Feasibility of enhancing well-child visits with family nutrition and physical activity risk assessment on body mass index.

OBJECTIVE: Integration of behavioural risk assessment into well-child visits is recommended by clinical guidelines, but its feasibility and impact is unknown. METHODS: A quasi-experimental study evaluated the feasibility and effectiveness of risk assessment on body mass index (BMI) at 1-year follow-up. Children with assessments (intervention) were compared with those who did not complete assessments (non-respondent) and those who received standard care (non-exposed). RESULTS: Analyses included 10,647 children aged 2-9 years (2,724 intervention, 3,324 non-respondent and 4,599 non-exposed). Forty-five per cent of parents completed the assessments. Intervention and non-respondent groups differed in change in BMI z-score at 1 year by -0.05 (confidence interval [CI]: -0.08, -0.02; P = 0.0013); no difference was observed with non-exposed children. The intervention group had a smaller increase in BMI z-score (0.07 ± 0.63) than non-respondent group (0.13 ± 0.63). For children with normal weight at baseline, intervention versus non-respondent groups differed in BMI z-score change by -0.06 (CI: -0.10, -0.02; P = 0.0025). However, children with overweight at baseline in the intervention versus the non-exposed group differed in BMI z-score change (0.07 [CI: 0.02, 0.14]; P = 0.016). When analysed by age, results were similar for 2- to 5-year-olds, but no differences were found for 6- to 9-year-olds. CONCLUSION: Automating risk assessment in paediatric care is feasible and effective in promoting healthy weight among preschool but not older children.

Changes in telomere length 3-5 years after gastric bypass surgery.

Increased inflammation and oxidative stress associated with obesity can accelerate aging. Telomere length (TL) has the capacity to serve as an aging indicator at the cellular level. Obesity has a known association with shorter TL. This study evaluated TL of immune cells in a population of obese individuals who underwent gastric bypass surgery. Pre- and post-operative DNA samples were available for 50 subjects who had gastric bypass surgery. DNA was analyzed via quantitative polymerase chain reaction to determine TL. Changes in TL were evaluated by comparing TL at baseline to TL at 3-5 years post gastric bypass surgery. Sixty percent of the individuals in the study observed an increase in TL. Significant lengthening was observed for those with the shortest baseline TL (P=0.0011), but not for those with intermediate baseline TL (P=0.411) or longest baseline TL (P=0.207). Change in TL was negatively correlated with age and triglycerides but not correlated with weight loss induced by bariatric surgery. This study confirms that TL lengthening is observed post bariatric surgery and is the first to detect TL lengthening 3-5 years after surgery.

Electronically captured, patient-reported physical function: an important vital sign in obesity medicine.

OBJECTIVES: Impaired physical function (i.e., inability to walk 200 feet, climb a flight of stairs or perform activities of daily living) predicts poor clinical outcomes and adversely impacts medical and surgical weight management. However, routine assessment physical function is seldom performed clinically. The PROMIS Physical Function Short Form 20a (SF-20a) is a validated questionnaire for assessing patient reported physical function, which includes published T-score percentiles adjusted for gender, age and education. However, the effect that increasing levels of obesity has on these percentiles is unclear. We hypothesized that physical function would decline with increasing level of obesity independent of gender, age, education and comorbidity. MATERIALS AND METHODS: This study included 1,627 consecutive weight management patients [(mean ± SEM), 44.7 ± 0.3 years and 45.1 ± 0.2 kg/m2] that completed the PROMIS SF-20a during their initial consultation. We evaluated the association between obesity level and PROMIS T-score percentiles using multiple linear regression adjusting for gender, age, education and Charlson Comorbidity Index (CCI). RESULTS: Multiple linear regression T-score percentiles were lower in obesity class 2 (-12.4%tile, p < 0.0001), class 3 (-17.0%tile, p < 0.0001) and super obesity (-25.1%tile, p < 0.0001) compared to class 1 obesity. CONCLUSION: In patients referred for weight management, patient reported physical function was progressively lower in a dose-dependent fashion with increasing levels of obesity, independent of gender, age, education and CCI.

Gene expression profiling in subcutaneous, visceral and epigastric adipose tissues of patients with extreme obesity.

OBJECTIVE: The goal of the present study was to identify differences in gene expression between SAT, VAT and EAT depots in Class III severely obese individuals. DESIGN: Human subcutaneous (SAT) and visceral (VAT) adipose tissues exhibit differential gene expression profiles. There is little information, however, about the other proximal white adipose tissue, epigastric (EAT), in terms of its function and contribution to metabolism. SUBJECTS AND METHODS: Using RNA from adipose biospecimens obtained from Class III severely obese patients undergoing open Roux-en-Y gastric bypass surgery, we compared gene expression profiles between SAT, VAT and EAT, using microarrays validated by real-time quantitative PCR. RESULTS: The three depots were found to share 1907 genes. VAT had the greatest number of genes (66) expressed exclusively in this depot, followed by SAT (23), and then EAT (14). Moreover, VAT shared more genes with EAT (65) than with SAT (38). Further analyses using ratios of SAT/EAT, VAT/EAT and SAT/VAT identified specific as well as overlapping networks and pathways of genes representing dermatological diseases, inflammation, cell cycle and growth, cancer and development. Targeted analysis of genes, having a role in adipose tissue development and function, revealed that Peroxisome proliferator-activated receptor Gamma Coactivator 1-alpha (PGC1-α) that regulates the precursor of the hormone Irisin (FNCD5) were abundantly expressed in all three fat depots, along with fibroblast growth factors (FGF) FGF1, FGF7 and FGF10, whereas, FGF19 and FGF21 were undetectable. CONCLUSIONS: These data indicate that EAT has more in common with VAT, suggesting similar metabolic potential. The human epigastric adipose depot could have a significant functional role in metabolic diseases and should be further investigated.

Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments.

UNLABELLED: To determine whether a process redesign could improve detection and treatment of osteoporosis, at-risk women over the age of 65 were identified using an electronic medical record and proactively contacted by letter and phone call. This resulted in a significant increase in testing for osteoporosis by DXA scan. The high-risk patients were then offered a shared medical appointment, which resulted in improved treatment outcomes compared to usual care. INTRODUCTION: Our objective was to determine if redesigning care through proactive contact with women 65 at-risk of osteoporosis increased BMD testing and to determine if a shared medical appointment (SMA) improved treatment for high-risk women. METHODS: Two primary care sites received the redesign intervention and two other sites served as the usual care controls. At the intervention sites, all women 65 who had not had a DXA scan performed in the prior 2 years were contacted by mail and phone calls. High-risk patients were invited to attend a SMA or follow-up visit with their primary physician. RESULTS: A significantly higher proportion of women at the intervention sites had a DXA (39.6% vs. 13.2%, p < 0.0001). Patients who attended the SMA were more likely to have calcium and vitamin D recommended, a vitamin D level checked, and receive a prescription medicine than those patients who had follow-up with their primary care physician. CONCLUSIONS: The redesigned process was highly effective in improving BMD testing for women 65. The SMA was shown to be a more effective method to make calcium and vitamin D recommendations, to evaluate secondary causes of low bone density, and to prescribe prescription medications, compared to usual care with the PCP.

Elevated blood pressure in primary care varies in relation to circadian and seasonal changes.

Blood pressure (BP) is known to vary by time of day and day of year. Studies differ substantially on the magnitude of the effect and there is doubt whether variation is clinically meaningful. We used more than 2 million BP measurements obtained between 1996 and 2004 from Geisinger Clinic primary care patients. General estimating equations were used to determine the effect of time of day and month of year on the probability of identifying BP values above four diagnostic cutoff points (SBP > or =120 mm Hg, SBP > or =140 mm Hg, DBP > or =80 mm Hg, DBP > or =90 mm Hg). Time of day and month of year were significantly associated with the odds of measuring elevated BP, regardless of definition. The odds ratio (OR) for SBP > or =120 mm Hg in the evening (1900 hours) versus midday (1200 hours) was 1.32 (P < 0.001). The OR for SBP > or =120 mm Hg in winter to summer months was 1.24 (P < 0.001). Similar results were found for each age/gender group. These data indicate that in clinical practice, measurement of an elevated BP may vary by 40% depending on the time of day and month of year. The magnitude of the variability in BP measurement attributable to the combined effect of these temporal factors is clinically significant. Anticipation of changes in BP attributable to temporal factors may improve accuracy of diagnosis and precision of therapy.

Clinical importance of the presence of giant cells in temporal arteritis.

BACKGROUND: The clinical significance of giant cells seen on temporal artery biopsy in temporal arteritis is unknown. AIM: To help define the prognostic value of the presence of giant cells in temporal arteritis. METHODS: The clinical course of all patients with biopsy proven temporal arteritis from 1994 to 2004 was reviewed. The 92 patients were divided into those with giant cells (GC) (n = 76) seen on biopsy and those with no giant cells (NGC) (n = 16). Clinical findings were compared between groups. An additional analysis combined results with a previous study at the same institution to compare occurrence of blindness. RESULTS: The GC group had a higher proportion of polymyalgia rheumatica (PMR) (36.8%) compared to the NGC group (12.5%) (p = 0.059). There was no significant difference in patient age, sex, sedimentation rate, or presenting symptoms. The length of time treated with corticosteroids and relapse rate was nearly identical for both groups. When combining data with the previous study, in the GC group 21/109 (19%) developed blindness, while only 2/34 (6%) became blind in the NGC group (p = 0.11). CONCLUSION: The presence of giant cells is not a significant factor in determining treatment or clinical progression of temporal arteritis. However, results showed the GC group to have three times the occurrence of blindness and PMR compared to the NGC group. Although the differences were not significant, this analysis suggests an association with giant cells and more aggressive disease.

Glucocorticoid-Induced Osteoporosis Program (GIOP): a novel, comprehensive, and highly successful care program with improved outcomes at 1 year.

INTRODUCTION: Patients who take chronic glucocorticoids (GC) are at increased risk of osteoporosis and fracture. Only a minority of patients who take chronic GC receive optimal osteoporosis prevention, diagnosis, and/or treatment. METHODS: An organized program of care--GIOP (Glucocorticoid-Induced Osteoporosis Program)--was designed and implemented. The program goals were to identify patients at risk of fracture, provide education, redesign and implement new pathways of care, and monitor outcomes. Two hundred chronic GC users were seen at baseline, and follow-up visits scheduled at 6 months and 1 year. RESULTS: Patient retention of knowledge, frequent exercise, and 25-OH Vitamin D levels all significantly improved at 1 year. A significant decrease in GC dose was seen. In terms of adherence, 91% of patients considered at high risk were taking a bisphosphonate or teriparatide at 1 year, and 96% of patients overall were adherent to their prescribed regimen of calcium, vitamin D, and prescription treatment (if indicated). Bone density at the spine and total hip increased significantly. CONCLUSIONS: GIOP is the first organized program of care for patients who take chronic GC that has demonstrated a clinically significant improvement in outcome. The program's design can be adapted and used by other health systems and organizations.

Outcome assessment in the elderly after total hip arthroplasty.

An analysis of the Short-Form 36 (SF-36) and Oxford Hip questionnaires, were used to assess 2 randomized groups, by either mail or interview, at a minimum 10-year follow up after total hip arthroplasty. Ninety-nine patients (median age 77 years) were reviewed at a median 11 years after total hip arthroplasty. There was a 91% response rate to participation in the study. There was no significant difference between the groups for missing values. The mode of administration did not affect the mean Oxford scores (P > .1), but significant differences were noted in SF-36 health scales Role Emotional and Role Physical (P = .01). Analysis of other demographic variables revealed unexpectedly that comorbidity affected the Pain score in the Oxford questionnaire (P = .002) and that age had no effect on scores obtained in either questionnaire (P > .05). The uses of both general health and disease-specific questionnaires complement each other in the assessment of such groups. The SF-36 and Oxford questionnaires give a more accurate reflection of health status when self-completed while accepting higher missing values in an elderly population.

Osteoporosis disease management in a rural health care population: hip fracture reduction and reduced costs in postmenopausal women after 5 years.

A 5 year observational study is reported which reviews the implementation of the Geisinger Health System Osteoporosis Disease Management Program. This program includes Osteoporosis Clinical Practice Guidelines, physician and allied health care provider education, community education, and a bone density testing program. All women over the age of 55 years enrolled in the Geisinger Health Plan (GHP) from 1996 to 2000 were included in this analysis. The guidelines led health care providers to increase the evaluation of osteoporosis via bone density measurements and to increase the prescription treatment of osteoporosis. Most importantly, the age-adjusted incidence of hip fractures fell significantly in the entire group as well as in several age strata (65-74, 75-84 and 85+ years). Compared with a predictive model of no intervention, there was an overall reduction in health care costs to GHP estimated to be US$7.8 million over a 5 year period. This report is the first to suggest that an organized Osteoporosis Disease Management Program delivered by a health care system can result in increased evaluation and treatment of osteoporosis with a resultant significant decrease in hip fractures while decreasing the total direct costs of care to a health plan.

Comparison of laboratory values obtained by means of routine venipuncture versus peripheral intravenous catheter after a normal saline solution bolus.

STUDY OBJECTIVE: This study compares selected laboratory values of blood samples obtained by means of venipuncture and by means of a peripheral intravenous catheter after a normal saline solution bolus. METHODS: In this prospective experimental study, each participant served as his or her own control. Hospital employees volunteered in the emergency department of a tertiary-care teaching hospital. Participants had a peripheral catheter placed in one upper extremity and received a 200-mL bolus of normal saline solution during a 10-minute period. After a 2-minute wait period, a 12-mL aspirate was withdrawn directly from the saline solution lock. A second 12-mL aspirate was also obtained. Concurrently, venipuncture was performed on the other upper extremity. All 3 samples were analyzed for CBC, electrolytes, blood urea nitrogen, creatinine, glucose, liver function tests, and prothrombin time/international normalized ratio (PT/INR). Limits of agreement analysis based on the definition of clinical equivalence, as determined by surveying residency-trained and board-certified emergency physicians, was used to compare the results of catheter aspirates with those of venipuncture aspirates. RESULTS: Thirty-three volunteers participated. When comparing venipuncture versus first aspirate, 16 of the 19 laboratory tests evaluated had 99% agreement intervals that were within the predetermined definition of clinical equivalence. Potassium, bicarbonate, and glucose did not demonstrate clinical equivalence, and this difference persisted after a 12-mL discard volume. CONCLUSION: This study supports the use of blood samples obtained by means of aspiration from a peripheral catheter when testing for CBC, blood urea nitrogen, creatinine, liver function tests, and PT/INR in healthy-appearing patients. Catheter aspiration, when testing for electrolytes and glucose, may be reasonable in a more select group of patients.

The effect of working serial night shifts on the cognitive functioning of emergency physicians.

STUDY OBJECTIVE: We sought to determine whether working 5 serial night shifts in the emergency department results in a decline in physician performance as measured with an intelligence test. METHODS: This study compared the cognitive functioning of emergency physicians who worked the day shift (7 AM to 5 pm) with those who worked 5 consecutive night shifts (11 pm to 7 am). The Fluid Scale of the Kaufman Adolescent and Adult Intelligence Test (KAIT) was administered to 16 emergency medicine residents. Half of the residents (group A) were tested while working day shifts, and the other half (group B) were tested after working 5 consecutive night shifts. After a minimum interval of 2 months, the residents were retested in reverse order, with group A tested after working night shifts and group B tested while working day shifts. RESULTS: A total of 16 emergency medicine residents were tested. A paired t test was used to determine whether day-shift KAIT scores are different from night-shift KAIT scores. The mean day-shift KAIT score was 119.1 (SD=7.7), and the mean night-shift KAIT score was 107.2 (SD=10.2). This difference was significant (mean difference=11.9; 95% confidence interval 7.0 to 16.8; P <.001), with the day-shift scores being statistically higher than the night-shift scores. CONCLUSION: Working a series of 5 night shifts results in a substantial decline in cognitive performance in physicians working in the ED.

Assessing the true risk of abdominal solid organ injury in hospitalized rib fracture patients.

BACKGROUND: Despite the lack of evidence, traditional trauma teaching has suggested that low rib fractures increase the risk of abdominal solid organ injury (ASOI). This study was designed to assess if in fact this is true, and to try and define other factors that increased the risk of ASOI in rib fracture patients. METHODS: The charts of 476 hospitalized rib fracture trauma patients were reviewed. Data were collected for age; sex; Injury Severity Score (ISS); rib fracture location; and the presence or absence of injuries to the abdominal organs, head, neck, face, thorax, great vessel, heart, thoracolumbar spine, pelvis, and extremities. RESULTS: The probability of liver injury increased with the presence of any right-sided rib fracture, any low rib fracture, female gender, young age, and an elevated ISS. The probability of splenic injury increased with the presence of left-sided rib fractures only, any low rib fracture, young age, and an elevated ISS. CONCLUSION: In hospitalized trauma patients, low rib fractures, right-sided rib fractures, female gender, young age, and an elevated ISS increased the probability of liver injury; and low rib fractures, left-sided only rib fractures, young age, and an elevated ISS increased the probability of splenic injury. Associated pelvic fractures and long bone fractures did not increase the likelihood of ASOI in this cohort.

A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic.

Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.

Intermittent and continuous ceftazidime infusion for critically ill trauma patients.

BACKGROUND: The adequacy of intermittent and continuous infusion ceftazidime for the treatment of nosocomial pneumonia in critically ill trauma patients was assessed by analyzing ceftazidime pharmacokinetics in relation to the minimum inhibitory concentration (MIC) and treatment outcome. METHODS: Serial blood samples were obtained during ceftazidime therapy in 31 trauma patients. Ceftazidime pharmacokinetics were compared with that of previously studied healthy volunteers. Ceftazidime pharmacokinetics were analyzed according to the time above the MIC and treatment outcome. RESULTS: Critically ill trauma patients had a significantly increased volume of distribution and clearance (0.32 +/- 0.14 L/kg and 2.35 +/- 0.89 mL. min(-1). kg(-1), respectively) compared with healthy volunteers (0.21 +/- 0.03 and 1.58 +/- 0.23 mL. min(-1). kg(-1)). The time above the MIC was >/=92% of the dosing interval for all patients and treatment outcomes were similar between the two treatment groups. CONCLUSIONS: Ceftazidime pharmacokinetics are significantly altered in critically ill trauma patients. Both intermittent and continuous ceftazidime regimens were equally effective for the treatment of nosocomial pneumonia caused by less virulent bacteria.

Incidence of intracranial hemorrhage complicating treatment with glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis of major clinical trials.

PURPOSE: The major risk of therapy with platelet glycoprotein IIb/IIIa receptor inhibitors is bleeding. We reviewed trials using these agents to determine if bleeding risks include an increased incidence of intracranial hemorrhage. METHODS: A Medline search identified 14 randomized trials of intravenous platelet glycoprotein IIb/IIIa receptor inhibitors for patients undergoing percutaneous coronary intervention or who had an acute coronary syndrome. We compared the incidence of intracranial hemorrhage among 15,850 patients treated with glycoprotein IIb/IIIa inhibitors with that among 12,039 patients treated with placebo. RESULTS: The incidence of intracranial hemorrhage with heparin plus any IIb/IIIa inhibitor was similar to placebo with heparin (0.12% vs 0.09%, odds ratio = 1.3, 95% confidence interval: 0.6 to 3.1, P = 0.59). The incidence of intracranial hemorrhage with glycoprotein IIb/IIIa drugs alone was similar to that with heparin alone (0.07% vs 0.06%), albeit with a wide confidence interval (odds ratio = 1.2, 95% confidence interval: 0.1 to 16, P = 1.0). CONCLUSIONS: Intravenous glycoprotein IIb/IIIa receptor inhibitors alone or in combination with heparin do not cause a statistically significant excess of intracranial hemorrhage as compared with heparin alone. Because of small numbers, the data do not exclude the possibility of an excess of intracranial hemorrhage in some groups of patients treated with glycoprotein IIb/IIIa receptor inhibitors.

Thrombocytopenia complicating treatment with intravenous glycoprotein IIb/IIIa receptor inhibitors: a pooled analysis.

BACKGROUND: Despite the increasingly prevalent role of platelet glycoprotein (GP) IIb/IIIa receptor inhibitors in acute coronary syndromes and percutaneous coronary interventions, the incidence and clinical relevance of thrombocytopenia occurring with their use remain unclear. METHODS: We identified 8 placebo-controlled, randomized, large trials of GP IIb/IIIa receptor inhibitors reporting the incidence of thrombocytopenia, grouped by severity. The clinical courses of 42 patients with GP IIb/IIIa-related thrombocytopenia in these studies and other case reports were reviewed for bleeding complications. RESULTS: Abciximab increased mild thrombocytopenia compared with placebo (4.2% vs 2.0%; P <.001; odds ratio 2.14) and increased severe thrombocytopenia compared with placebo (1.0% vs 0.4%; P =.01; odds ratio 2.48). Small-molecule IIb/IIIa inhibitors did not significantly increase mild or severe thrombocytopenia compared with placebo. Mild thrombocytopenia occurred more frequently in acute coronary syndrome trials than in coronary intervention trials, even in patients not receiving any IIb/IIIa inhibitors. No major bleeding sequelae were reported in 23 patients with severe thrombocytopenia or in 19 patients with profound thrombocytopenia. CONCLUSIONS: Abciximab, but not eptifibatide or tirofiban, increases the incidence of thrombocytopenia compared with placebo in patients also treated with heparin. Thrombocytopenia associated with GP IIb/IIIa inhibition does not routinely lead to severe bleeding complications.