were included. There is evidence to support the association between genetic factors and low physical activity with excessive fatness in children and adolescents. Current studies yielded mixed evidence for the contribution of sedentary behaviour, dietary intake, physiological biomarkers, family factors and the community physical activity environment. No conclusions could be drawn about social cognitive factors, peer factors, school nutrition and physical activity environments, and the community nutrition environment. There is a dearth of longitudinal evidence that examines specific factors contributing to the development of excessive fatness in childhood and adolescence. Given that childhood obesity is a worldwide public health concern, the field can benefit from large-scale, long-term prospective studies that use state-of-the-art measures in a diverse sample of children and adolescents.

Remission of metabolic syndrome following a 15-week low-calorie lifestyle change program for weight loss.

OBJECTIVE: To evaluate the rate of remission of metabolic syndrome (Met Syn) among patients undergoing a brief, low-calorie lifestyle change weight loss intervention and to compare the baseline characteristics of patients who were remitted and not remitted from Met Syn at post-treatment. RESEARCH METHODS AND PROCEDURES: Obese adults (N=36) meeting criteria for Met Syn enrolled in an outpatient fee-for-service behavioral weight loss intervention. Participants were assessed on key Met Syn variables (waist circumference, blood pressure, triglycerides, high-density lipoprotein (HDL) cholesterol and fasting blood glucose) at pre- and post-treatment. RESULTS: The majority of patients (61%) responded to treatment after a 9.9% mean weight loss. Although Met Syn responders did not differ significantly from Met Syn non-responders on any baseline Met Syn criterion variable, responders had significantly lower baseline body mass indices (BMI; kg/m(2)) and met criteria for fewer baseline Met Syn variables. As expected, Met Syn responders, compared with Met Syn non-responders, had significantly lower post-treatment waist circumference, systolic and diastolic blood pressures, triglycerides and fasting blood glucose. Patient groups did not differ significantly on weight lost (kg or %), or on the proportion of patients losing > or =10% of initial body weight. DISCUSSION: In a community population, Met Syn responds to weight loss through a low-calorie lifestyle intervention; for some patients, however, the recommended 10% weight loss may not be enough for Met Syn remission.

A comparison of mental health hospital admissions in a cohort of heroin users prior to and after rapid opiate detoxification and oral naltrexone maintenance.

Mental health (MH) hospital admissions were investigated in a cohort (N=1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.

Utility and validity of the eating behavior inventory in clinical obesity research: a review of the literature.

The Eating Behavior Inventory (EBI) is a questionnaire designed to assess behaviours associated with weight loss and weight management. In the 25 years since it was first published, the EBI has been used to examine weight management behaviours of adults and children in more than 20 weight loss investigations. This paper systematically reviews the use of the EBI in these studies. Results indicate that baseline EBI scores have remained quite consistent over time and are generally not influenced by patient variables. The EBI has also been shown to be consistently sensitive to behavioural weight management interventions, but it appears that the amount of change in EBI scores has decreased slightly over time. Finally, the amount of change in EBI score with treatment typically correlates positively with the amount of weight subjects lose. Overall, the research that has used the EBI has provided solid and consistent evidence of the utility of the EBI as a valid tool for assessing weight management behaviours.

Blood naltrexone and 6-beta-naltrexol levels following naltrexone implant: comparing two naltrexone implants.

The aim of this study was to profile and compare blood naltrexone and 6-beta-naltrexol levels with time following treatment with two sustained-release naltrexone preparations produced by GoMedical Industries, Australia at a community heroin treatment clinic in Perth, Western Australia. A sample of 10 patients who each received a 1.7 g naltrexone implant were compared to 24 patients who each received a 3.4 g naltrexone implant as treatment for heroin dependence. Blood naltrexone levels following treatment with the 1.7 g naltrexone implant remained above 2 and 1 ng/ml for approximately 90 and 136 days, respectively. Use of the 3.4 g naltrexone implant extended the period of coverage to approximately 297 (1 ng/ml) or 188 (2 ng/ml) days. Blood 6-beta-naltrexol levels remained above 10 ng/ml for approximately 18 and 83 days, respectively, following use of the 1.7 g and 3.4 g naltrexone implants. The current study data indicate that blood naltrexone and 6-beta-naltrexol levels following treatment with either the 1.7 g or 3.4 g naltrexone implant are greater than those reported in other published data on other sustained-release naltrexone preparations. Furthermore, duration of blood naltrexone and 6-beta-naltrexol levels achieved following use of the 3.4 g implant were superior to those achieved with the 1.7 g naltrexone implant, with naltrexone blood levels maintained above 2 ng/ml for a period of approximately 6.3 months compared to 3 months, respectively. The implications of this in managing the heroin-dependent patient, especially those who find it difficult to shift away from dependent use patterns, are discussed.

Night eating syndrome: effects of brief relaxation training on stress, mood, hunger, and eating patterns.

BACKGROUND: Night eating syndrome (NES) is characterized by a lack of appetite in the morning, consumption of 50% or more of daily food intake after 6:00 p.m., and difficulty falling and/or staying asleep. It has been associated with stress and with poor results at attempts to lose weight. OBJECTIVE: The purpose of this study was to determine whether a relaxation intervention (Abbreviated Progressive Muscle Relaxation Therapy, APRT) that has been shown to significantly reduce stress levels in normal, healthy adults would also benefit an NES sample. RESEARCH METHODS AND PROCEDURES: A total of 20 adults with NES were randomly assigned to either a relaxation training (APRT) or a Control (quietly sitting for the same amount of time) group, and all subjects attended two laboratory sessions 1 week apart. Pre- and postsession indices of stress, anxiety, relaxation, and salivary cortisol were obtained, as well as Day 1 and Day 8 indices of mood. Food diaries and hunger ratings were also obtained. RESULTS: The results indicated that 20 min of a muscle relaxation exercise significantly reduced stress, anxiety, and salivary cortisol immediately postsession. After practicing these exercises daily for a week, subjects exhibited lowered stress, anxiety, fatigue, anger, and depression on Day 8. APRT was also associated with significantly higher a.m. and lower p.m. ratings of hunger, and a trend of both more breakfast and less night-time eating. DISCUSSION: These data support the role of stress and anxiety in NES and suggest that practicing relaxation may be an important component of treatment for this condition.

ADF/cofilin and actin dynamics in disease.

ADF/cofilins are key regulators of actin dynamics in normal cells. Recent findings suggest that, under cellular stress, the wild-type proteins might form complexes with actin that can alter cell function. Owing to their rapid formation, these complexes might initiate or aid in the progression of diseases as diverse as Alzheimer's disease and ischemic kidney disease. Although evidence for their involvement in diseases other than Alzheimer's and ischemic kidney disease is tenuous, recent studies suggest that altered production, regulation or localization of these proteins might lead to cognitive impairment, inflammation, infertility, immune deficiencies and other pathophysiological defects.

Transduction of cellular sequence by a human immunodeficiency virus type 1-derived vector.

During studies examining the rate of human immunodeficiency virus type 1 (HIV-1) mutation in a single cycle of replication, the 5' long terminal repeat of one progeny provirus was found to contain an insertion of 147 bp including an entire tRNA sequence as well as an additional 66 bp insertion of nonviral origin. Database searches revealed that 65 of 66 bp aligned with the human CpG island sequence found on chromosomes 6, 14, and 17. Therefore it seems probable that it is of human cellular sequence origin and was transduced by HIV-1. This is the first demonstration that HIV-1 can capture a cellular sequence. The site of integration of the parental provirus was mapped to chromosome 1p32.1. Sequence with homology to the transduced CpG island was not found on chromosome 1, suggesting that the transduced cellular sequence was not linked to the site of viral integration.

Sublingual capnometry and indexes of tissue perfusion in patients with circulatory failure.

OBJECTIVE: To examine the relationship between sublingual PCO(2) (PslCO(2)) and other indexes of tissue perfusion. DESIGN: Prospective observational study. SETTING: Medical and coronary ICUs in a tertiary-care teaching hospital. SUBJECTS: Twenty-five patients with circulatory failure, 19 patients with sepsis, and 6 patients with cardiac failure. MEASUREMENTS AND MAIN RESULTS: PslCO(2), gastric intramucosal PCO(2) (PiCO(2)), arterial lactate concentration, systemic oxygen delivery, and systemic oxygen consumption were measured at baseline and at 1, 3, 6, 12, and 24 h after the beginning of the study. PslCO(2) and the PslCO(2)-PaCO(2) gradient were increased but not significantly different in nonsurvivors compared to survivors at baseline. At 24 h, the mean (+/- SE) PslCO(2) was 45 +/- 4 mm Hg in survivors and 61 +/- 4 mm Hg in nonsurvivors (p = 0.06), while the PslCO(2)-PaCO(2) gradient was 14 +/- 3 mm Hg in survivors and 29 +/- 4 mm Hg in nonsurvivors (p < 0.05). No other significant differences in survivors and nonsurvivors were observed in any other index of perfusion. For all patients, the correlations between PslCO(2) and PiCO(2) (r = 0.459; p < 0.05) and cardiac index (r = 0.285; p < 0.05) were observed. The PslCO(2)-PaCO(2) gradient also was correlated with the PiCO(2)-PaCO(2) gradient (r = 0.323; p < 0.05). When patients were placed into subsets of sepsis and cardiac failure, the strength of the correlations increased in the patients with cardiac failure (PslCO(2) vs lactate, r = 0.611 and p < 0.05; PslCO(2) vs PiCO(2), r = 0.613 and p < 0.05; PslCO(2) vs PiCO(2)-PaCO(2) gradient, r = 0.648 and p < 0.05). CONCLUSION: PslCO(2) correlated best with PiCO(2) and arterial lactate concentration in patients with cardiac failure. PslCO(2) and the PslCO(2)-PaCO(2) gradient may be useful as indexes of the severity of perfusion failure.

Assessing dietary intake in the management of obesity.

This paper focuses on assessing the caloric-intake side of the energy balance equation in clinical settings. In the treatment of obesity, dietary assessment may have many purposes including the following: 1) establishing a baseline of eating patterns to determine targets of intervention and to gauge progress, 2) providing a means of monitoring change in the targeted dietary areas and behaviors, and 3) allowing for ongoing feedback to the patient. The types of data to be gathered in dietary assessment will depend on the purposes of the assessment. The nature, advantages, and disadvantages of the following dietary assessment methods are reviewed: 24-hour recall, diet history interview and questionnaire, and self-monitoring. When used on an ongoing basis in treatment, self-monitoring enhances weight-loss outcomes. However, compliance with self-monitoring varies widely across patients and over time. Possible methods of increasing compliance are discussed. Recent technological advances in software and hardware systems offer promise in improving compliance and effectiveness of self-monitoring.

Which comes first in the pathogenesis of bulimia nervosa: dieting or bingeing?

OBJECTIVE: Clinical experience has indicated that dieting usually precedes the onset of binge eating in the development of bulimia nervosa (BN). However, data confirming this in nonclinical, representative samples are lacking. METHOD: Using results obtained from the National Women's Study (NWS), we were able to determine the chronological relationship between age of onset of significant dieting (attempting to lose 15 lbs) and onset of bingeing in 85 respondents who met DSM-III-R criteria for BN. These respondents were a subset of over 3,000 female adult U.S. women who completed a random telephone interview (averaging 40 min and including screenings for rape, sexual molestation, aggravated assault, posttraumatic stress disorder [PTSD], and BN). RESULTS: We found that the age of first serious attempt to diet preceded the age of first binge in 46% of cases. There were no significant differences in histories of victimization experiences among the groups. First binge preceded first serious diet in 37% of cases, and these behaviors occurred during the same age in 17% of cases. DISCUSSION: These data confirm that dieting is more likely to precede binge eating, although binge eating precedes significant dieting in a substantial proportion of bulimic respondents.

The perceived relative worth of reaching and maintaining goal weight.

OBJECTIVE: To examine the perceived relative worth of reaching and maintaining a self-selected goal weight, for obese and non-obese individuals. DESIGN: Cross-sectional study. SUBJECTS: Twenty-five obese treatment-seekers (age 41.0 y, BMI 42.5) and a community sample of 31 obese (age 40.8 y, BMI 32.2) and 64 non-obese participants (age 32.4 y, BMI 23.4). MEASUREMENT: An 18-item forced-choice questionnaire evaluating what participants would hypothetically sacrifice to reach and maintain their goal weight. RESULTS: Most obese treatment-seekers would hypothetically endure much to achieve their desired weight. For example, 88% or more would forego a job promotion, retiring with full-pay, eliminating the national debt, or winning their dream house or car or an all-expense-paid vacation, and smaller majorities would suffer loss of half their income or a job demotion. Many non-treatment-seeking obese would forfeit future rewards to reach goal weight, but fewer would incur negative events. About a third of non-obese participants would forgo certain positive events, but few would suffer an adverse event to achieve goal weight. Within the combined obese sample, females viewed attaining goal weight as more important than did males, but there were no significant racial differences. An index of overall worth of weight goal was related positively to current weight and BMI and negatively to goal weight as percentage of current weight (P<0.01). CONCLUSION: Excessive value may be placed on attaining less than realistic weight goals, particularly but not exclusively by treatment-seeking and heavier obese people and those who desire greater weight loss. Clinicians should take this phenomenon into consideration, and public health initiatives should attempt to place body weight in a more balanced perspective.

Short-term impact of a church-based approach to lifestyle change on cardiovascular risk in African Americans.

While lifestyle modification decreases cardiovascular risk, there are barriers to lifestyle education in usual clinical practice, especially among the medically underserved. To address this gap, "Lighten Up," a church-based lifestyle program was developed in collaboration with the local African-American Christian community. Lighten Up includes a baseline health assessment (week 1), eight educational sessions (weeks 2-9) combining study of scripture and a health message, a short-term health check (week 10) and a long-term health check (week 52). Baseline and 10 week risk factor data have been obtained in 133 African Americans from eight sites (83% women) and form the basis of this report. At baseline, 76% of participants had two or more modifiable risk factors (overweight, hypertension, borderline high cholesterol, or diabetes). The entire group had significant short-term reductions in weight (-2.3 pounds, P<.01), mean blood pressure (BP, -2.1 mm Hg, P<.05), and triglycerides (-11 mg/dl, P<.05). Risk factor improvement was greater among the 60 subjects who attended 75% or more of the educational sessions. In this group, weight fell 2.9+/-0.6 pounds (mean +/- SEM; P<.01), mean BP declined 3.8+/-1.2 mm Hg (P<.01), total cholesterol was lowered 6+/-4 mg/ dl (P = .12), and triglycerides were reduced 17+/-9 mg/dl (P = .05). Lighten Up is reaching a group with multiple cardiovascular risk factors that is not optimally managed by existing healthcare resources. Of the 133 participants, 70% attended half or more of the sessions, and several components of the risk factor cluster were favorably affected.

A prospective study of holiday weight gain.

BACKGROUND: It is commonly asserted that the average American gains 5 lb (2.3 kg) or more over the holiday period between Thanksgiving and New Year's Day, yet few data support this statement. METHODS: To estimate actual holiday-related weight variation, we measured body weight in a convenience sample of 195 adults. The subjects were weighed four times at intervals of six to eight weeks, so that weight change was determined for three periods: preholiday (from late September or early October to mid-November), holiday (from mid-November to early or mid-January), and postholiday (from early or mid-January to late February or early March). A final measurement of body weight was obtained in 165 subjects the following September or October. Data on other vital signs and self-reported health measures were obtained from the patients in order to mask the main outcome of interest. RESULTS: The mean (+/-SD) weight increased significantly during the holiday period (gain, 0.37+/-1.52 kg; P<0.001), but not during the preholiday period (gain, 0.18+/-1.49 kg; P=0.09) or the postholiday period (loss, 0.07+/-1.14 kg; P=0.36). As compared with their weight in late September or early October, the study subjects had an average net weight gain of 0.48+/-2.22 kg in late February or March (P=0.003). Between February or March and the next September or early October, there was no significant additional change in weight (gain, 0.21 kg+/-2.3 kg; P=0.13) for the 165 participants who returned for follow-up. CONCLUSIONS: The average holiday weight gain is less than commonly asserted. Since this gain is not reversed during the spring or summer months, the net 0.48-kg weight gain in the fall and winter probably contributes to the increase in body weight that frequently occurs during adulthood.

Orlistat, a lipase inhibitor, for weight maintenance after conventional dieting: a 1-y study.

BACKGROUND: Long-term maintenance of weight loss remains a therapeutic challenge in obesity treatment. OBJECTIVE: This multicenter, double-blind, placebo-controlled study was designed to test the hypothesis that orlistat, a gastrointestinal lipase inhibitor, is significantly more effective than a placebo in preventing weight regain. DESIGN: Obese subjects who lost > or = 8% of their initial body weight during a 6-mo lead-in of a prescribed hypoenergetic diet (4180-kJ/d deficit) with no adjunctive pharmacotherapy were randomly assigned to receive placebo, 30 mg orlistat, 60 mg orlistat, or 120 mg orlistat 3 times daily for 1 y in combination with a maintenance diet to help prevent weight regain. Of 1313 recruited subjects [body mass index (in kg/m2): 28-43], 729 subjects lost > or =8% of their initial body weight during the 6-mo weight-loss lead-in period and were enrolled in the double-blind phase. RESULTS: After 1 y, subjects treated with 120 mg orlistat 3 times daily regained less weight than did placebo-treated subjects (32.8 +/- 4.5% compared with 58.7 +/- 5.8% regain of lost weight; P < 0.001). Moreover, more subjects in the 120-mg orlistat group than in the placebo group regained < or = 25% of lost weight (47.5% of subjects compared with 29.9%). In addition, orlistat treatment (120 mg 3 times daily) was associated with significantly greater reductions in total and LDL-cholesterol concentrations than was placebo (P < 0.001). CONCLUSION: The use of orlistat during periods of attempted weight maintenance minimizes weight readjustment and facilitates long-term improvement in obesity-related disease risk factors.

Cognitive appraisals of dietary transgressions by obese women: associations with self-reported eating behavior, depression, and actual weight loss.

OBJECTIVE: To identify three groups of obese people entering weight loss treatment, who have distinctly different cognitive appraisals of dietary transgressions and to compare these groups on self-report inventories of eating patterns, dieting, and depression, as well as on treatment completion rates and weight loss. DESIGN: Retrospective review of clinical records. Using a measure which evaluates eating-related cognitive appraisals, participants were categorized into one of three cognitive groups (All-or-None, Rationalization, Matter-of-Degree). SUBJECTS: 289 treatment-seeking obese women (age: 40.9 y, body mass index (BMI): 34.7 kg/m2). MEASUREMENTS: Self-reported eating and dieting behavior (Three-Factor Eating Questionnaire and Eating Behavior Inventory); depression (Beck Depression Inventory); attendance information and body weight obtained during treatment. RESULTS: The cognitive group representing objective thinkers (Matter-of-Degree) reported significantly fewer problems with overeating and more personal control over eating than did the rigid, dichotomous thinkers (All-or-None). In addition, the Matter-of-Degree (MAT) group endorsed significantly less subjective hunger and fewer depressive symptoms than the other two cognitive groups. The Rationalization group was more likely to complete a treatment program than was the All-or-None group, with the MAT group not differing from either. Despite these findings, there were no significant differences among cognitive groups on total weight loss. CONCLUSIONS: Cognitive appraisals of weight-control lapses appear to be associated with self-reported eating behavior, depressive symptoms and treatment completion rates, but not with treatment-induced weight loss. The relationship between long-term weight loss and cognitive appraisals of dieting lapses is yet to be determined. It appears necessary to assess empirically the validity of assumptions regarding factors associated with treatment outcome.

Matrix metalloproteinase-1 is associated with poor prognosis in oesophageal cancer.

The matrix metalloproteinases (MMPs) are a family of closely related proteolytic enzymes which are involved in the degradation of different components of the extracellular matrix. There is increasing evidence to indicate that individual MMPs have an important role in tumour invasion and tumour spread. Monoclonal antibodies specific for MMP-1, MMP-2, or MMP-9 have been produced, using as immunogens peptides selected from the amino acid sequences of individual MMPs. The presence of MMP-1, MMP-2, and MMP-9 in oesophageal cancer was investigated by immunohistochemistry on formalin-fixed, wax-embedded sections of oesophageal cancers. The relationship of individual MMPs to prognosis and survival was determined. MMP-1 was present in 24 per cent of oesophageal cancers, while MMP-2 and MMP-9 were present in 78 and 70 per cent of tumours, respectively. The presence of MMP-1 was associated with a particularly poor prognosis (log rank test 8.46, P < 0.004) and was an independent prognostic factor (P = 0.02). The identification of individual MMPs in oesophageal cancer provides a rational basis for use in the treatment of oesophageal cancer of MMP inhibitors which are currently undergoing clinical trial.