Qualitative inquiry with persons with obesity about weight management in primary care and referrals

Introduction

Referrals to evidence-based weight management in the community-commercial sector are aligned with clinical recommendations but underutilized.

Methods

This qualitative study explored patients' perceptions and expectations about obesity treatment in primary care and referral to community-commercial sector programs. Individual semi-structured interviews were conducted with a sample of US persons with obesity via telephone. Audiotape transcripts, interviewer notes, and independent review of data by two investigators allowed for data and investigator triangulation. Transcripts were analyzed using thematic analysis.

Results

Data saturation was reached with 30 participants who had a mean age of 41.6 years (SD 9.4), 37% male, 20% Black/African American and 17% Hispanic, 57% college educated, and 50% were employed full-time. Three primary themes emerged: (1) frustration with weight management in primary care; (2) patients expect providers to be better informed of and offer treatment options; and (3) opportunities and challenges with referrals to community-commercial programs.

Discussion

Patients expect that providers offer personalized treatment options and referrals to effective community-commercial programs are an acceptable option. If patient-level data are shared between clinical and community entities to facilitate referrals, then privacy and security issues need attention. Future research is needed to determine feasibility of implementing clinical to community-commercial referrals for obesity treatment in the United States.

Qualitative inquiry with primary care providers and specialists about adult weight management care and referrals

Obesity is a highly prevalent disease and providers are expected to offer or refer patients for weight management yet increasingly fewer clinical visits address obesity. Challenges to offering care are known but less is known about referrals and how specialists who treat obesity-related comorbidities address care and referrals. This study explored perceptions of primary care providers (PCPs) and specialty providers regarding care and referrals for weight management, specifically referrals to programs in the community setting. A qualitative design was used to interview 33 PCPs (mean age 54 years) and 31 specialists (cardiology, gynecology, endocrinology, and orthopedics [mean age 62 years]) in the USA during 2019. Each interview was conducted by telephone, audio-recorded, and transcribed verbatim. Inductive analysis was used and followed the constant comparative method. Four themes emerged from the data including (a) Clinical guidelines and provider discretion influence obesity care; (b) Facilitators and barriers to discussing weight and small step strategies; (c) Informal referrals are made for weight management in community settings; and (d) Opportunities and challenges for integrating clinical and community services for weight management. Facilitating referrals to effective programs, ideally with a feedback loop could coordinate care and enhance accountability, but education, compliance, and cost issues need addressed. Care may be offered but not be well-aligned with clinical guidelines. Knowledge gaps regarding community programs' offerings and efficacy were evident. Referrals could be systematically promoted, facilitated, and tracked to advance weight management objectives.

"Bioelectrical impedance analysis in managing sarcopenic obesity in NAFLD"

INTRODUCTION

Sarcopenic obesity and its association with nonalcoholic fatty liver disease (NAFLD) is under-recognized by many healthcare providers in Western medicine due to the lack of awareness and diagnostic guidelines. The result is delayed recognition and treatment, which leads to further health deterioration and increased healthcare costs. Sarcopenic obesity is characterized by the presence of increased fat mass in combination with muscle catabolism related to chronic inflammation and/or inactivity. Previous research has recommended evaluating body composition and physical function performance to adequately diagnose sarcopenic obesity. Body composition analysis can be performed by imaging applications through magnetic resonance imaging, computed tomography, and dual-energy x-ray absorptiometry. Due to the cost of each device and radiation exposure for patients as evidenced in all three modalities, bioelectrical impedance analysis offers a noninvasive approach capable of providing quick and reliable estimates of lean body and fat mass.

METHODS AND RESULTS

This review analyzes the current evidence-based literature, indicating a lower skeletal muscle mass and increased visceral adipose tissue correlation to the advancement of fibrosis in fatty liver disease.

CONCLUSION

Given the substantial promising research conducted in predominantly Asian populations regarding body tissue distribution and NAFLD, additional prospective research is needed to extend these findings in Western populations.

External pneumatic compression and fibrinolysis in abdominal surgery

INTRODUCTION

External pneumatic compression (EPC) devices prevent lower extremity deep venous thrombosis by increasing venous flow and thereby reducing stasis. Early studies suggested that they also enhance systemic fibrinolytic activity and thus prevent thrombus formation; more recent studies have been conflicting. The hypothesis of this study was that EPC devices enhance systemic fibrinolysis or reduce postoperative fibrinolytic impairment in patients undergoing abdominal surgical procedures.

METHODS

Each of 48 patients (98% male; mean age, 67 years) undergoing major intra-abdominal surgical procedures (36 bowel procedures, 12 aortic reconstructions) was prospectively randomized to one of three treatments for deep venous thrombosis prophylaxis: subcutaneous heparin injections (HEP group), use of a thigh-length sequential EPC device (EPC group), or both (HEP + EPC group). Antecubital venous samples were collected for measurement of systemic fibrinolytic activity on the day before surgery, after induction of anesthesia but before prophylaxis was initiated, and on postoperative days 1, 3, and 5. Fibrinolysis was assessed through measurement of the activities of the rate limiting fibrinolytic activator, tissue plasminogen activator, and its inhibitor plasminogen activator inhibitor-1 with amidolytic methods.

RESULTS

On the day before surgery, plasminogen activator inhibitor-1 activity was elevated in all groups in comparison with that in age-matched and sex-matched controls (20.3 +/- 0.6 AU/mL). In the HEP group, plasminogen activator inhibitor-1 activity was further elevated above the value for the day before surgery on postoperative day 1 (28.5 +/- 4.3 AU/mL; P =.04) and postoperative day 3 (25.1 +/- 1.9 AU/mL; P =.07). No significant decrease in plasminogen activator inhibitor-1 activity occurred in either group treated with EPC devices in comparison with the HEP group at any time. There were no changes in tissue plasminogen activator activity postoperatively in the HEP group and no significant increases in either EPC group at any point.

CONCLUSIONS

Reduced systemic fibrinolytic activity ("fibrinolytic shutdown") occurred in these patients after abdominal surgery; it was manifested as increased plasminogen activator inhibitor-1 activity. EPC devices did not enhance systemic fibrinolysis or prevent postoperative shutdown either by decreasing plasminogen activator inhibitor-1 activity or by increasing tissue plasminogen activator activity. These data suggest that EPC devices do not prevent deep venous thrombosis by fibrinolytic enhancement; effective prophylaxis is achieved only when the devices are used in a manner that reduces lower extremity venous stasis.

Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

PURPOSE

Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals.

METHODS

In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases.

RESULTS

Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a "pantaloon" aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications.

CONCLUSION

The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy.

Assessment of ocular perfusion after carotid endarterectomy with color-flow duplex scanning

PURPOSE

The purpose of this study was to assess the effect of carotid endarterectomy (CEA) on ocular perfusion with the measurement of the ophthalmic artery (OA) and the central retinal artery (CRA) flow velocities with color-flow ocular duplex scanning (ODS). Ocular hemodynamics also were examined in a subset of patients with visual symptoms in an attempt to characterize the origin of the ocular symptoms and their response to surgery.

METHODS

Twenty-five patients with internal carotid artery stenoses (>/=70%) underwent 29 CEAs. All the patients underwent ODS for the measurement of the peak systolic velocity (PSV) in the OA and the CRA of the ipsilateral eye before and after CEA. The preoperative and postoperative flow velocities were compared in all the patients and in the patients with and without visual symptoms.

RESULTS

The preoperative PSV in the OA was 21.6 +/- 2.2 cm/s and in the CRA was 7.7 +/- 0.7 cm/s. These values were reduced as compared with normative values (OA, 37.8 cm/s; CRA, 10.7 cm/s). After CEA, the PSV increased significantly in both vessels (postoperative OA, 38.6 +/- 2.5 cm/s, P <.0001; postoperative CRA, 12.1 +/- 0.9 cm/s, P =.0008). Fifteen of the 29 CEAs were performed for visual symptoms. The patients with ocular symptoms had significantly lower preoperative PSVs in the CRA as compared with those patients without visual symptoms (CRA with ocular symptoms, 6.5 +/- 0.8 cm/s; CRA with no ocular symptoms, 9.4 +/- 0.9 cm/s; P =.02). The PSV in the OA was not significantly lower in the patients with ocular symptoms. Eight patients (28%) were found to have reversed OA flow before surgery, but only three patients had ocular symptoms. All eight patients had normal antegrade flow in the OA after surgery.

CONCLUSION

Severe carotid stenosis may be associated with reduced ocular perfusion, which can be quantitatively evaluated with ODS. Reduced OA and CRA flow velocities are corrected with successful CEA. The patients with ocular symptoms were observed to have significant reductions in CRA flow velocities. Reversed flow in the OA was not a marker for ocular symptoms in this study. ODS can identify global ocular ischemia and may be helpful in the evaluation of patients with atypical visual symptoms or with amaurosis fugax and no evidence of retinal emboli.

Progressive intermittent claudication is associated with impaired fibrinolysis

PURPOSE

Acute complications of atherosclerosis such as stroke and myocardial infarction are caused by thrombosis and may be associated with impaired fibrinolytic activity. The current study was performed to determine whether peripheral arterial disease (PAD) and its progression are also associated with impaired fibrinolysis, by measurement of tissue plasminogen activator (tPA, the activator of fibrinolysis) and its inhibitor plasminogen activator inhibitor-1 (PAI-1).

METHODS

The study group consisted of 80 men with a mean age of 69 years. This included 18 patients with mild intermittent claudication (MC, pain-free walking distance > or = 200 meters) and 51 patients with severe claudication (SC, walking distance <200 meters). Eleven age- and sex-matched patients without PAD served as controls. All patients had measurements of serum tPA antigen using an enzyme-linked immunoadsorbent assay. Serum levels of tPA and PAI-1 activity were assayed with an amidolytic method. Mean +/- SEM levels of the enzyme levels in patients with progressively more severe PAD were compared with normal controls.

RESULTS

Serum PAI-1 activity levels were significantly elevated in both PAD groups compared with normal controls (p < 0.02). There were no significant differences in the PAI-1 activity levels in groups with worsening degrees of PAD. There was a significant decrease in tPA activity levels in patients with SC (p = 0.01) relative to those with MC and the normal subjects. There was also a significant increase in tPA antigen level in the patients with SC compared with those with MC and the control subjects, as well as a significant inverse correlation between tPA antigen levels and pain-free walking time in patients with claudication (p = 0.001).

CONCLUSIONS

All patients with PAD in this study had significant reductions in endogenous fibrinolytic activity. Patients with SC had more impaired fibrinolytic activity than those with MC and the control subjects, suggesting that the progression to more severe levels of PAD may be associated with worsening endogenous fibrinolysis.