Defining Physiological Ketosis Following Very-Low-Calorie Diets

INTRODUCTION

Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance.

MATERIALS AND METHODS

Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005.

CLINICALTRIALS

gov ID: NCT05442918.

RESULTS

Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1.

CONCLUSIONS

Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.

Percentage of intrathoracic stomach predicts operative and post-operative morbidity, persistent reflux and PPI requirement following laparoscopic hiatus hernia repair and fundoplication

PURPOSE

Large hiatus hernias are relatively common and can be associated with adverse symptoms and serious complications. Operative repair is indicated in this patient group for symptom management and the prevention of morbidity. This study aimed to identify predictors of poor outcomes following laparoscopic hiatus hernia repair and fundoplication (LHHRaF) to aid in counselling potential surgical candidates.

METHODOLOGY

A retrospective analysis was performed from a prospectively maintained, multicentre database of patients who underwent LHHRaF between 2014 and 2020. Revision procedures were excluded. Hernia size was defined as the intraoperative percentage of intrathoracic stomach, estimated by the surgeon to the nearest 10%. Predictors of outcomes were determined using a prespecified multivariate logistic regression model.

RESULTS

625 patients underwent LHHRaF between 2014 and 2020 with 443 patients included. Median age was 65 years, 62.9% were female and 42.7% of patients had ≥ 50% intrathoracic stomach. In a multivariate regression model, intrathoracic stomach percentage was predictive of operative complications (P = 0.014, OR 1.05), post-operative complications (P = 0.026, OR 1.01) and higher comprehensive complication index score (P = 0.023, OR 1.04). At 12 months it was predictive of failure to improve symptomatic reflux (P = 0.008, OR 1.02) and persistent PPI requirement (P = 0.047, OR 1.02). Operative duration and blood loss were predicted by BMI (P = 0.004 and < 0.001), Type III/IV hernias (P = 0.045 and P = 0.005) and intrathoracic stomach percentage (P = 0.009 and P < 0.001). Post-operative length of stay was predicted by age (P < 0.001) and emergency presentation (P = 0.003).

CONCLUSION

In a multivariate regression model, intrathoracic stomach percentage was predictive of operative and post-operative morbidity, PPI use, and failure to improve reflux symptoms at 12 months.

13 Medical Students’ Mood Adversely Affected By COVID-19 Pandemic: An Interim Analysis from the SPICE-19 Prospective Cohort Study Of 2075 Medical Students and Interim Foundation Doctors

Introduction

In order to appropriately support medical students and foundation year doctors, it is imperative that we understand the impact the COVID-19 pandemic has had upon them. This study assessed the effects of the COVID-19 pandemic on medical students and interim foundation year doctors across the United Kingdom (UK), and the support that they received and sought.

Method

A prospective, observational, multicentre study was conducted. All medical students and interim foundation year doctors were eligible to participate.

Results

A total of 2075 individuals participated. There was a decrease in participants’ mood when comparing their mood before the pandemic to during the pandemic (p < 0.0001). Social distancing negatively impacted the mood of the greatest number of participants. All areas of life included in the study were found to have been significantly more negatively impacted than positively impacted (p < 0.0001). 931 participants wanted more support from their university.

Conclusions

When medical students return to their universities, there is likely to be a need for enhanced wellbeing support, adaptations in the short-term and long-term strategies for medical education, and provision of financial guidance. If no action is taken, there may be a knock-on effect on workforce planning and the health of our future workforce.

878 Comparing Treatment Outcomes for Unruptured Brain Arteriovenous Malformations: A Retrospective Cohort Study

Background

Unruptured brain arteriovenous malformations (bAVMs) carry a lifetime risk of haemorrhage. Treatment strategies include conservative management, microsurgical excision, endovascular treatment (EVT) and radiosurgery (SRS). Optimal treatment selection remains unclear.

Method

A single-centre retrospective cohort study of adult unruptured bAVMs (2007-2019). Patients who underwent intervention were propensity matched using baseline features (age, sex, size, deep drainage, eloquence, and Spetzler-Martin grade) with patients conservatively managed. Rates of neurological disability and mortality due to intervention or bleed were compared.

Results

137 patients (mean age 48 years [SD = 16], males 64) were included; 34 (25%) EVT, 20 (15%) surgery, 31 (22%) SRS and 51 (37%) conservative. After a median follow-up of 49 months (IQR 23-75), rates of disability were as follows: surgery 35%, EVT 21%, SRS 13% and conservative 8%. Matched cohorts (intervention/conservative) were: surgery-19/18, SRS-30/22 and EVT-33/34. Comparison of disability rates across matched cohorts revealed no statistically significant differences (surgery p = 0.07, SRS p = 0.65 and EVT p = 0.11). Three conservatively managed patients died.

Conclusions

Unruptured bAVMs carry a significant risk of neurological morbidity, regardless of intervention choice. Treatment choice may have an impact on patient outcomes but requires investigation of stratified cohorts. Findings are consistent with the nuances of AVM treatment selection.

Intragastric laparoscopy for oesophageal eroded mesh removal: An approach to avoid resection

The augmentation of hiatal repair for large hiatus hernia with mesh is controversial. There is some evidence that recurrence rates are less with mesh repair; however, there is a risk of mesh erosion. Complicated erosion may require complex revisional surgery and oesophagogastric resection. We present a novel approach to the treatment of oesophageal mesh erosion, by utilising a combined approach of endoscopy and intragastric laparoscopy. The symptomatic relief from this procedure may obviate the need for foregut resection in some patients.

Trans-hiatal repair for Oesophageal and Junctional perforation: a case series

Background

Oesophageal perforation is a life-threatening condition that requires urgent intervention. Surgical repair is recommended within 24 h of onset to minimise mortality risk, traditionally via an open thoracotomy or a laparotomy. Primary oesophageal repair via a laparoscopic trans-hiatal approach has been seldomly reported due to concerns of inadequate eradication of soilage in the mediastinum and pleural space, as well as poor access and an increased operative time in an unwell population.

Case presentation

We report a case series of 3 oesophageal and junctional perforations with varying presentations, demonstrating how the laparoscopic trans-hiatal approach can be used successfully to manage oesophageal perforations.

Conclusions

Laparoscopic trans-hiatal repair is an attractive option for oesophageal and junctional perforations, in haemodynamically stable surgical candidates, in the absence of gross contamination of the thoracic cavity.

Gallstones top to toe: what the radiologist needs to know

Gallstone-related disease can have significant associated morbidity and mortality worldwide. The incidence of gallstone-related disease in the Western world is on the increase. There are multiple different pathological manifestations of gallstone disease: the presentation, diagnosis and associated complications of which vary significantly depending on anatomical location. The role of imaging in gallstone-related disease is broad with radiology playing an essential role in the diagnosis, management and follow-up of gallstone-related pathologies. This paper distills the broad range of gallstone-related pathologies into an anatomical map, discussing the disease processes involved at each point along the biliary tree and reviewing the strengths and weaknesses of different imaging modalities for each distinct disease process.

Laparoscopic management of chylous ascites posthiatal hernia repair with Toupet fundoplication

We present a case of chylous ascites in a 69-year-old man 5 months after a laparoscopic Toupet fundoplication (posterior 270°). This was successfully treated with laparoscopic ligation of tissue adjacent to the right crus. Laparoscopic ligation is a management option that should be considered after this rare complication, offering rapid results.

Effects of an introduced, novel prey on diet and reproduction in the diet-specialist European Starling (Sturnus vulgaris)

Diet specialization has important consequences for how individuals or species deal with environmental change that causes changes in availability of prey species. We took advantage of a “natural experiment” — establishment of a commercial insect farm — that introduced a novel prey item, black soldier flies (Hermetia illucens (Linnaeus, 1758)), to the diet-specialist European Starling (Sturnus vulgaris Linnaeus, 1758). We investigated evidence for individual diet specialization (IDS) and the consequences of diet specialization and exploitation of novel prey on breeding productivity. In all 4 years of our study, tipulid larvae were the most common prey item. Soldier flies were not recorded in diets in 2013–2014; however, coincident with the establishment of the commercial insect farming operation, they comprised 22% and 30% of all prey items in the diets of European Starling females and males, respectively, in 2015. There was marked individual variation in use of soldier flies (4%–48% and 2%–70% in females and males, respectively), but we found little evidence of dichotomous IDS, i.e., where only some individuals have a specialized diet. We found no evidence for negative effects of use of soldier flies on breeding productivity: brood size at fledging and chick quality (mass, tarsus length) were independent of the number and proportion (%) of soldier flies returned to the nest.

Long-term outcomes of laparoscopic large hiatus hernia repair with nonabsorbable mesh

The use of mesh to augment suture repair of large hiatus hernias remains controversial. Repair with mesh may help reduce the recurrence rate of primary repair, but concerns about the potential for serious complications, such as mesh erosion or stricturing, continue to limit its use. We aim to evaluate the long-term outcome of primary hiatus hernia repair with lightweight polypropylene mesh (TiMesh) specifically looking at rates of clinical recurrence, dysphagia, and mesh-related complications. From a prospectively maintained database, 50 consecutive patients who underwent elective primary laparoscopic hiatal hernia repair with TiMesh between January 2005 and December 2007 were identified. Case notes and postoperative endoscopy reports were reviewed. Clinical outcomes were evaluated using a structured questionnaire, including a validated dysphagia score. Of the 50 patients identified, 36 (72%) were contactable for follow-up. At a median follow-up of 9 years, the majority of patients (97%) regarded their surgery as successful. Twelve patients (33%) reported a recurrence of their symptoms, but only 4 (11%) reported that their symptoms were as severe as prior to the surgery. There was no significant difference between pre- and postoperative dysphagia scores. Postoperative endoscopy reports were available for 32 patients at a median time point of 4 years postoperatively, none of which revealed any mesh-related complications. One patient had undergone a revision procedure for a recurrent hernia at another institution. In this series, primary repair of large hiatus hernia with nonabsorbable mesh was not associated with any adverse effects over time. Patient satisfaction with symptomatic outcome remained high in the long term.

Underdetection of comorbid drug use at acute psychiatric admission

Aims and Method

The ability of routine clinical practice to detect drug use at acute psychiatric admission was assessed by comparing the results of urinalysis with information on drug use extracted from patient records (n=112).

Results

Urinalysis detected drug use in 23% of the sample. Cannabis was the drug most frequently found. Of the cases of drug use positively identified by urinalysis, 54% were not identified in the notes. Some information on drug use proximal to admission was found in 40% of patient records. Patients asked about proximal drug use were younger than those not asked.

Clinical Implications

All patients should be asked about drug use.

Flexible polygon-mirror based laser scanning microscope platform for multiphoton in-vivo imaging

Commercial microscopy systems make use of tandem scanning i.e. either slow or fast scanning. We constructed, for the first time, an advanced control system capable of delivering a dynamic line scanning speed ranging from 2.7 kHz to 27 kHz and achieve variable frame rates from 5 Hz to 50 Hz (512 × 512). The dynamic scanning ability is digitally controlled by a new customized open-source software named PScan1.0. This permits manipulation of scanning rates either to gain higher fluorescence signal at slow frame rate without increasing laser power or increase frame rates to capture high speed events. By adjusting imaging speed from 40 Hz to 160 Hz, we capture a range of calcium waves and transient peaks from soma and dendrite of single fluorescence neuron (CAL-520AM). Motion artifacts arising from respiratory and cardiac motion in small animal imaging reduce quality of real-time images of single cells in-vivo. An image registration algorithm, integrated with PScan1.0, was shown to perform both real time and post-processed motion correction. The improvement is verified by quantification of blood flow rates. This work describes all the steps necessary to develop a high performance and flexible polygon-mirror based multiphoton microscope system for in-vivo biological imaging.

The impact of human papillomavirus type on colposcopy performance in women offered HPV immunisation in a catch-up vaccine programme: a two-centre observational study

OBJECTIVE

To determine whether human papillomavirus (HPV) immunisation has affected the prevalence of HPV genotypes and colposcopic features of cervical intraepithelial neoplasia (CIN) in young women referred for colposcopy.

DESIGN

A two-centre observational study including vaccinated and unvaccinated women.

SETTING

Colposcopy clinics serving two health regions in Scotland, UK.

POPULATION

A total of 361 women aged 20-25 years attending colposcopy following an abnormal cervical cytology result at routine cervical screening.

METHODS

Cervical samples were obtained from women for HPV DNA genotyping and mRNA E6/E7 expression of HPV 16, 18, 31, 33, and 45. Demographic data, cytology, and histology results and colposcopic features were recorded. Chi-square analysis was conducted to identify associations between vaccine status, HPV genotypes, and colposcopic features.

MAIN OUTCOME MEASURES

Colposcopic features, HPV genotypes, mRNA expression, and cervical histology.

RESULTS

The prevalence of HPV 16 was significantly lower in the vaccinated group (8.6%) compared with the unvaccinated group (46.7%) (P = 0.001). The number of cases of CIN2+ was significantly lower in women who had been vaccinated (P = 0.006). The HPV vaccine did not have a statistically significant effect on commonly recognised colposcopic features, but there was a slight reduction in the positive predictive value (PPV) of colposcopy for CIN2+, from 74% (unvaccinated) to 66.7% (vaccinated).

CONCLUSIONS

In this group of young women with abnormal cytology referred to colposcopy, HPV vaccination via a catch-up programme reduced the prevalence of CIN2+ and HPV 16 infection. The reduced PPV of colposcopy for the detection of CIN2+ in women who have been vaccinated is at the lower acceptable level of the UK national cervical screening programme guidelines.

TWEETABLE ABSTRACT

Reduction of hrHPV positivity and CIN in immunised women consistent with lower PPV of colposcopy for CIN2+.

Quality of life after total and subtotal gastrectomy for gastric carcinoma

BACKGROUND

There remains debate as to whether quality of life (QoL) is better for patients following sub-total gastrectomy (SG) or total gastrectomy (TG) for cancer. Both have similar survival rates provided an R0 resection is performed and in many series the morbidity and mortality after TG is higher than SG. The aim of this study was to evaluate the QoL in patients after TG and SG for cancer.

METHOD

All surviving patients who had undergone TG or SG between 1994 and 2009 were identified from a prospectively collected database and sent the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (QLQ-C30 v.3) and the gastric module (QLQ-STO22).

RESULTS

From a total of 261 patients who had undergone TG or SG in the study period, 91 were still alive and 53 responded. There was no significant difference between the QoL between TG and SG based on functional scales and global health status. However dysphagia and eating restrictions were significantly worse in the TG group.

CONCLUSION

This study has demonstrated that there is no difference in overall QoL in patients with TG or SG although eating restrictions and dysphagia are worse after TG.

P3-01-10: DMBA-Breast Cancer in Diet Induced Obesity (DIO) and Lean Mice Is Related to Leptin Signaling

Introduction: Leptin, the major adipokine released by adipose tissue, is strongly linked to obesity related-cancers. We have shown previously that inhibition of leptin signaling with pegylated leptin peptide receptor antagonist 2 (PEG-LPrA2) negatively impacted human xenograft and syngeneic mouse breast cancer growth as well as VEGF/VEGFR2 levels [1,2].

Objective: We hypothesize that leptin signaling is essential for 7,12-dimethylbenz[A]anthracene (DMBA)-mammary tumor (MT) particularly in obese mice.

Methods: The study investigated the potential of PEG-LPrA2 to prevent MT in lean and diet-induced-obesity (DIO)-C57BL/6J female mice treated with 1 mg/dose/weekly for 6 weeks of DMBA. Obesity was induced by feeding DIO-mice (95% obese mice after 5 weeks) with high fat diet (PDI-1; 45% Kcal from fat). Lean mice were fed a normal diet (PDI-1; 5% Kcal from fat). PEG-LPrA2 was administered intravenously. Lean and DIO-mice received either one or two PEG-LPrA2 dose/week (50 ml/0.1 mM) two weeks prior to DMBA to test its preventative potential through the end point (32 weeks). Control mice received saline injections.

Results: Obesity was positively correlated to the development of DMBA-MT in mice. MTs were found in 17% of lean control and 69% of DIO-control mice. Notably, PEG-LPrA2 prevented the onset of DMBA-MT in lean (one and two doses: 0% tumor-bearing mice) and DIO-mice (one-dose, 29% and two-dose 0% MT). PEG-LPrA2 treatment did not alter body weight nor food intake in lean or DIO-mice. VEGF levels were significant higher (32 fold) in control DIO-mice. PEG-LPrA2 inhibition of leptin signaling decreased tumor levels of Notch ligands (Jagged-1 & DLL-4), receptors (Notch 1–4) and target genes (Survivin and Hey2) and reduced OB-R, IL-1R tI, VEGF/VEGFR2, bcl-2, HIF-1a and NFκB (p50 and p105).

Conclusions: Present data strongly suggest that leptin signaling is essential for DMBA-induced MT in the context of obesity. Overall, the effective chemoprevention of DMBA-MT by PEG-LPrA2 treatment in DIO and lean mice reinforces the potential use of leptin signaling inhibition for breast cancer prevention. These observations are most significant for obese populations showing higher levels of leptin and incidence of breast cancer. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 to L.S.C; the Morehouse School of Medicine (MSM) MBRS RISE Program (NIH/NIGMS 506 GM08248) to T.Z.M; and facilities and support services at Morehouse School of Medicine (NIH RR03034 and 1C06 RR18386)].

References:

[1] Gonzalez RR, Chefils S, Escobar M, et al. Leptin signaling promotes the growth of mammary tumors and increases the expression of vascular endothelial growth factor (VEGF) and its receptor type two (VEGF-R2). J Biol Chem 2006, 281(36): 26320–26328.

[2] Gonzalez RR, Watters A, Xu, Y, et al. Leptin-signaling inhibition results in efficient anti-tumor activity in estrogen receptor positive or negative breast cancer. Breast Cancer Res 2009, 11:R36.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-01-10.

P5-06-10: Leptin Signaling Impacts Notch and Wnt Crosstalk in Breast Cancer

Background: Triple negative breast cancer (TNBC: ER-, PR- and Her2/neu-) is an aggressive form of the disease that disproportionately affects women of color, has an early onset, and is associated with poor survival and a resistance to common therapeutic treatments. We have previously demonstrated an association between the adipocytokine leptin and Notch signaling pathways in breast cancer. Notch participates in a crosstalk relationship with many signaling pathways involved in carcinogenesis, including Wnt and leptin, which could in turn increase tumor burden and cell survival of MMTV-Wnt1 obese mice. We hypothesize that leptin signaling crosstalk with Notch and Wnt is instrumental in the development of drug-resistant features (increased survival and proliferation) of TNBC.

Objective: The aim of this study was to determine whether leptin mediated crosstalk of the Notch and Wnt pathways has a differential impact on TNBC compared to ER+ cells.

Materials & Methods: ER+ MCF-7 and TNBC-MDA MB-231 cells (96-well plate; 1×104 cells/well) were serum deprived for 24 hours and treated with varying doses of Doxorubicin and Cisplastin for 24h in conjunction with pharmacological doses of leptin, leptin peptide antagonist (LPrA2), Wnt agonist (Wnt-1) and antagonist (Wif-1). Cell proliferation was measured via WST assay. The effect of the various treatments on the activation of Wnt (total/pβ-catenin), Notch (Notch 1–4 and JAG1/Dll-4 and targets survivin/Hey2), and leptin (STAT3 and targets VEGF/VEGFR-2) signaling pathways were measured using western blot and ELISA. β-Catenin levels were also investigated by IHC in DMBA-breast cancer samples from lean and DIO (diet-induced obese mice) mice treated with LPrA2. Apoptosis was also measured.

Results: Leptin increased the levels of beta-catenin mainly in TNBC cells. This leptin-induced effect was also detected in breast tumors from DIO-mice. Interestingly, leptin increased survival (bcl-2 and Caspase-3 activation)/proliferation (cell number and Cyclin D1), expression of Notch and attenuated the detrimental effects of Doxorubicin and Cisplastin on breast cancer cells. Wnt-1 had similar but less pronounced effects compared to leptin. We also observed differences in Notch expression. Moreover, MDA MB-231 cells showed decreased response to Wnt1 in the presence of leptin.

Conclusions: Our findings suggest that leptin could play a negative role in TNBC by increasing drug-resistance through its crosstalk with Wnt and Notch signaling pathways. This may imply that obesity, characterized by elevated leptin levels, could negatively affect the outcome of TBNC treatment. Taken together, this data supports the theory that inhibition of leptin signaling could be a novel way to prevent and treat TBNC, particularly in the context of obesity and abnormal Wnt and Notch signaling. [This work was supported in part by NIH/NCI1SC1CA138658-02; NIH/ARRA/3SC1CA138658-02S1 and the Georgia Cancer Coalition Distinguished Cancer Scholar Award (to RRGP); CREDO (MSCR) 2R25RR017694-06A1 (to L.S.C); NIGMS506GM08248 and NCRR 5P20RR11104 (to T.Z.M); and facilities and support services at MSM (NIH RR03034 and 1C06 RR18386)].

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P5-06-10.

Emission characteristics of a homologous series of bimesogenic liquid-crystal lasers

In this study we have fabricated eight different liquid-crystal lasers using the same gain medium but different homologues from the bimesogenic series alpha-(2',4-difluorobiphenyl-4'-yloxy)-omega-(4-cyanobiphenyl-4'-yloxy)alkanes, whereby the number of methylene units in the spacer chain varied from n=5 to n=12. To quantify the performance of these lasers, the threshold energy and the slope efficiency were extracted from the input-output characteristics of each laser. A clear odd-even effect was observed when both the excitation threshold and the slope efficiency were plotted as a function of the number of methylene units in the spacer chain. In all cases, the bimesogen lasers for which n is even exhibit lower threshold energies and higher slope efficiencies than those for which n is odd. These results are then interpreted in terms of the macroscopic physical properties of the liquid-crystalline compounds. In accordance with a previous study [S. M. Morris, A. D. Ford, M. N. Pivnenko, O. Hadeler, and H. J. Coles, Phys. Rev. E. 74, 061709 (2006)], a combination of a large birefringence and high order parameters are found, in the most part, to correlate with low-threshold energy and high slope efficiency. This indicates that the threshold and slope efficiency are dominated by the host macroscopic properties as opposed to intermolecular interactions between the dye and the liquid crystal. However, certain differences in the slope efficiency could not be explained by the birefringence and order parameter values alone. Instead, we find that the slope efficiency is further increased by increasing the elastic constants of the liquid-crystal host so as to decrease the scattering losses incurred by local distortions in the director field under high-energy optical excitation.

The clinical needs of patients with chronic gastrointestinal symptoms after pelvic radiotherapy

BACKGROUND

After radiotherapy for pelvic cancer, gastrointestinal symptoms affecting quality of life are common. How they affect daily living is unknown.

AIM

To investigate the day-to-day impact of gastrointestinal symptoms in patients after pelvic radiotherapy.

METHODS

New patients referred for gastroenterological evaluation of radiotherapy-induced symptoms were sent a questionnaire.

RESULTS

Over 15 months, 75 of 100 questionnaires were completed before the gastroenterology appointment by 45 men (median age 70) and 30 women (median age 57) treated for urological (n = 44), gynaecological (n = 27) and gastrointestinal (n = 4) cancers. Time since radiotherapy was 3 years (median) for women and 1.5 years (men). Women experienced 6 (median) symptoms whilst men experienced 4. Having someone listen to problems was often as important as treatment. Urgency, diarrhoea, pain, rectal bleeding, flatulence and bloating were particularly troublesome. 57% women and 33% men were 'very affected'. Symptoms rarely improved with time and in 33% had been present for more than 2 years. Gastrointestinal symptoms affected quality of life through change of routine (F 37%, M 22%), social limitation (F 17%, M 33%), physical limitations (F 33%, M 16%), emotional difficulties (F 47%, M 18%) and sexual problems (F 30%, M 51%).

CONCLUSIONS

Patients experience a high number of physical symptoms for long periods before referral. Clinicians must focus systematically on physical, emotional and psychosexual issues.

A randomized trial of teaching clinical skills using virtual and live standardized patients

BACKGROUND

We developed computer-based virtual patient (VP) cases to complement an interactive continuing medical education (CME) course that emphasizes skills practice using standardized patients (SP). Virtual patient simulations have the significant advantages of requiring fewer personnel and resources, being accessible at any time, and being highly standardized. Little is known about the educational effectiveness of these new resources. We conducted a randomized trial to assess the educational effectiveness of VPs and SPs in teaching clinical skills.

OBJECTIVE

To determine the effectiveness of VP cases when compared with live SP cases in improving clinical skills and knowledge.

DESIGN

Randomized trial.

PARTICIPANTS

Fifty-five health care providers (registered nurses 45%, physicians 15%, other provider types 40%) who attended a CME program.

INTERVENTIONS

Participants were randomized to receive either 4 live cases (n=32) or 2 live and 2 virtual cases (n=23). Other aspects of the course were identical for both groups.

RESULTS

Participants in both groups were equivalent with respect to pre-post workshop improvement in comfort level (P=.66) and preparedness to respond (P=.61), to screen (P=.79), and to care (P=.055) for patients using the skills taught. There was no difference in subjective ratings of effectiveness of the VPs and SPs by participants who experienced both (P=.79). Improvement in diagnostic abilities were equivalent in groups who experienced cases either live or virtually.

CONCLUSIONS

Improvements in performance and diagnostic ability were equivalent between the groups and participants rated VP and SP cases equally. Including well-designed VPs has a potentially powerful and efficient place in clinical skills training for practicing health care workers.

Secular trends in desired weight of adults

CONTEXT

The prevalence of overweight and obese adults in the United States is at record levels.

OBJECTIVE

The primary purpose is to describe secular trends in desired weight among adults from 1994 to 2003, and secondarily, to examine the hypothetical impact of achieving desired weight on obesity prevalence.

DESIGN

Data were from the Behavioral Risk Factor Surveillance System (1994, 1996, 1998, 2000, 2003), a random-digit-dialed telephone survey.

SETTING

Sample included respondents from 47 states and the District of Columbia.

PARTICIPANTS

Non-institutionalized adults aged 18 years or older were included (N=703 286).

MAIN OUTCOME MEASURES

Primary outcome measures included reported weight and desired weight.

RESULTS

Means for desired weight increased 2.3 kg between 1994 and 2003, and reported weights increased 3.9 kg. The increased trend was observed across several subgroups for age, race/ethnicity and education. Within subgroups of weight status, the trend has remained relatively stable, particularly when examined in relation to the difference between reported and desired weight as a percentage of reported body weight. Generally, overweight men desired weights approximately 4.5% less than their reported weight, and obese men desired weights approximately 15% less than their reported weight for each corresponding year. For women, approximate values of desired weight were 12% less than reported weight for overweight women and 24% less for obese women. The prevalence of obesity would decrease to 4.4% if individuals weighed their desired weight.

CONCLUSIONS

Americans are shifting their desired weight upward, concomitantly with an increase in their reported body weight.

Dietary pattern as a predictor of change in BMI z-score among girls

OBJECTIVES

To describe child and adolescent dietary patterns and to determine associations between childhood dietary pattern and longitudinal change in body mass index (BMI) z-score among girls.

POPULATION AND METHODS

Healthy girls (n = 101) aged 8-12 years at baseline and 11-19 years at follow-up participated in a longitudinal study of growth and development. Participants kept 7-day dietary records at two points in time. We incorporated time of day, frequency, and amount of energy consumed (defined as percentage of total energy consumed per dietary event) when characterizing dietary patterns.

RESULTS

Girls ate an average of 4-5 times per day and consumed most energy in the afternoon and in the evening/night, rather than in the morning. After controlling for baseline BMI, the mean percentage of daily energy consumed in the evening/night was positively associated with change in BMI z-score (P = 0.039). Eating between 4.0 and 5.9 times per day overall and no more than 1.9 times in the evening/night daily were negatively associated with change in BMI z-score (P = 0.002 and 0.047, respectively), after controlling for baseline BMI z-score.

DISCUSSION

Recommendations to decrease the percentage of energy coming from the evening/night meal and the number of dietary events to no more than six times per day and two times in the evening/night should be evaluated in future longitudinal investigations.

Comparative endocrinology of the insulin-like growth factor-binding protein

Emerging early in chordate evolution, the IGF-regulatory axis diverged from an insulin-like predecessor into a vertebrate regulatory system specializing in cell growth activation and allied anabolic functions. Essential to the divergence of the IGF and insulin systems was an early presence of soluble IGF-binding proteins (IGFBPs), which bind IGF peptides at much higher affinity than that of the insulin receptor but at comparable affinities to that of the IGF receptor. IGFBPs have no homology with IGF receptors. Instead, IGFBPs are a derived group of proteins within a superfamily of cysteine-rich growth factors, whose members are found throughout the animal taxa. While blocking IGF actions through the insulin receptor is a fundamental role, IGFBPs evolved within the vertebrate line into centralized, 'integrators' of the endocrine growth-regulatory apparatus. IGFBPs have substantial influences on the distribution and bioavailability of IGF peptides in the cellular and physiological environments, but they have a variety of other properties. The six principal mammalian IGFBPs exhibit an array of specialized properties that appear to be derived from a complex evolutionary history (including cell membrane association, interaction with proteins that post-translationally modify them, direct IGF-independent effects on cells, and others) and they are regulated by a diversity of 'outside' factors (e.g. other hormones, metabolic status, stress). Thus, IGFBPs are multifunctional integrators having diverse physiological 'agendas'. Much less is known about IGFBPs and their properties in the other vertebrate taxa. Increasingly, however, it is being recognized that they play equally important endocrine roles, in both conserved and non-conserved ways, when compared with those currently defined in mammals. This review highlights selected 'comparative aspects' in current IGFBP research, in an attempt to view this essential group of endocrine regulators from a wider, biological perspective.

High serum retinyl esters are not associated with reduced bone mineral density in the Third National Health And Nutrition Examination Survey, 1988-1994

Hypervitaminosis A is sometimes associated with abnormalities of calcium metabolism and bone mineral status. A recent study found a negative association between reported dietary vitamin A intake and bone mineral density (BMD). Some segments of the U.S. population have high fasting serum retinyl ester concentrations, a physiological marker that may reflect high and possibly excessive vitamin A intake. We examined the association between fasting serum retinyl esters and BMD in the Third National Health and Nutrition Examination Survey, 1988-1994 (NHANES III), a large, nationally representative sample of the U.S. population. BMD was measured for the femoral neck, trochanter, intertrochanter, and total hip on all nonpregnant participants aged > or = 20 years; 5,790 participants also had complete data on fasting serum retinyl esters and covariates including age, body mass index (BMI), smoking, alcohol consumption, dietary supplement use, diabetes, physical activity, and, among women, parity, menopausal status, and the use of oral contraceptives or estrogen-replacement therapy. The sample included non-Hispanic white, non-Hispanic black, and Mexican American men and women. We examined the association between fasting serum retinyl esters and BMD at each site, controlling for covariates with multiple linear regression. We examined the association with osteopenia and osteoporosis with multiple logistic regression. Although the prevalences of high fasting serum retinyl esters concentration and low BMD were both substantial in this sample, there were no significant associations between fasting serum retinyl esters and any measure of bone mineral status.

Serum retinyl esters are not associated with biochemical markers of liver dysfunction in adult participants in the third National Health and Nutrition Examination Survey (NHANES III), 1988--1994

BACKGROUND

Serum retinyl ester concentrations are elevated in hypervitaminosis A. It was suggested that retinyl esters >10% of total serum vitamin A indicate potential hypervitaminosis, but this cutoff was derived from small clinical samples that may not be representative of the general population.

OBJECTIVE

We sought to examine the distribution of serum retinyl ester concentrations and associations between retinyl ester concentrations and biochemical markers of liver dysfunction in a nationally representative sample.

DESIGN

We assessed the associations between serum retinyl ester concentrations and 5 biochemical indexes of liver dysfunction by using multivariate linear and multiple logistic regression techniques and controlling for age, sex, use of supplements containing vitamin A, alcohol consumption, smoking status, and use of exogenous estrogens in 6547 adults aged > or =18 y in the third National Health and Nutrition Examination Survey (NHANES III), 1988--1994.

RESULTS

Thirty-seven percent of the sample had serum retinyl ester concentrations >10% of total serum vitamin A and 10% of the sample had serum retinyl esters >15% of total vitamin A. We found no associations between serum retinyl ester concentrations and 1) concentrations of any biochemical variable (multiple linear regression) or 2) risk of having biochemical variables above the reference range (multiple logistic regression). We did not find a serum retinyl ester value with statistically significant sensitivity and specificity for predicting increases in biochemical indexes of liver dysfunction.

CONCLUSIONS

The prevalence of serum retinyl ester concentrations >10% of the total vitamin A concentration in the NHANES III sample was substantially higher than expected but elevated retinyl ester concentrations were not associated with abnormal liver function.

C-reactive protein and body mass index in children: findings from the Third National Health and Nutrition Examination Survey, 1988-1994

OBJECTIVES

To examine the relationship between C-reactive protein (CRP) concentration and body mass index (BMI) in children.

STUDY DESIGN

With the use of data from 5305 children aged 6 to 18 years in the Third National Health and Nutrition Examination Survey (1988 to 1994), a cross-sectional health survey, we examined whether CRP concentrations were elevated among overweight children.

RESULTS

Among children whose BMI was below the age- and sex-specific 15th percentile, 6.6% of boys and 10.7% of girls had an elevated CRP concentration (>2.1 mg/L) compared with 24.2% of boys and 31.9% of girls whose BMI was > or =95th percentile. After adjustment was done for age, sex, race or ethnicity, poverty income ratio, high-density lipoprotein cholesterol concentration, white blood cell count, and history of chronic bronchitis, the adjusted odds of having an elevated CRP concentration were 2.20 (95% CI 1.30, 3.75) for children with a BMI of 85th to <95th percentile and 4.92 (95% CI 3.39, 7.15) for children with a BMI of > or =95th percentile compared with children who had a BMI of 15th to <85th percentile. The associations did not differ significantly by age, sex, or race or ethnicity.

CONCLUSIONS

In a large representative sample of US children, CRP concentration was significantly elevated among children with a BMI > or=85th percentile, thus confirming previous findings of this association in children and extending previous research in adults to children. Excess body weight may be associated with a state of chronic low-grade inflammation in children.

Serum retinol distributions in residents of the United States: third National Health and Nutrition Examination Survey, 1988-1994

BACKGROUND

Inadequate vitamin A status has been a potential nutritional problem for some segments of the US population, particularly children and the poor.

OBJECTIVE

We evaluated serum retinol concentration by using population-representative data from 16058 participants aged 4 to >/=90 y in the third National Health and Nutrition Examination Survey, 1988-1994.

DESIGN

We used multivariate regression to examine the simultaneous associations of sociodemographic, biologic, and behavioral factors with serum retinol concentration.

RESULTS

In children, serum retinol concentrations were greater with greater age, body mass index, serum lipids, and the use of supplements containing vitamin A. In adults, male sex, serum lipids, alcohol consumption, and age were positively associated with serum retinol concentration in most racial/ethnic strata. Household income was not associated with serum retinol concentration in children; associations were inconsistent in adults. The prevalence of serum retinol <0.70 micromol/L was very low in all strata; the prevalence of serum retinol <1.05 micromol/L was 16.7-33.9% in children aged 4-8 y and 3.6-14.2% in children aged 9-13 y, depending on sex and racial/ethnic group. The prevalence of serum retinol<1.05 micromol/L was higher in non-Hispanic black and Mexican American children than in non-Hispanic white children; these differences remained significant (P < 0.0001) after covariates were controlled for. Among adults, nonwhite women were significantly (P < 0.0001) more likely than white women to have serum retinol <1.05 micromol/L after covariates were controlled for.

CONCLUSIONS

Clinically low serum retinol concentration is uncommon in US residents aged > or = 4 y, although racial/ethnic and socioeconomic differences in serum retinol concentration still exist.

Beverage choices affect adequacy of children's nutrient intakes

OBJECTIVE

To assess the relationship between beverage choices and the adequacy of nutrient intakes among children and adolescents.

DESIGN

Beverages reported in 24-hour recall records were classified as milk, 100% juice, fruit-flavored drinks, or carbonated sodas. Recommended intakes were based on Recommended Dietary Allowances or Dietary Reference Intakes.

PARTICIPANTS

Four thousand seventy children aged 2 to 5, 6 to 11, and 12 to 17 years participating in the 1994-96 Continuing Survey of Food Intakes by Individuals.

STATISTICAL ANALYSIS

The likelihood of achieving recommended intakes of selected nutrients on the day of recall was assessed with multiple logistic regression including ounces of milk, juice, fruit-flavored drinks, and carbonated sodas in the model while controlling for sex, age in years, race/ethnic group, household income, and total energy intake.

RESULTS

Milk consumption was positively (P<.0001) associated with the likelihood of achieving recommended vitamin A, folate, vitamin B(12), calcium, and magnesium intakes in all age strata. Juice consumption was positively (P< or =. 001) associated with achieving recommended vitamin C and folate intakes in all age strata and magnesium intakes among children aged 6 years and older. Carbonated soda consumption was negatively (P< or =. 01) associated with achieving vitamin A intake in all age strata, calcium in children younger than 12 years, and magnesium in children aged 6 years and older.

CONCLUSION

Beverage choice can have a significant effect on the nutrient adequacy of the diets of children and adolescents.

A rapid food screener to assess fat and fruit and vegetable intake

BACKGROUND

The U.S. Preventive Services Task Force recommends that Americans lower dietary fat and cholesterol intake and increase fiber and fruit/vegetables to reduce prevalence of heart disease, cancer, stroke, hypertension, obesity, and non-insulin-dependent diabetes mellitus in the United States. To provide preventive services to all, a rapid, inexpensive, and valid method of assessing dietary intake is needed.

METHODS

We used a one-page food intake screener based on national nutrition data. Respondents can complete and score the screener in a few minutes and can receive immediate, brief feedback. Two hundred adults self-administered the food screener. We compared fat, fiber, and fruit/vegetable intake estimates derived from the screener with estimates from a full-length, 100-item validated questionnaire.

RESULTS

The screener was effective in identifying persons with high-fat intake, or low-fruit/vegetable intake. We found correlations of 0.6-0.7 (p<0. 0001) for total fat, saturated fat, cholesterol, and fruit/vegetable intake. The screener could identify persons with high percentages of calories from fat, total fat, saturated fat, or cholesterol, and persons with low intakes of vitamin C, fiber, or potassium.

CONCLUSIONS

This screener is a useful tool for quickly monitoring patients' diets. The health care provider can use it as a prelude to brief counseling or as the first stage of triage. Persons who score poorly can be referred for more extensive evaluation by low-cost paper-and-pencil methods. Those who still have poor scores at the second stage ultimately can be referred for in-person counseling.

A controlled trial of exercise training in older coronary patients

BACKGROUND

This study compared the effects of a formal exercise conditioning program of 3 and 12 months duration to spontaneous recovery in a population of older, post-coronary event patients.

METHODS

Indices of peak exercise and submaximal exercise performance such as oxygen consumption, treadmill work capacity, minute ventilation, heart rate, and systolic blood pressure were assessed before and after conditioning in 60 post-myocardial infarction and post-coronary bypass surgery patients (mean age 68 +/- 5 years) and compared to measures of fitness in a usual care control group (n = 23, mean age 68 +/- 5 years).

RESULTS

Maximal treadmill work capacity increased by 47% in the intervention group at 3 months compared to no improvement in the usual care control group. However, both groups increased peak oxygen consumption similarly at 3 and 12 months, increasing by 16% and 20% in the intervention group at 3 and 12 months and by 7% and 14% in the control group (p = n.s.). Only the exercise training group manifested submaximal indices of conditioning such as a lower heart rate and minute ventilation at a standard workload.

CONCLUSION

While spontaneous improvements in peak oxygen consumption are seen in older coronary patients in the months following a coronary event, a formal exercise training program results in significantly greater increases in peak exercise capacity and in peak and submaximal exercise efficiency.