Obesity medicine as a subspecialty and United States certification - A review

Background

Certification of obesity medicine for physicians in the United States occurs mainly via the American Board of Obesity Medicine (ABOM). Obesity medicine is not recognized as a subspecialty by the American Board of Medical Specialties (ABMS) or the American Osteopathic Association (AOA). This review examines the value of specialization, status of current ABOM Diplomates, governing bodies involved in ABMS/AOA Board Certification, and the advantages and disadvantages of an ABMS/AOA recognized obesity medicine subspecialty.

Methods

Data for this review were derived from PubMed and appliable websites. Content was driven by the expertise, insights, and perspectives of the authors.

Results

The existing ABOM obesity medicine certification process has resulted in a dramatic increase in the number of Obesity Medicine Diplomates. If ABMS/AOA were to recognize obesity medicine as a subspecialty under an existing ABMS Member Board, then Obesity Medicine would achieve a status like other ABMS recognized subspecialities. However, the transition of ABOM Diplomates to ABMS recognized subspecialists may affect the kinds and the number of physicians having an acknowledged focus on obesity medicine care. Among transition issues to consider include: (1) How many ABMS Member Boards would oversee Obesity Medicine as a subspecialty and which physicians would be eligible? (2) Would current ABOM Diplomates be required to complete an Obesity Medicine Fellowship? If not, then what would be the process for a current ABOM Diplomate to transition to an ABMS-recognized Obesity Medicine subspecialist (i.e., "grandfathering criteria")? and (3) According to the ABMS, do enough Obesity Medicine Fellowship programs exist to recognize Obesity Medicine as a subspecialty?

Conclusions

Decisions regarding a transition to an ABMS recognized Obesity Medicine Subspecialty versus retention of the current ABOM Diplomate Certification should consider which best facilitates medical access and care to patients with obesity, and which best helps obesity medicine clinicians be recognized for their expertise.

Estimating wetland connectivity to streams in the Prairie Pothole Region: an isotopic and remote sensing approach

Understanding hydrologic connectivity between wetlands and perennial streams is critical to understanding the reliance of stream flow on inputs from wetlands. We used the isotopic evaporation signal in water and remote sensing to examine wetland-stream hydrologic connectivity within the Pipestem Creek watershed, North Dakota, a watershed dominated by prairie-pothole wetlands. Pipestem Creek exhibited an evaporated-water signal that had approximately half the isotopic-enrichment signal found in most evaporatively enriched prairie-pothole wetlands. Groundwater adjacent to Pipestem Creek had isotopic values that indicated recharge from winter precipitation and had no significant evaporative enrichment, indicating that enriched surface water did not contribute significantly to groundwater discharging into Pipestem Creek. The estimated surface-water area necessary to generate the evaporation signal within Pipestem Creek was highly dynamic, varied primarily with the amount of discharge, and was typically greater than the immediate Pipestem Creek surface-water area, indicating that surficial flow from wetlands contributed to stream flow throughout the summer. We propose a dynamic range of spilling thresholds for prairie-pothole wetlands across the watershed allowing for wetland inputs even during low flow periods. Combining Landsat estimates with the isotopic approach allowed determination of potential (Landsat) and actual (isotope) contributing areas in wetland-dominated systems. This combined approach can give insights into the changes in location and magnitude of surface water and groundwater pathways over time. This approach can be used in other areas where evaporation from wetlands results in a sufficient evaporative isotopic signal.

Biota: Providing often-overlooked connections among freshwater systems

When we think about connections in and among aquatic systems, we typically envision clear headwater streams flowing into downstream rivers, river floodwaters spilling out onto adjacent floodplains, or groundwater connecting wetlands to lakes and streams. However, there is another layer of connectivity moving materials among freshwater systems, one with connections that are not always tied to down-gradient flows of surface waters and groundwater. These movements are those of organisms, key components of virtually every freshwater system on the planet. In their movements across the landscape, biota connect aquatic systems in often-overlooked ways.

Physiological response of glandular-haired alfalfa to potato leafhopper (Hemiptera: Cicadellidae) injury

Plant tolerance to herbivory is a key approach for managing pests. In alfalfa, Medicago sativa, the potato leafhopper, Empoasca fabae, is a major pest as a result of the cascade of plant responses to piercing-sucking injury. To identify tolerance to its injury based on alfalfa physiology, experiments were conducted in the field and greenhouse. In our comparison of the response of field-grown alfalfa cultivars to standardized leafhopper densities, net photosynthesis and transpiration rates of 'Geneva' leaves were reduced by 18 and 21%, respectively, by leafhopper presence compared with a rate change of <1% of resistant 'EverGreen' leaves. Under greenhouse conditions, alfalfa clones varied in their level of gas exchange (net photosynthesis and transpiration) and stem elongation responses to leafhopper injury. For example, in the comparison of seven clones, net photosynthesis declined an average of 40.7% with leafhopper injury, although individual clones varied from 26.6 to 74.3% reduction. Internode elongation after 2 d was 60.3% less on injured stems compared with healthy stems, but again, the individual clones varied from 17.3 to 91.9%. In a time-course study of selected clones, clones varied in their level of injury just after and 3 d after insect removal. Gas exchange responses of all clones recovered by 7 d after cessation of injury. In a choice test, leafhoppers spent similar amounts of time on the susceptible clone and the most tolerant clone; however, their precise feeding behaviors were not measured. Thus, the variable response of clones to injury may be either true physiological tolerance or antixenosis from a change in feeding behavior. This study showed putative tolerance to leafhopper injury among alfalfa genotypes, suggesting that tolerance could be the basis for crop protection in alfalfa from potato leafhopper injury.

Herpes simplex esophagitis in a renal transplant patient treated with cyclosporine A: a case report

Herpes simplex esophagitis is a rare disease occurring mostly in immunocompromised and cancer patients. We report the first case of herpes esophagitis in a renal transplant patient treated with Cyclosporine A while on chronic steroid therapy. With the increasing use of Cyclosporine A in transplant patients, the incidence of herpes esophagitis may increase. The disease is suggested endoscopically by its typical appearance. The diagnosis is confirmed by cytology, tissue studies, and viral cultures. Based on the limited knowledge of the natural history of herpetic esophagitis and lack of prospective antiviral trials, symptomatic therapy with viscous Xylocaine appears reasonable. The definitive role of antiviral therapy is yet to be clarified.

Pregnancy-specific beta-glycoprotein (SP1) in normal pregnancy in Nigeria

The circulating levels of pregnancy-specific beta 1-glycoproteins (SP1) were measured in 71 normal pregnant women in Northern Nigeria by immunoelectrophoresis. The levels showed a steady rise up to 34 weeks as in Caucasians and then plateaued with a slight fall just before term. The mean individual values were lower than those found in Caucasians at comparable gestation periods. This was thought to be related to the lower mean fetal weight in the Nigerian women.

Immunological evaluation of renal transplant patients: changes in levels of beta-2-microglobulin, immunoglobulins and complement components during graft rejection

Levels of IgG and IgM and complement components C4 and C3 were measured using rate nephelometry and serum levels of beta-2-microglobulin (beta 2m) by rocket immunoelectrophoresis (RIEP) and these assays have been applied serially following cadaveric renal transplantation on 28 patients 14 of whom were treated with cyclosporin A. There were 31 rejection episodes of which 7 were irreversible. Elevated pre-transplant serum beta 2m levels fell rapidly in the first 24-48 hr post-transplant in all patients with primary functioning grafts and the mean base-line control value was 4.5 +/- 1.27 micrograms/ml in patients with stable graft function in the period 5-10 days post-transplant. At the onset of all 31 rejection episodes however the level of beta 2m increased compared to control values and significantly exceeded the 95% confidence limits of +/- 2.0 micrograms/ml. Control values for serum IgG and IgM were significantly lower than paired pre-transplant levels and, whereas IgM increased during rejection episodes with significant differences between paired rejection and control values, no significant changes in IgG levels were detected. In contrast mean control values for C4 and C3 were not significantly different to mean pre-transplant values; however, mean levels of C4 and C3 decreased significantly during rejection episodes compared to both pre-transplant and control values.

beta-2-microglobulin. Quantitation by rocket immunoelectrophoresis and evaluation of serum levels in renal transplant patients

An assay using Laurell rocket immunoelectrophoresis has been developed for quantitation of beta-2-microglobulin (beta 2m) and serial levels of beta 2m have been measured in sera obtained daily from 52 patients following renal transplantation. The RIEP assay was performed using 1% low-endosmosis agarose gels containing 4% polyethylene glycol 6000 and the IgG fraction of rabbit antihuman beta 2m. Elevated beta 2m levels pretransplant fell markedly in the first 48 hr posttransplant in all patients with primary functioning grafts. Base-line control values for serum beta 2m were obtained in patients when stable graft function was established. Serum beta 2m levels increased during renal graft rejection, and significant elevations of serum beta 2m were detected at the onset of all graft rejection episodes as compared with control values. It is suggested that serum beta 2m quantitation by rocket immunoelectrophoresis is a simple and valuable assay to assess posttransplant renal graft function.