Mortality following elective abdominal aortic aneurysm repair in women.

BACKGROUND: Previous studies have focused on patient-related risk factors to explain the higher mortality risk in women undergoing elective abdominal aortic aneurysm (AAA) repair. The aim of this study was to evaluate whether hospital-related factors influence outcomes following AAA repair in women. METHODS: Patients undergoing elective AAA repair in 61 hospitals in the Netherlands were identified from the Dutch Surgical Aneurysm Audit registry (2013-2018). A mixed-effects logistic regression analysis was conducted to assess the effect of sex on in-hospital and/or 30-day mortality. This analysis accounted for possible correlation of outcomes among patients who were treated in the same hospital, by adding a hospital-specific random effect to the statistical model. The analysis adjusted for patient-related risk factors and hospital volume of open surgical repair (OSR) and endovascular aneurysm repair (EVAR). RESULTS: Some 12 034 patients were included in the analysis. The mortality rate was higher in women than among men: 53 of 1780 (3.0 per cent) versus 152 of 10 254 (1.5 per cent) respectively. Female sex was significantly associated with mortality after correction for patient- and hospital-related factors (odds ratio 1.68, 95 per cent c.i. 1.20 to 2.37). OSR volume was associated with lower mortality (OR 0.91 (0.85 to 0.95) per 10-procedure increase) whereas no such relationship was identified with EVAR volume (OR 1.03 (1.01 to 1.05) per 10-procedure increase). CONCLUSION: Women are at higher risk of death after abdominal aortic aneurysm repair irrespective of patient- and hospital-related factors.

Short-term outcomes of open surgical abdominal aortic aneurysm repair from the Dutch Surgical Aneurysm Audit.

BACKGROUND: The sharp decrease in open surgical repair (OSR) for abdominal aortic aneurysm (AAA) has raised concerns about contemporary postoperative outcomes. The study was designed to analyse the impact of complications on clinical outcomes within 30 days following OSR. METHODS: Patients who underwent OSR for intact AAA registered prospectively between 2016 and 2019 in the Dutch Surgical Aneurysm Audit were included. Complications and outcomes (death, secondary interventions, prolonged hospitalization) were evaluated. The adjusted relative risk (aRr) and 95 per cent confidence intervals were computed using Poisson regression. Subsequently, the population-attributable fraction (PAF) was calculated. The PAF reflects the expected percentage reduction of an outcome if a complication were to be completely prevented. RESULTS: A total of 1657 patients were analysed. Bowel ischaemia and renal complications had the largest impact on death (aRr 12·44 (95 per cent c.i. 7·95 to 19·84) at PAF 20 (95 per cent c.i. 8·4 to 31·5) per cent and aRr 5·07 (95 per cent c.i. 3·18 to 8.07) at PAF 14 (95 per cent c.i. 0·7 to 27·0) per cent, respectively). Arterial occlusion had the greatest impact on secondary interventions (aRr 11·28 (95 per cent c.i. 8·90 to 14·30) at PAF 21 (95 per cent c.i. 14·7 to 28·1) per cent), and pneumonia (aRr 2·52 (95 per cent c.i. 2·04 to 3·10) at PAF 13 (95 per cent c.i. 8·3 to 17·8) per cent) on prolonged hospitalization. Small effects were observed on outcomes for other complications. CONCLUSION: The greatest clinical impact following OSR can be made by focusing on measures to reduce the occurrence of bowel ischaemia, arterial occlusion and pneumonia.

Edmonton Obesity Staging System for Pediatrics, quality of life and fitness in adolescents with obesity.

BACKGROUND: Body mass index (BMI) is often used to diagnose obesity in childhood and adolescence but has limitations as an index of obesity-related morbidity. The Edmonton Obesity Staging System for Pediatrics (EOSS-P) is a clinical staging system that uses weight-related comorbidities to determine health risk in paediatric populations. The purpose of this study was to investigate the associations of EOSS-P and BMI percentile with quality of life (QOL), cardiorespiratory fitness (CRF) and muscular strength in adolescents with obesity. METHODS: Participants were enrolled at baseline in the Healthy Eating, Aerobic and Resistance Training in Youth trial (BMI = 34.6 ± 4.5 kg m-2, age = 15.6 ± 1.4 years, N = 299). QOL, CRF (peak oxygen uptake, VO2peak) and muscular strength were assessed by the Pediatric QOL Inventory (PedsQL), indirect calorimetry during a maximal treadmill test and eight-repetition maximum bench and leg press tests, respectively. Participants were staged from 0 to 3 (absent to severe health risk) according to EOSS-P. Associations were assessed using age-adjusted and sex-adjusted general linear models. RESULTS: Quality of life decreased with increasing EOSS-P stages (p < 0.001). QOL was 75.7 ± 11.4 in stage 0/1, 69.1 ± 13.1 in stage 2 and 55.4 ± 13.0 in stage 3. BMI percentile was associated with VO2peak (ß = -0.044 mlO2 kg-1 min-1 per unit increase in BMI percentile, p < 0.001), bench press (ß = 0.832 kg per unit increase in BMI percentile, p = 0.029) and leg press (ß = 3.992 kg, p = 0.003). There were no significant differences in treadmill time or VO2peak between EOSS-P stages (p > 0.05). CONCLUSION: As EOSS-P stages increase, QOL decreases. BMI percentile was negatively associated with CRF and positively associated with muscular strength.

Understanding low adherence to an exercise program for adolescents with obesity: the HEARTY trial.

INTRODUCTION: Despite efforts to improve adherence to physical activity interventions in youth with obesity, low adherence and attrition remain areas of great concern. OBJECTIVE: The study was designed to determine which physiological and/or psychological factors predicted low adherence in adolescents with obesity enrolled in a 6-month exercise intervention study aimed to improve body composition. METHODS: Three hundred four adolescents with obesity aged 14-18 years who volunteered for the HEARTY (Healthy Eating Aerobic and Resistance Training in Youth) randomized controlled trial completed physiological (body mass index, waist circumference, per cent body fat, resting metabolic rate and aerobic fitness) and psychological (body image, mood, self-esteem and self-efficacy) measures. RESULTS: One hundred forty-one out of 228 (62%) randomized to exercise groups had low adherence (completed <70% of the prescribed four exercise sessions per week) to the intervention protocol. Logistic regression revealed that there were no baseline demographic or physiological variables that predicted low adherence in the participants. Appearance concern (a subscale of body image) (odds ratio [OR] 1.46, 95% confidence interval [CI]: 1.01, 2.1, P = 0.04), depressive mood (OR 1.12, 95% CI: 1.01, 1.23, P = 0.03) and confused mood (OR 1.16, 95% CI: 1.05, 1.27, P = 0.003) (two subscales of mood) were significant predictors of low adherence. CONCLUSIONS: Adolescents with obesity who had higher appearance concerns and depressive and confused moods were less likely to adhere to exercise. Body image and mood should be screened to identify adolescents who may be at high risk of poor adherence and who may need concurrent or treatment support to address these psychological issues to derive maximal health benefits from an exercise programme.

Addressing weight bias and discrimination: moving beyond raising awareness to creating change.

Weight discrimination is the unjust treatment of individuals because of their weight. There have been very few interventions to address weight discrimination, due in part to the lack of consensus on key messages and strategies. The objective of the third Canadian Weight Bias Summit was to review current evidence and move towards consensus on key weight bias and obesity discrimination reduction messages and strategies. Using a modified brokered dialogue approach, participants, including researchers, health professionals, policy makers and people living with obesity, reviewed the evidence and moved towards consensus on key messages and strategies for future interventions. Participants agreed to these key messages: (1) Weight bias and obesity discrimination should not be tolerated in education, health care and public policy sectors; (2) obesity should be recognized and treated as a chronic disease in health care and policy sectors; and (3) in the education sector, weight and health need to be decoupled. Consensus on future strategies included (1) creating resources to support policy makers, (2) using personal narratives from people living with obesity to engage audiences and communicate anti-discrimination messages and (3) developing a better clinical definition for obesity. Messages and strategies should be implemented and evaluated using consistent theoretical frameworks and methodologies.

Weight bias reduction in health professionals: a systematic review.

Innovative and coordinated strategies to address weight bias among health professionals are urgently needed. We conducted a systematic literature review of empirical peer-reviewed published studies to assess the impact of interventions designed to reduce weight bias in students or professionals in a health-related field. Combination sets of keywords based on three themes (1: weight bias/stigma; 2: obesity/overweight; 3: health professional) were searched within nine databases. Our search yielded 1447 individual records, of which 17 intervention studies satisfied the inclusion criteria. Most studies (n = 15) included medical, dietetic, health promotion, psychology and kinesiology students, while the minority included practicing health professionals (n = 2). Studies utilized various bias-reduction strategies. Many studies had methodological weaknesses, including short assessment periods, lack of randomization, lack of control group and small sample sizes. Although many studies reported changes in health professionals' beliefs and knowledge about obesity aetiology, evidence of effectiveness is poor, and long-term effects of intervention strategies on weight bias reduction remain unknown. The findings highlight the lack of experimental research to reduce weight bias among health professionals. Although changes in practice will likely require multiple strategies in various sectors, well-designed trials are needed to test the impact of interventions to decrease weight bias in healthcare settings.

Effects of aerobic and resistance training on abdominal fat, apolipoproteins and high-sensitivity C-reactive protein in adolescents with obesity: the HEARTY randomized clinical trial.

OBJECTIVES: To investigate the effects of aerobic training, resistance training, or both on abdominal subcutaneous fat (subcutaneous adipose tissue (SAT)) (deep and superficial), visceral fat (visceral adipose tissue (VAT)), apolipoproteins A-1 and B (ApoA-1, ApoB), ApoB/ApoA-1 ratio and high-sensitivity C-reactive protein (HSCRP) in post-pubertal adolescents with obesity. PARTICIPANTS: After a 4-week supervised moderate-intensity exercise run-in period, 304 postpubertal adolescents with overweight (body mass index (BMI) ⩾85th percentile for age and sex+diabetes risk factor) or obesity (⩾95th BMI percentile) aged 14-18 years were randomized to four groups for 22 weeks (5 months): aerobic training, resistance training, combined training or a non-exercising control. METHODS: This study used a randomized controlled design. All groups received dietary counseling designed to promote healthy eating with a maximum daily energy deficit of 250 kcal. Abdominal fat (SAT and VAT) at the level of the fourth and fifth lumbar vertebrae (L4-L5) was measured by magnetic resonance imaging and ApoA-1, ApoB and HSCRP were measured after a 12-h fast at baseline and after 6 months. RESULTS: Changes in SAT at L4-L5 were -16.2 cm(2) in aerobic (P=0.04 vs control), -22.7 cm(2) in resistance (P=0.009 vs control) and -18.7 cm(2) in combined (P=0.02 vs control). Combined training reduced ApoB levels from 0.81±0.02 to 0.78±0.02 g l(-1) (P=0.04 vs control) and ApoB/ApoA-1 ratio from 0.67±0.02 to 0.64±0.02 (P=0.02 vs control and P=0.04 vs aerobic). There were no significant differences in VAT, ApoA-1 or HSCRP levels between groups. CONCLUSIONS: Aerobic and resistance training and their combination decreased abdominal SAT in adolescents with obesity. Combined training caused greater improvements in ApoB/ApoA-1 ratio compared with aerobic training alone.

A review of randomized controlled trials of aerobic exercise training on fitness and cardiometabolic risk factors in obese adolescents.

Aerobic training is the most prescribed exercise modality for the management of pediatric obesity. There is strong evidence that it decreases waist circumference, percent body fat and visceral fat, increases cardiorespiratory fitness, and decreases blood pressure in obese adolescents. However, the independent effects of aerobic exercise training on other cardiometabolic risk factors (ie, insulin resistance markers, plasma lipid levels, and inflammatory markers) are limited and yield inconsistent findings. Our article reviews randomized controlled trials evaluating the effects of aerobic exercise training on body composition, fitness, lipid levels, and insulin resistance in obese adolescents (aged 13-18 years) and outlines future research directions for this population.

Healthy Eating, Aerobic and Resistance Training in Youth (HEARTY): study rationale, design and methods.

PURPOSE: The objective of the Healthy Eating Aerobic and Resistance Training in Youth (HEARTY) trial (ClinicalTrials.Gov # NCT00195858) was to examine the effects of resistance training, with and without aerobic training, on percent body fat in sedentary, post-pubertal overweight or obese adolescents aged 14-18 years. This paper describes the HEARTY study rationale, design and methods. METHODS: After a 4-week supervised low-intensity exercise run-in period, 304 overweight or obese adolescents with a body mass index≥85th percentile for age and sex were randomized to 4 groups for 22 weeks (5 months): diet+aerobic exercise, diet+resistance exercise, diet+combined aerobic and resistance exercise, or a diet only waiting-list control. All participants received dietary counseling designed to promote healthy eating with a maximum daily energy deficit of -250 kcal. OUTCOMES: The primary outcome is percent body fat measured by Magnetic Resonance Imaging. Secondary outcomes include changes in anthropometry, regional body composition, resting energy expenditure, cardiorespiratory fitness, musculoskeletal fitness, cardiometabolic risk markers, and psychological health. SUMMARY: To our knowledge, HEARTY is the largest clinical trial examining effects of aerobic training, resistance training, and combined aerobic and resistance training on changes in adiposity and cardiometabolic risk markers in overweight and obese adolescents. The findings will have important clinical implications regarding the role that resistance training should play in the management of adolescent obesity and its co-morbidities.

Overweight and obese teenagers: why is adolescence a critical period?

This paper discusses the critical period of adolescence and its potential role in the development and persistence of obesity. The adolescent years are characteristic of changes in body composition (location and quantity of body fat), physical fitness and decreased insulin sensitivity during puberty. This period of growth and maturation is also marked with behavioural changes in diet, physical activity, sedentary behaviour and psychological health. Physical activity and sport participation decline during adolescence especially in teenage girls, while sedentary behaviour, risk for depression and body esteem issues increase during the teenage years. These physiological and behavioural changes during adolescence warrant the attention of health practitioners to prevent the onset and continuation of obesity throughout the lifespan.

Definition of the DNA-binding site repertoire for the Drosophila transcription factor SNAIL.

The Drosophila gene snail (sna) which encodes a zinc finger protein is essential for dorsal-ventral pattern formation in the developing embryo. We have defined a repertoire of SNAIL (SNA) binding sites using recombinant SNA proteins to select specific binding sequences from a pool of random sequence nucleotides. The bound sequences which were selected by multiple rounds of gel retardation and amplification by the polymerase chain reaction (PCR) were subsequently cloned and sequenced. The consensus sequence, 5'G/A A/t G/A A CAGGTG C/t A C 3', with a highly conserved core of 6 bases, CAGGTG, shares no significant homology with known binding sequences of other Drosophila zinc finger proteins. However, the CAGGTG core is identical to the core motif of aHLH (helix-loop-helix) binding sites. The strongest SNA binding is obtained with sequences containing this core motif whereas reduced binding is seen for sequences with canonical CANNTG HLH motifs. Interestingly, SNA binding is detected in the promoter region of the snail gene. Transient expression in co-transfection experiments using a SNA binding element (SBE) linked to a heterologous promoter indicates that SNA has the ability to function as a transcription activator.

The snail gene required for mesoderm formation in Drosophila is expressed dynamically in derivatives of all three germ layers.

The zygotic effect gene snail (sna) encodes a zinc-finger protein required for mesoderm formation in Drosophila embryos. By in situ analysis, sna transcripts are first detected at syncytial blastoderm and persist until very late stages of embryogenesis. Expression of sna is transient and is observed in tissues derived from all three germ layers. Prior to germband elongation, sna RNA accumulation is consistent with its genetically determined role in mesoderm formation. Starting at germband elongation, a second phase of sna expression appears to be initiated, characterized by a highly dynamic accumulation of transcripts in the developing central and peripheral nervous systems. Translation of sna RNA is apparently delayed as the sna protein is not detected before the onset of gastrulation. Its regional distribution generally correlates with that of sna transcripts. The complex pattern of sna expression strongly suggests that the function of the gene is not restricted to mesoderm formation.

The Drosophila developmental gene snail encodes a protein with nucleic acid binding fingers.

Pattern formation in the Drosophila embryo requires the concerted expression of maternal and zygotic genes. At least nineteen genes, twelve of which are maternally expressed, are involved in the establishment of dorsal-ventral polarity. Mutations in any one of these genes result in distinct alterations of cell fates and in the formation of an abnormal dorsal-ventral pattern. Mutants of the 'dorsal group', eleven of the maternal genes, have a common recessive phenotype similar to that described for dorsal, in that cells located at ventral and lateral positions assume dorsal fates and ventral structures fail to develop. Thus the dorsal group gene products may be involved in the establishment of a gradient of positional information along the dorsal-ventral axis. We have cloned snail (sna), a zygotic gene, whose expression is essential for the correct specification of dorsal-ventral pattern. In this report, we present evidence that the complementary DNA-deduced protein product of sna contains five copies of a nucleic acid-binding finger motif previously identified in two transcription factors, and in the protein product of several putative regulatory genes.

A reappraisal of ecdysteroid binding in Drosophila.

Ecdysteroid binding was investigated in Kc cells and larval fat body of Drosophila. After incubation of intact Kc cells, 200-300 specific binding sites were detected for both 20-OH ecdysone and ponasterone A. However, if cells were fractionated prior to incubation with 20-OH ecdysone, no specific binding was observed. In the fat body the number of specific nuclear binding sites appears to be enhanced by the factor of polyteny if compared with Kc cells. Both systems displayed a high degree of non-specific cytoplasmic binding. The intracellular distribution of specifically bound ponasterone A was different from that of the physiological hormones. In fat body, even after an incubation of 60 min at 22 degrees C, the majority of specifically bound ponasterone A was located in the cytoplasm. Differences between the results of this study and previous reports on ecdysteroid binding are discussed.

Distribution of estradiol receptor and vitellogenin gene in chick liver chromatin fractions.

The distribution of estradiol receptor and vitellogenin gene was studied in estradiol stimulated chick liver chromatin fractions prepared by limited DNAse II digestion and MgCl2 precipitation. The receptor was found in all fractions, undigested chromatin (P1), Mg2+ insoluble chromatin (P2) and Mg2+ soluble chromatin (S2). This last fraction was rich in acidic proteins, had a high protein:DNA ratio (7.0 w/w), contained 28% of rapidly labelled RNA, 20% of the receptor, 3-5% of chromatin DNA and showed a 2 fold enrichment of vitellogenin DNA sequences over unfractionated chromatin as well as P1 and P2 DNA. On isopycnic metrizamide gradients, all chromatin fractions showed a receptor peak banding at 1.23 g/cm3, the density of nucleoproteins. Hybridization experiments showed that the DNA banding at this density in fraction S2 was enriched 4 fold in vitellogenin DNA sequences over unfractionated chromatin as well as P1 and P2 DNA. These results suggest an association of hormone receptor complex with nucleoprotein structures of an apparently active chromatin fraction.