Management of inadequate weight loss or weight regain in post-bariatric surgical patients.

Nurse practitioners play a key role in the front-line treatment of obesity in primary care practice settings. National guidelines for the management of obesity are provided by a majority of national organizations, yet little guidance is provided for the management of post-bariatric surgical patients who experience inadequate weight loss or early weight regain. As the number of surgical procedures increases, guidelines and interventions for managing this complex outcome are needed.

Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD).

OBJECTIVES: Therapies for post-traumatic stress disorder (PTSD) endorsed by the Department of Defense and Veterans Administration are relatively lengthy, costly, and yield variable success. We evaluated Accelerated Resolution Therapy (ART) for the treatment of combat-related psychological trauma. METHODS: A randomized controlled trial of ART versus an Attention Control (AC) regimen was conducted among 57 U.S. service members/veterans. After random assignment, those assigned to AC were offered crossover to ART, with 3-month follow-up on all participants. Self-report symptoms of PTSD and comorbidities were analyzed among study completers and by the intention-to-treat principle. RESULTS: Mean age was 41 ± 13 years with 19% female, 54% Army, and 68% with prior PTSD treatment. The ART was delivered in 3.7 ± 1.1 sessions with a 94% completion rate. Mean reductions in symptoms of PTSD, depression, anxiety, and trauma-related guilt were significantly greater (p < 0.001) with ART compared to AC. Favorable results for those treated with ART persisted at 3 months, including reduction in aggression (p < 0.0001). Adverse treatment-related events were rare and not serious. CONCLUSIONS: ART appears to be a safe and effective treatment for symptoms of combat-related PTSD, including refractory PTSD, and is delivered in significantly less time than therapies endorsed by the Department of Defense and Veterans Administration.

Malabsorption anemia and iron supplement induced constipation in post-Roux-en-Y gastric bypass (RYGB) patients.

PURPOSE: Over 250,000 bariatric surgical procedures for the management of morbid obesity are performed in the United States annually. The Roux-en-Y gastric bypass (RYGB) is an effective bariatric procedure because of its efficacy in achieving significant weight loss, low complication rates, and outcomes in reducing cardiovascular and all cause mortality. Because food bypasses the portion of the small intestine whereby micronutrients are normally absorbed, micronutrient deficiencies following surgery may lead to iron deficiency anemia. Iron deficiency anemia is estimated to occur in 6%-50% of post-RYGB patients. Consequently, the procedure requires lifelong behavioral change to ensure therapeutic iron supplementation. DATA SOURCES: A nonsystematic literature search for clinical guidelines, review articles, and research was conducted. CONCLUSIONS: Clinical recommendations include prophylactic iron supplementation with ferrous sulfate to prevent iron deficiency anemia. Ferrous sulfate is a well-established cause of constipation possibly resulting in low patient tolerability and subsequent low adherence rates. CLINICAL IMPLICATIONS: Strategies for managing the side effects of iron supplementation including constipation may require a unique approach based on the anatomical and functional changes in the post-RYGB patient and the requirement for lifelong iron supplementation.

Relationship among low cholesterol levels, depressive symptoms, aggression, hostility, and cynicism.

BACKGROUND: Treatment guidelines for lipids have become increasingly more aggressive. However, naturally low or therapeutically reduced cholesterol levels may be associated with adverse psychological health symptoms, including depression, aggression, and hostility. OBJECTIVE: To examine relationships between low total cholesterol (TC) and low-density lipoprotein (LDL) cholesterol levels and measures of psychosocial status among middle-aged adults. METHODS: A total of 1995 subjects enrolled in the Heart Strategies Concentrating on Risk Evaluation study with data on TC, LDL cholesterol, and self-reported ratings of psychological health were evaluated. To quantify ratings of depression, aggression, cynicism, and hostility, psychological measures included the Center for Epidemiologic Studies Depression Scale (CES-D) and Cook-Medley Hostility Inventory. RESULTS: Of 1995 participants, 25.1% were taking a lipid-lowering agent at baseline. Mean CES-D scores were similar between participants with low (<150 mg/dL) versus greater (≥150 mg/dL) TC and low (<100 mg/dL) versus higher (≥100 mg/dL) LDL cholesterol. However, among 22 participants with LDL cholesterol <70 mg/dL, the prevalence of clinically significant depressive symptomatology (CES-D score ≥16) was 31.8% compared with 12.1% in the remaining cohort (P = .005). In multivariable analysis, low LDL cholesterol (<100 mg/dL) was associated with cynicism (partial r = -0.14, P = .02) and hostility (partial r = -0.18, P = .004), but only in the subgroup of white subjects currently taking lipid-lowering medications. Low LDL cholesterol (versus non-low) was associated with greater aggression scores but only among participants currently taking psychiatric medications (3.4 ± 1.7 vs 2.8 ± 1.5, P = .02). CONCLUSIONS: Our data indicate mixed evidence for independent relationships between low total and LDL cholesterol levels and impaired psychological health.

Breastfeeding status and maternal cardiovascular variables across the postpartum.

BACKGROUND: There have been recent reports that lactational history is associated with long-term women's health benefits. Most of these studies are epidemiological. If particular cardiometabolic changes that occur during lactation ultimately influence women's health later is unknown. METHODS: Seventy-one healthy women participated in a prospective postpartum study that provided an opportunity to study anthropometric, endocrine, immune, and behavioral variables across time. Variables studied were heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), C-reactive protein, body mass index (BMI), perceived stress, and hormones. A cohort of women without a change in breastfeeding (N=22) or formula feeding (N=23) group membership for 5 months was used for analysis of effects of feeding status. The data were analyzed using factorial repeated measures analysis of variance and analysis of covariance. RESULTS: SBP and HR declined across the postpartum and were significantly lower in breastfeeding compared to formula feeding mothers (p<0.05). These differences remained statistically significant when BMI was added to the model. Other covariates of income, stress, marital status, and ethnicity were not significantly associated with these variables over time. DBP was also lower, but the significance was reduced by the addition of BMI as a covariate. Stress also was lower in breastfeeders, but this effect was reduced by the addition of income as a covariate. CONCLUSIONS: These data suggest that there are important physiological differences in women during months of breastfeeding. These may have roles in influencing or programming later risks for a number of midlife diseases.

Preparticipation cardiovascular screening among National Collegiate Athletic Association Division I institutions.

BACKGROUND: Sudden cardiac arrest is the leading cause of death in competitive athletes during sport, and screening strategies for the prevention of sudden cardiac death are debated. The purpose of this study was to assess the incorporation of routine non-invasive cardiovascular screening (NICS), such as ECG or echocardiography, in Division I collegiate preparticipation examinations. METHODS: Cross-sectional survey of current screening practices sent to the head athletic trainer of all National Collegiate Athletic Association (NCAA) Division I football programmes listed in the National Athletic Trainers' Association directory. RESULTS: Seventy-four of 116 (64%) programmes responded. Thirty-five of 74 (47%) of responding schools have incorporated routine NICS testing. ECG is the primary modality for NICS in 31 (42%) of schools, and 17 (49%) also utilise echocardiography. Sixty-four per cent of the programmes that do NICS routinely screen their athletes only once as incoming freshmen. Of institutions that do not conduct NICS, American Heart Association guidelines against routine NICS and cost were the most common reasons reported. CONCLUSIONS: While substantial debate exists regarding protocols for cardiovascular screening in athletes, nearly half of NCAA Division I football programmes in this study already incorporate NICS into their preparticipation screening programme. Additional research is needed to understand the impact of NICS in collegiate programmes.

Sudden cardiac death in division I collegiate athletics: analysis of automated external defibrillator utilization in National Collegiate Athletic Association division I athletic programs.

OBJECTIVE: To determine current outcomes of automated external defibrillator (AED) interventions in sports medicine programs in National Collegiate Athletic Association (NCAA) division I athletics. DESIGN: Qualitative scripted telephone interview with all positive responders to prior NCAA division I-wide study on AED utilization and implementation. SETTING: NCAA division I sports medicine programs. Head athletic trainers were the main data source. PARTICIPANTS: All positive responders to a previously published study on AED implementation in the NCAA division I sports medicine community. Positive responders were those that indicated that they had used their departmental AEDs in a sudden cardiac death (SCD) scenario. MAIN OUTCOME MEASUREMENTS: Survival to hospital discharge was the main outcome sought. When available, additional outcomes were time to defibrillation, time to notification of athletic training staff, EMS response time, location of event, and sudden cardiac victim type (i.e., student, coach, fan). RESULTS: Sixteen departments that previously reported having had an SCD event at their institution responded to this follow-up telephone survey. Twenty percent of AED uses were attributed to student athletes, with 33% of utilizations for athletic department staff and 47% for fans. Defibrillation was actually administered in 53% of AED unit applications. Time to shock was an average of 3.4 minutes, with average EMS response time of 8.2 minutes for those events without EMS on site. Reported survival to hospital discharge in this university athletic department setting for SCD was 0% for students, 75% for staff, 57% for fans, and 61% overall. CONCLUSIONS: The results of this study demonstrate the need for NCAA division 1 athletic sports medicine programs to examine, and possibly expand, the traditional scope of practice of caring primarily for student athletes to include the larger community of sports participants comprised of athletes, departmental staff, and spectators. Athletic department AED programs were extremely successfully at increasing survival of SCD far above national prehospital standards, mainly in the nonathletic population. Further study is also necessary in the realm of AED placement, maintenance, and training of staff.

Automated external defibrillators in National Collegiate Athletic Association Division I Athletics.

BACKGROUND: Sudden cardiac death is the leading cause of death in athletes. Evidence on current sudden cardiac death prevention through preparticipation history, physicals, and noninvasive cardiovascular diagnostics has demonstrated a low sensitivity for detection of athletes at high risk of sudden cardiac death. Data are lacking on automated external defibrillator programs specifically initiated to respond to rare dysrhythmia in younger, relatively low-risk populations. METHODS: Surveys were mailed to the head athletic trainers of all National Collegiate Athletic Association Division I athletics programs listed in the National Athletic Trainers' Association directory. In all, 303 surveys were mailed; 186 departments (61%) responded. RESULTS: Seventy-two percent (133) of responding National Collegiate Athletic Association Division I athletics programs have access to automated external defibrillator units; 54% (101) own their units. Proven medical benefit (55%), concern for liability (51%), and affordability (29%) ranked highest in frequency of reasons for automated external defibrillator purchase. Unit cost (odds ratio = 1.01; 95% confidence interval, 1.01-1.0), donated units (odds ratio = 1.92; confidence interval, 3.66-1.01), institution size (odds ratio =.0001; confidence interval, 1.3 E-4 to 2.2E-05), and proven medical benefit of automated external defibrillators (odds ratio = 24; confidence interval, 72-8.1) were the most significant predictors of departmental defibrillator ownership. Emergency medical service response time and sudden cardiac death event history were not significantly predictive of departmental defibrillator ownership. The majority of automated external defibrillator interventions occurred on nonathletes. CONCLUSIONS: Many athletics medicine programs are obtaining automated external defibrillators without apparent criteria for determination of need. Usage and maintenance policies vary widely among departments with unit ownership or access. Programs need to approach the issue of unit acquisition and implementation with knowledge of the surrounding emergency medical service system, geography of their individual sports medicine facilities, numbers and relative risk of their athletes, and budgetary constraints.