No increase in frequency of antifungal resistance among yeasts isolated from normally sterile sites in patients at Foothills Hospital from 1993 to 1996.

OBJECTIVE: To determine the prevalence of resistance to antifungal drugs among yeasts isolated from sterile sites from patients in one hospital and the relationship of resistance to antifungal use, and to assess whether resistance was increasing. METHOD: Susceptibility testing performed by National Committee for Clinical Laboratory Standards (NCCLS) (Villanova, Pennsylvania) microdilution method and by E test. Antifungal use was determined by selected chart review and from pharmacy data. SPECIMENS AND SETTING: Tertiary care adult hospital with neonatal intensive care. POPULATION STUDIED: Distinct yeast isolates from sterile site specimens collected during the years 1993 to 1996. RESULTS: A total of 132 yeast isolates were studied, of which 78 (59%) were Candida albicans. The proportion of C albicans remained steady over the four-year period, and there was no trend to increased resistance among C albicans. The number of isolates of all species with fluconazole microdilution minimum inhibitory concentration (MIC) greater than 8 mg/L in each of the four years were one of 32 in 1996, three of 26 in 1994, six of 33 in 1995, and one of 41 in 1996. A single isolate had an itraconazole microdilution MIC greater than 0.5 mg/L in each year. Prior use of antifungal therapy was rare in this patient population. CONCLUSIONS: The increase in resistance to antifungal drugs reported by some centres did not occur in this institution over the course of the study. This experience may reflect differences in infection control practices and in patterns of use of antifungal agents. The NCCLS method was found to be superior to the E test as a routine method for testing susceptibility of yeasts.

Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program.

Exercise is the best predictor of long-term weight loss. This study evaluated two strategies for improving exercise adherence and long-term weight loss in obese outpatients. Obese men and women (N = 193) were randomized to 1 of 5 treatment groups for 18 months: standard behavior therapy (SBT); SBT with supervised walks (SW) 3 times per week; SBT + SW with personal trainers (PT), who walked with participants, made phone reminders, and did make-up SW; SBT + SW with monetary incentives (I) for completing SW; and SBT + SW + PT + I. Both PT and I enhanced attendance at SWs, the combination producing the best adherence. Increased walk attendance did not result in higher overall energy expenditure, however, and long-term weight loss was also not improved. Post hoc analyses suggest that the level of exercise needed for successful long-term weight loss is much higher than that usually recommended in behavioral treatment programs.

Food provision vs structured meal plans in the behavioral treatment of obesity.

OBJECTIVE: Providing overweight patients with the food they should eat has been shown to significantly improve weight loss in a behavioral treatment program. The objective of this study was to examine the contribution of three components of food provision to these positive effects: the specific meal plans indicating what foods should be eaten at each meal; the food itself; and the fact that the food was provided free. SUBJECTS: 163 overweight women. DESIGN: Randomized, controlled study with subjects assigned to one of four conditions: (1) a standard behavioral treatment program (SBT) with weekly meetings for six months; (2) SBT plus structured meal plans and grocery lists; (3) SBT plus meal plans plus food provision, with subjects sharing the cost; or (4) SBT plus meal plans plus free food provision. RESULTS: Subjects in Group 1 lost significantly less weight than subjects in Groups 2-4 at the end of the six month program (-8.0 kg vs -12.0, -11.7 and -11.4 kg respectively) and at follow-up one year later (-3.3 kg vs -6.9, -7.5 and -6.6 kg respectively). No significant differences were seen in weight loss between Groups 2-4, suggesting that the component of food provision that is responsible for its success is the provision of highly structured meal plans and grocery lists. Subjects receiving meal plans were more likely to exhibit an eating pattern of three meals/day, had more definite plans regarding what to eat and reported more favorable changes in foods stored in their homes and in perceived barriers to weight loss. CONCLUSIONS: Providing structured meal plans and grocery lists improves outcome in a behavioral weight control program; no further benefit is seen by actually giving food to patients.

Strengthening behavioral interventions for weight loss: a randomized trial of food provision and monetary incentives.

Behavioral treatments for obesity seek to modify eating and exercise behaviors by a change in their antecedents and consequences. More direct modification of antecedents and consequences by (a) the provision of food to patients and (b) the provision of financial rewards for weight loss was hypothesized to improve treatment outcomes. Two hundred two men and women were randomly assigned to no treatment, standard behavioral treatment (SBT), SBT plus food provision, SBT plus incentives, or SBT plus food provision and incentives. The major finding was that food provision significantly enhanced weight loss. Weight losses with SBT averaged 7.7, 4.5, and 4.1 kg at 6, 12, and 18 months, respectively, compared with 10.1, 9.1, and 6.4 kg, respectively, at the same intervals with the addition of food. Food provision also enhanced attendance, completion of food records, quality of diet, and nutrition knowledge. We conclude that the provision of food to weight-loss patients is a promising methodology that deserves further exploration.

Change in waist-hip ratio with weight loss and its association with change in cardiovascular risk factors.

We investigated whether weight loss decreases the waist-hip ratio (WHR) in overweight men and women, and whether changes in WHR relates to change in cardiovascular risk factors, independent of change in weight. Weight loss correlated significantly with decreases in the circumference of the waist and hips, and decreases in WHR in men and women. At comparable levels of weight loss, men had greater decreases in the waist, and smaller decreases in the hips than women, resulting in greater decreases in WHR. Cardiovascular risk factors improved significantly with weight loss. However, after controlling for weight loss, there was no evidence that change in WHR or change in circumference measures were related to change in risk factors. These data suggest that WHR is modifiable by weight loss, especially in men, but that change in WHR may not be independently related to changes in cardiovascular risk factors.

Persistence mechanisms in Pseudomonas aeruginosa from cystic fibrosis patients undergoing ciprofloxacin therapy.

The mechanisms of persistence to ciprofloxacin in nine sets of Pseudomonas aeruginosa strains isolated during ciprofloxacin therapy of chronic lung infections in cystic fibrosis patients were studied. Low to moderate levels of ciprofloxacin resistance developed in each case. Each set of pretherapy ciprofloxacin-susceptible, during-therapy ciprofloxacin-resistant, and posttherapy ciprofloxacin-susceptible isolates were shown to be genotypically related by using a radiolabeled epidemiological gene probe. All ciprofloxacin-resistant isolates were found to have altered susceptibilities to both nalidixic acid and various chemically unrelated antibiotics. Analysis of possible resistance mechanisms showed that the strains had altered outer membrane protein or lipopolysaccharide profiles. Complementation of possible DNA gyrase mutations with a plasmid-borne, wild-type Escherichia coli gyrA gene indicated that altered DNA gyrase was at least partly responsible for ciprofloxacin resistance in all strains tested. Attempts to generate ciprofloxacin-susceptible revertants in vitro showed that in some strains reversion was rapid in the absence of ciprofloxacin, while in other strains it was not possible to generate revertants. These data indicate that persistence of Pseudomonas aeruginosa to ciprofloxacin involves changes in DNA gyrase and is associated with pleiotropic changes in outer membrane proteins and lipopolysaccharide.