A Prototype Software Framework for Transferable Computational Health Economic Models and Its Early Application in Youth Mental Health

We are developing an economic model to explore multiple topics in Australian youth mental health policy. To help make that model more readily transferable to other jurisdictions, we developed a software framework for authoring modular computational health economic models (CHEMs) (the software files that implement health economic models). We specified framework user requirements for: a simple programming syntax; a template CHEM module; tools for authoring new CHEM modules; search tools for finding existing CHEM modules; tools for supplying CHEM modules with data; reproducible analysis and reporting tools; and tools to help maintain a CHEM project website. We implemented the framework as six development version code libraries in the programming language R that integrate with online services for software development and research data archiving. We used the framework to author five development version R libraries of CHEM modules focussed on utility mapping in youth mental health. These modules provide tools for variable validation, dataset description, multi-attribute instrument scoring, construction of mapping models, reporting of mapping studies and making out of sample predictions. We assessed these CHEM module libraries as mostly meeting transparency, reusability and updatability criteria that we have previously developed, but requiring more detailed documentation and unit testing of individual modules. Our software framework has potential value as a prototype for future tools to support the development of transferable CHEMs.Code: Visit https://www.ready4-dev.com for more information about how to find, install and apply the prototype software framework.

Initial Implementation of the My Heart, My Life Program by the National Heart Foundation of Australia: Pilot Mixed Methods Evaluation Study

BACKGROUND

Coronary heart disease (CHD) remains the leading cause of death in Australia, with a high residual risk of repeat events in survivors. Secondary prevention therapy is crucial for reducing the risk of both death and other major adverse cardiac events. The National Heart Foundation of Australia has developed a consumer-facing support program called My Heart, My Life (MHML) to address the gap in the secondary prevention of CHD in Australia. The MHML pilot program supplies advice and support for both patients and their caregivers, and it was conducted over 8 months from November 2019 to June 2020.

OBJECTIVE

This study aims to describe and examine the implementation of a novel multimodality secondary CHD prevention pilot program called MHML, which was delivered through booklets, text messages, emails, and telephone calls.

METHODS

This pilot study consists of a mixed methods evaluation involving surveys of participants (patients and caregivers) and health professionals, in-depth interviews, and digital communication (SMS text message, electronic direct mail, and call record analytics). This study was performed in people older than 18 years with acute coronary syndrome or angina and their caregivers in 38 Australian hospitals from November 2019 to June 2020 through the National Heart Foundation of Australia web page. The main outcome measures were reach, accessibility, feasibility, barriers, and enablers to implementation of this program.

RESULTS

Of the 1004 participants (838 patients and 164 caregivers; 2 missing), 60.9% (608/1001) were males, 50.7% (491/967) were aged between 45 and 64 years, 27.4% (276/1004) were from disadvantaged areas, 2.5% (24/946) were from Aboriginal or Torres Strait Islander background, and 16.9% (170/1004) reported English as their second language. The participants (patients and their caregivers) and health professionals reported high satisfaction with the MHML program (55/62, 88.7% and 33/38, 87%, respectively). Of the 62 participants who took the survey, 88% (55/62) used the text messaging service and reported a very high level of satisfaction. Approximately 94% (58/62) and 89% (55/62) of the participants were satisfied with the quick guide booklets 1 and 2, respectively; 79% (49/62) were satisfied with the monthly email journey and 71% (44/62) were satisfied with the helpline calls. Most participants reported that the MHML program improved preventive behaviors, that is, 73% (45/62) of them reported that they maintained increased physical activity and 84% (52/62) reported that they maintained a healthy diet even after the MHML program.

CONCLUSIONS

The findings of our pilot study suggest that a multimodal support program, including digital, print, phone, and web-based media, for the secondary prevention of CHD is useful and could be a potential means of providing customized at-scale secondary prevention support for survivors of acute coronary syndrome.

Early safety outcome in patients requiring conversion to general anesthesia during transfemoral transcatheter aortic valve replacement

Background

Transfemoral TAVR (tf-TAVR) has become an established therapy. Conscious sedation (CS) is a alternative to general anesthesia (GA). So far, the outcome of patients undergoing unplanned conversion from CS to GA has not been investigated.

Methods

All patients undergoing tf-TAVR in CS between 2014 and 2019 were included. Primary endpoint was early safety at 30 days according to VARC-2 criteria. The reasons for conversion and length of ICU-/ hospital-stay were further analyzed.

Results

Of 1058 patients 35 (3.3%) required a conversion. Baseline characteristics were similar among groups. The combined VARC-2 endpoint was documented in 13 (37%) of the converted and 110 (11%) of non-converted patients (p<0.001). Four major sub-groups were underlying causes: unrest in 11/35, procedural complications in 10/35, respiratory distress in 8/35 and cardiovascular decompensation in 6/35 patients. An univariable analysis was performed to identify risk factors for unplanned conversion due to respiratory distress or cardiovascular decompensation (Table). Compared to the group without conversion (Median [IQR], 4 [4–5] days), length of hospital stay was longest in the group with procedural complications (6 [1–11] days) followed by cardiovascular decompensation (5 [4–7] days).

Conclusions

The conversion rate to general anesthesia was overall low but associated with a higher observation of the composite endpoint. Hospital stay was longer dependent on the reason for conversion. A thorough understanding of the frequency, causal factors and clinical significance of unplanned conversion to general anesthesia is of utmost clinical relevance taking a general trend towards a minimalist approach into consideration.

Funding Acknowledgement

Type of funding source: None

Correlates of walking among disadvantaged groups: A systematic review

Socioeconomically disadvantaged groups are less likely to be physically active. Walking is important to public health, therefore understanding correlates of walking will inform the development of targeted interventions. The aim of this systematic review was to examine the correlates of walking among socioeconomically disadvantaged adults. PubMed/MEDLINE and Scopus were searched up to February 2020 and titles/abstracts and full-texts were screened against eligibility criteria. Methodological quality was assessed. Correlates were synthesized when two or more comparisons were available. 35 studies were selected for synthesis. 21 examined overall walking, 16 examined leisure-time walking and 9 examined walking for transport (8 examined two or more types of walking). Employment status, home ownership, self-rated health, density or number of social ties, perceived neighborhood aesthetics, perceived walkability and perceived individual safety were positively associated with overall walking. Social support for physical activity from friends and family and perceived individual safety were positively associated with leisure-time walking. Objective walkability, perceived walkability and perceived individual safety were positively associated with walking for transport. Most studies were cross-sectional, did not report response rates and used a validated measure of physical activity. Strategies to improve self-rated health, social ties, neighborhood aesthetics, walkability and perceptions of individual safety should be the focus of interventions that aim to improve walking among socioeconomically disadvantaged groups. Recommendations for future studies include the need to focus on leisure-time walking and walking for transport; the correlates of walking in males; prospective longitudinal designs; psychological, cognitive and emotional variables; and social, behavioral attributes and skills.

Correlates of Physical Activity Among Disadvantaged Groups: A Systematic Review

CONTEXT

Socioeconomically disadvantaged adults have lower engagement in leisure-time physical activity than those who are more affluent. Identification of correlates of physical activity can inform the design of effective interventions. The aim of this systematic review was to identify consistent correlates of unspecified physical activity and leisure-time physical activity among socioeconomically disadvantaged adults.

EVIDENCE ACQUISITION

PubMed and Scopus were searched up to May 2018, and titles/abstracts and full texts were screened against eligibility criteria. Methodologic quality was assessed, and correlates were synthesized from July to September 2018.

EVIDENCE SYNTHESIS

Seventy-three studies were selected for synthesis; 48 examined unspecified physical activity and 31 examined leisure-time physical activity (6 examined both). Self-rated health, functional capacity, and physical activity self-efficacy were consistently, positively associated with unspecified physical activity. Mental health status and perceived benefits and enjoyment of physical activity were consistently, positively associated with leisure-time physical activity. Most studies were cross-sectional and used validated self-report measures of physical activity; few reported response rates >50%.

CONCLUSIONS

Few factors were consistently associated with either unspecified physical activity or leisure-time physical activity. Based on available evidence, strategies to increase physical activity should consider the needs of, and focus on, those with poor self-rated health and functional capacity and should use strategies to improve physical activity self-efficacy. Strategies to increase leisure-time physical activity should focus on simultaneously addressing leisure-time physical activity and mental health concerns and improving perceptions of physical activity benefits and enjoyment. It is recommended that future studies focus on leisure-time physical activity, focus on men, use longitudinal design, examine variables related to behavioral attributes and skills, and carefully consider and plan recruitment strategies.

Equity of a government subsidised exercise referral scheme: A population study

BACKGROUND

Health inequities could increase if utilisation of physical activity interventions is lower among socioeconomically disadvantaged groups. We examined associations between area level socioeconomic disadvantage and utilisation of Australian government-subsidised, general practitioner (GP)-referred, accredited exercise physiologist (AEPs) services.

METHODS

We conducted a cross-sectional analysis of Australian Medical Benefits Scheme (MBS) data (N = 228,771 AEP services) for the 2015-2016 financial year and aggregated publicly available data from several sources. Spearman's correlations examined associations between utilisation of AEP services and area-level socioeconomic disadvantage, indicated by Index of Relative Socioeconomic Disadvantage (IRSD) decile scores. Lower IRSD scores indicate greater levels of socioeconomic disadvantage.

RESULTS

Significant correlations between IRSD score and study variables were as follows: Out-of-pocket expenses/service (rs = 0.52); number of patients/AEP provider (rs = -0.42); number of patients/1000 population (rs = -0.24); AEP services/1000 population (rs = -0.18); average services/patient (rs = 0.24); and AEP provider/1000 population (rs = 0.14).

CONCLUSION

Patients living in areas of greater disadvantage utilised government-subsidised, GP-referred AEP services at a higher rate and paid lower out-of-pocket fees than those living in more affluent areas. Thus, AEP services are equitably distributed, from a utilisation perspective, and acceptable to patients living in areas of disadvantage. However, the higher caseloads and lower fees that characterise AEP services in areas of greater disadvantage may result in shorter consultation times. Further research on exercise referral schemes is warranted, particularly whether socioeconomic disadvantage is associated with adherence to exercise sessions and health outcomes.

Interventions to improve physical activity among socioeconomically disadvantaged groups: an umbrella review

Background

People from socioeconomically disadvantaged population groups are less likely to be physically active and more likely to experience adverse health outcomes than those who are less disadvantaged. In this umbrella review we examined across all age groups, (1) the effectiveness of interventions to improve physical activity among socioeconomically disadvantaged groups, (2) the characteristics of effective interventions, and (3) directions for future research.

Methods

PubMed/MEDLINE and Scopus were searched up to May 2017 to identify systematic reviews reporting physical activity interventions in socioeconomically disadvantaged populations or sub-groups. Two authors independently conducted study screening and selection, data extraction (one author, with data checked by two others) and assessment of methodological quality using the ‘Assessment of Multiple Systematic Reviews’ scale. Results were synthesized narratively.

Results

Seventeen reviews met our inclusion criteria, with only 5 (30%) reviews being assessed as high quality. Seven (41%) reviews focused on obesity prevention and an additional four focused on multiple behavioural outcomes. For pre school children, parent-focused, group-based interventions were effective in improving physical activity. For children, school-based interventions and policies were effective; few studies focused on adolescents and those that did were generally not effective; for adults, there was mixed evidence of effectiveness but characteristics such as group-based interventions and those that focused on physical activity only were associated with effectiveness. Few studies focused on older adults. Across all ages, interventions that were more intensive tended to be more effective. Most studies reported short-term, rather than longer-term, outcomes and common methodological limitations included high probability of selection bias, low response rates, and high attrition.

Conclusions

Interventions can be successful at improving physical activity among children from socioeconomically disadvantaged groups, with evidence for other age groups weak or inconclusive. More high-quality studies in this population group are needed, which adopt strategies to increase recruitment rates and reduce attrition, report longer term outcomes, and provide adequate intervention details, to allow determination of the characteristics of effective interventions. We recommend that the benefits of physical activity be recognised more broadly than obesity prevention in future studies, as this may have implications for the design and appeal of interventions.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0676-2) contains supplementary material, which is available to authorized users.

Effectiveness of interventions for reducing non-occupational sedentary behaviour in adults and older adults: a systematic review and meta-analysis

Background

No systematic reviews of the effectiveness of interventions for reducing non-occupational sedentary behaviour are available. Therefore, the aim of this systematic review was to assess the effectiveness of interventions for reducing non-occupational sedentary behaviour in adults and older adults.

Methods

An electronic search of nine databases was performed. Randomised controlled trials (RCT) and cluster RCTs among adults testing the effectiveness of interventions aimed to reduce non-occupational sedentary behaviour were considered for inclusion. Two review authors independently screened studies for eligibility, completed data extraction and assessed the risk of bias.

Results

Nineteen studies that evaluated multicomponent lifestyle interventions, counselling or education, television (TV) control devices and workplace interventions were included. Evidence from the meta-analyses suggested that interventions can reduce leisure sitting time in adults in the medium term (−30 min/day; 95% CI −58 to –2), and TV viewing in the short term (−61 min/day; 95% CI −79 to –43) and medium term (−11 min/day; 95% CI −20 to –2). No significant pooled effects were found for transport sitting time, leisure-time computer use and longer term outcomes. No evidence was available on the effectiveness of interventions for reducing non-occupational sedentary time in older adults.

Conclusions

The findings of this systematic review suggest the interventions may be effective in reducing non-occupational sedentary behaviour in the short to medium term in adults. However, no significant effect was found on longer term outcomes. The quality of evidence was, however, low to very low. No evidence was available on the effectiveness of non-occupational interventions on reducing sedentary time in older adults. Further high-quality research with larger samples is warranted.

Screen Time, Other Sedentary Behaviours, and Obesity Risk in Adults: A Review of Reviews

PURPOSE OF REVIEW

The aim of this paper is to assess the association between sedentary behaviours, including screen time, and risk of obesity in adults. A review of 10 systematic reviews was undertaken.

RECENT FINDINGS

Available evidence is generally not supportive of associations between sedentary behaviour and obesity in adults. Most studies that found significant associations indicated mostly small effect sizes. Somewhat more consistent associations were shown for screen time (mainly TV viewing), among older adults, and for pre-adult sedentary behaviour to increase the risk of obesity in adulthood. Some evidence also exists for breaks in sedentary time to be associated with a more favourable BMI, and for use of a car to be associated with greater risk of obesity. There is limited evidence for an association between sedentary behaviour in adulthood and obesity and any association that exists does not seem to be causal. Future research is required investigating potentially positive effects for frequent breaks from sitting, less car use, and an uncoupling of TV viewing and dietary intake.

Sedentary behaviour and adiposity in youth: a systematic review of reviews and analysis of causality

Background

Sedentary behaviour (sitting time) has becoming a very popular topic for research and translation since early studies on TV viewing in children in the 1980s. The most studied area for sedentary behaviour health outcomes has been adiposity in young people. However, the literature is replete with inconsistencies.

Methods

We conducted a systematic review of systematic reviews and meta-analyses to provide a comprehensive analysis of evidence and state-of-the-art synthesis on whether sedentary behaviours are associated with adiposity in young people, and to what extent any association can be considered ‘causal’. Searches yielded 29 systematic reviews of over 450 separate papers. We analysed results by observational (cross-sectional and longitudinal) and intervention designs.

Results

Small associations were reported for screen time and adiposity from cross-sectional evidence, but associations were less consistent from longitudinal studies. Studies using objective accelerometer measures of sedentary behaviour yielded null associations. Most studies assessed BMI/BMI-z. Interventions to reduce sedentary behaviour produced modest effects for weight status and adiposity. Accounting for effects from sedentary behaviour reduction alone is difficult as many interventions included additional changes in behaviour, such as physical activity and dietary intake. Analysis of causality guided by the classic Bradford Hill criteria concluded that there is no evidence for a causal association between sedentary behaviour and adiposity in youth, although a small dose-response association exists.

Conclusions

Associations between sedentary behaviour and adiposity in children and adolescents are small to very small and there is little to no evidence that this association is causal. This remains a complex field with different exposure and outcome measures and research designs. But claims for ‘clear’ associations between sedentary behaviour and adiposity in youth, and certainly for causality, are premature or misguided.

Office workers' objectively assessed total and prolonged sitting time: Individual-level correlates and worksite variations

Sedentary behavior is highly prevalent in office-based workplaces; however, few studies have assessed the attributes associated with this health risk factor in the workplace setting. This study aimed to identify the correlates of office workers' objectively-assessed total and prolonged (≥ 30 min bouts) workplace sitting time. Participants were 231 Australian office workers recruited from 14 sites of a single government employer in 2012-13. Potential socio-demographic, work-related, health-related and cognitive-social correlates were measured through a self-administered survey and anthropometric measurements. Associations with total and prolonged workplace sitting time (measured with the activPAL3) were tested using linear mixed models. Worksites varied significantly in total workplace sitting time (overall mean [SD]: 79% [10%] of work hours) and prolonged workplace sitting time (42% [19%]), after adjusting for socio-demographic and work-related characteristics. Organisational tenure of 3-5 years (compared to tenure > 5 years) was associated with more time spent in total and prolonged workplace sitting time, while having a BMI categorised as obese (compared to a healthy BMI) was associated with less time spent in total and prolonged workplace sitting time. Significant variations in sitting time were observed across different worksites of the same employer and the variation remained after adjusting for individual-level factors. Only BMI and organisational tenure were identified as correlates of total and prolonged workplace sitting time. Additional studies are needed to confirm the present findings across diverse organisations and occupations.

Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome†

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is a treatment strategy for patients with severe aortic stenosis. Although general anaesthesia (TAVI-GA) and sedation (TAVI-S) have previously been described for TAVI, the difference in safety and efficacy of both methods has not been studied in a randomized trial.

METHODS

The INSERT trial was a single centre, controlled parallel-group trial with balanced randomization. Sixty-six patients (68-94 yr) with acquired aortic stenosis undergoing transfemoral CoreValve™ were assigned to TAVI-GA or TAVI-S. Comparable operative risk was determined from risk-scores (EUROscore, STS-Score). Monitoring and anaesthetic drugs were standardized. Near-Infrared-Spectroscopy was used to monitor cerebral-oxymetry blinded. Primary outcome was the perioperative cumulative cerebral desaturation. As secondary outcomes, changes in neurocognitive function and respiratory and haemodynamic adverse events were evaluated.

RESULTS

Of 66 included patients, 62 (TAVI-GA: n=31, TAVI-S: n=31) were finally analysed. Baseline characteristics were comparable. In 24 patients (39%) cerebral desaturation was observed. Cumulative cerebral desaturation was comparable (TAVI-GA:(median [IQR]) (0[0/1308] s%) vs. TAVI-S:(0[0/276] s%); P=0.505) between the groups. Neurocognitive function did not change within and between groups. Adverse events were more frequently observed in TAVI-S patients (P<0.001). Bradypnoea (n=16, 52%) and the need for airway manoeuvres (n=11, 36%) or bag-mask-ventilation (n=6, 19%) were the most common respiratory adverse events.

CONCLUSIONS

Cerebral desaturation occurred in both patient groups, but there was no significant difference between the two groups. Based on primary outcome, both methods were shown to be comparable. Neurocognitive outcome was similar. The higher incidence of adverse events in the sedation group suggests a potential advantage of general anaesthesia.

CLINICAL TRIAL REGISTRATION

NCT 01251328.

Plerixafor plus pegfilgrastim is a safe, effective mobilization regimen for poor or adequate mobilizers of hematopoietic stem and progenitor cells: a phase I clinical trial

The safety, kinetics and efficacy of plerixafor+pegfilgrastim for hematopoietic stem and progenitor cell (HSPC) mobilization are poorly understood. We treated 12 study patients (SP; lymphoma n=10 or myeloma n=2) with pegfilgrastim (6 mg SC stat D1) and plerixafor (0.24 mg/kg SC nocte from D3). Six SP were 'predicted poor-mobilizers' and six were 'predicted adequate-mobilizers'. Peripheral blood (PB) CD34(+) monitoring commenced on D3. Apheresis commenced on D4. Comparison was with 22 historical controls (HC; lymphoma n=18, myeloma n=4; poor mobilizers n=4), mobilized with pegfilgrastim alone. Eight (67%) SP had PB CD34(+) count ⩽5 × 10(6)/L D3 post pegfilgrastim; all SP surpassed this threshold the morning after plerixafor. In SP, PBCD34(+) counts peaked D4 6/12 (50%), remaining ⩾5 × 10(6)/L for 4 days in 8/12 (67%). All SP successfully yielded target cell numbers (⩾2 × 10(6)/kg) within four aphereses. After maximum four aphereses, median total CD34+ yield was higher in SP than HC; 8.0 (range 2.4-12.9) vs 4.8 (0.4-14.0) × 10(6)/kg (P=0.04). Seven of twelve (58%) SP achieved target yield after one apheresis. Flow cytometry revealed no tumor cells in PB or apheresis product of SP. Plerixafor+pegfilgrastim was well tolerated with bone pain (n=2), diarrhoea (n=2) and facial paraesthesiae (n=3). Plerixafor+pegfilgrastim is a simple, safe and effective HSPC mobilization regimen in myeloma and lymphoma, in both poor and good mobilizers, and is superior to pegfilgrastim alone.

[Not Available]

Based on the Federal Health Survey from 1998, the Augsburg heart attack registry, and the ninth coordinated population prediction, we have estimated the occurrence of heart attacks in Germany up to the year 2050. From the mere demographic perspective - regardless of medical and social influences - we can expect that the need for cardiac care will increase considerably. If we assume that the risk or the frequency of having a heart attack will remain the same, then the number of heart attacks in people aged 25 to over 90 and 35 to under 90 will increase, although the population size of these age groups will decline. The population over 75 years of age will with certainty determine the course of the incidence and prevalence of heart attacks. In addition to standardised incidence and/or prevalence rates, estimations of the absolute number of incidents and/or prevalent cases of the respective target illness have to be included in morbidity predictions in order to avoid misinterpretations.

Reducing office workers' sitting time: rationale and study design for the Stand Up Victoria cluster randomized trial

Background

Excessive time spent in sedentary behaviours (sitting or lying with low energy expenditure) is associated with an increased risk for type 2 diabetes, cardiovascular disease and some cancers. Desk-based office workers typically accumulate high amounts of daily sitting time, often in prolonged unbroken bouts. The Stand Up Victoria study aims to determine whether a 3-month multi-component intervention in the office setting reduces workplace sitting, particularly prolonged, unbroken sitting time, and results in improvements in cardio-metabolic biomarkers and work-related outcomes, compared to usual practice.

Methods/Design

A two-arm cluster-randomized controlled trial (RCT), with worksites as the unit of randomization, will be conducted in 16 worksites located in Victoria, Australia. Work units from one organisation (Department of Human Services, Australian Government) will be allocated to either the multi-component intervention (organisational, environmental [height-adjustable workstations], and individual behavioural strategies) or to a usual practice control group. The recruitment target is 160 participants (office-based workers aged 18–65 years and working at least 0.6 full time equivalent) per arm. At each assessment (0- [baseline], 3- [post intervention], and 12-months [follow-up]), objective measurement via the activPAL3 activity monitor will be used to assess workplace: sitting time (primary outcome); prolonged sitting time (sitting time accrued in bouts of ≥30 minutes); standing time; sit-to-stand transitions; and, moving time. Additional outcomes assessed will include: non-workplace activity; cardio-metabolic biomarkers and health indicators (including fasting glucose, lipids and insulin; anthropometric measures; blood pressure; and, musculoskeletal symptoms); and, work-related outcomes (presenteeism, absenteeism, productivity, work performance). Incremental cost-effectiveness and identification of both workplace and individual-level mediators and moderators of change will also be evaluated.

Discussion

Stand Up Victoria will be the first cluster-RCT to evaluate the effectiveness of a multi-component intervention aimed at reducing prolonged workplace sitting in office workers. Strengths include the objective measurement of activity and assessment of the intervention on markers of cardio-metabolic health. Health- and work-related benefits, as well as the cost-effectiveness of the intervention, will help to inform future occupational practice.

Trial registration

ACTRN1211000742976

Reducing sitting time in office workers: short-term efficacy of a multicomponent intervention

OBJECTIVE

To investigate the short-term efficacy of a multicomponent intervention to reduce office workers' sitting time.

METHODS

Allocation for this non-randomized controlled trial (n=43 participants; 56% women; 26-62 years; Melbourne, Australia) was by office floor, with data collected during July-September 2011. The 4-week intervention emphasized three key messages: "Stand Up, Sit Less, Move More" and comprised organizational, environmental, and individual elements. Changes in minutes/day at the workplace spent sitting (primary outcome), in prolonged sitting (sitting time accumulated in bouts ≥ 30 min), standing, and moving were objectively measured (activPAL3).

RESULTS

Relative to the controls, the intervention group significantly reduced workplace sitting time (mean change [95%CI]: -125 [-161, -89] min/8-h workday), with changes primarily driven by a reduction in prolonged sitting time (-73 [-108, -40] min/8-h workday). Workplace sitting was almost exclusively replaced by standing (+127 [+92, +162] min/8-h workday) with non-significant changes to stepping time (-2 [-7, +4] min/8-h workday) and number of steps (-70 [-350, 210]).

CONCLUSIONS

This multicomponent workplace intervention demonstrated that substantial reductions in sitting time are achievable in an office setting. Larger studies with longer timeframes are needed to assess sustainability of these changes, as well as their potential longer-term impacts on health and work-related outcomes.

Increased formation of sister chromatid exchanges, but not of micronuclei, in anaesthetists exposed to low levels of sevoflurane

We have assessed, for the first time, genotoxicity (i.e. sister chromatid exchanges and micronuclei) in anaesthetists exposed to a single volatile anaesthetic (sevoflurane) without nitrous oxide. The anaesthetists were exposed to an 8-h time-weighted average of 0.2 parts per million sevoflurane. Internists served as non-exposed controls. Mean (SD) sister chromatid exchanges per cell were significantly higher in anaesthetists compared to internists (6.6 (0.9) vs 5.1 (0.8); p < 0.001) whereas median (IQR [range]) micronuclei per 1000 binucleated cells did not differ (9.5 (6.3-10.8 [2.0-15.5]) vs 8.5 (6.0-10.5 [3.0-25.5]), respectively). Although the anaesthetists were exposed to rather low concentrations of sevoflurane, this 30% increase of sister chromatid exchanges is in agreement with a recently reported 300% increase with a high level exposure to sevoflurane and nitrous oxide. Omitting nitrous oxide does not normalise increased rates of sister chromatid exchanges.

Increased brain serotonin turnover in panic disorder patients in the absence of a panic attack: reduction by a selective serotonin reuptake inhibitor

Since the brain neurotransmitter changes characterising panic disorder remain uncertain, we quantified brain noradrenaline and serotonin turnover in patients with panic disorder, in the absence of a panic attack. Thirty-four untreated patients with panic disorder and 24 matched healthy volunteers were studied. A novel method utilising internal jugular venous sampling, with thermodilution measurement of jugular blood flow, was used to directly quantify brain monoamine turnover, by measuring the overflow of noradrenaline and serotonin metabolites from the brain. Radiographic depiction of brain venous sinuses allowed differential venous sampling from cortical and subcortical regions. The relation of brain serotonin turnover to serotonin transporter genotype and panic disorder severity were evaluated, and the influence of an SSRI drug, citalopram, on serotonin turnover investigated. Brain noradrenaline turnover in panic disorder patients was similar to that in healthy subjects. In contrast, brain serotonin turnover, estimated from jugular venous overflow of the metabolite, 5-hydroxyindole acetic acid, was increased approximately 4-fold in subcortical brain regions and in the cerebral cortex (P < 0.01). Serotonin turnover was highest in patients with the most severe disease, was unrelated to serotonin transporter genotype, and was reduced by citalopram (P < 0.01). Normal brain noradrenaline turnover in panic disorder patients argues against primary importance of the locus coeruleus in this condition. The marked increase in serotonin turnover, in the absence of a panic attack, possibly represents an important underlying neurotransmitter substrate for the disorder, although this point remains uncertain. Support for this interpretation comes from the direct relationship which existed between serotonin turnover and illness severity, and the finding that SSRI administration reduced serotonin turnover. Serotonin transporter genotyping suggested that increased whole brain serotonin turnover most likely derived not from impaired serotonin reuptake, but from increased firing in serotonergic midbrain raphe neurons projecting to both subcortical brain regions and the cerebral cortex.

Increased expression of the adipokine genes resistin and fasting-induced adipose factor in hypoxic/ischaemic mouse brain

Adipose tissue is the primary source of the adipokines resistin and fasting-induced adipose factor (FIAF). We reported that the brain is also a site of adipokine expression, although their function there is unknown. Peripheral resistin and fasting-induced adipose factor are reported to be inflammatory markers, and we hypothesized that they would be induced in the brain by hypoxia/ischaemia. We show that neonatal hypoxia/ischaemia rapidly increased fiaf mRNA in the injured cortex and hippocampus at 2 and 7 days after hypoxia/ischaemia. In contrast, resistin (retn) mRNA was increased in the cortex only at 21 days after hypoxia/ischaemia. As a lipopolysaccharide-induced inflammatory response did not increase brain fiaf and retn mRNA levels, we conclude that brain injury may be responsible for the novel hypoxia/ischaemia-induced changes in adipokine gene expression. In summary, our results indicate that brain injury, or an inflammatory stimulus, regulates the central expression of two genes normally considered to be adipose tissue-specific. These observations add to our previous evidence that the brain is an important site of adipokine gene expression.

Exposition des Personals gegenüber Sevofluran

BACKGROUND

Occupational exposure to volatile anaesthetics cannot be completely avoided even in modern operating theatres. In 1997, the staff exposure during balanced anaesthesia in our hospital was low (sevoflurane 0.49 ppm; N(2)O 11.5 ppm). In 1999, N(2)O was completely omitted at our hospital, therefore, exposure to volatile anaesthetics, namely sevoflurane, might have increased.

METHODS

Environmental exposure was measured by photoacoustic infrared spectrometry. To determine the personal exposure and to compare it with environmental exposure, 14 anaesthetists wore diffusion samplers near their breathing zones for 1 week.

RESULTS

The median environmental concentration of sevoflurane was between 0.09 and 0.21 ppm in central operating theatres and between 0 and 24.8 ppm in intervention rooms. The median personal concentration was 0.19 ppm.

CONCLUSION

The occupational exposure to volatile anaesthetics is not higher using sevoflurane alone compared to the combination of sevoflurane and N(2)O. In addition, the data acquired from environmental and personal measurements showed similar results.

[Multiple chemical sensitivity (MCS) -- a case series]

BACKGROUND AND OBJECTIVE

The phenomenon of Multiple Chemical Sensitivity which generally cannot be explained organically is frequently associated with psychic impairment. This case series deals with the question if in addition to a standardized interview a routine psychiatric-psychosomatic examination alters the classification if a patient suffers from symptoms compatible with MCS or not.

METHODS

Nine consecutive outpatients (m = 3, f = 6, mean age 44 yrs) of the environmental medicine centre were investigated. Somatic diseases were evaluated by standard medical procedures and emotional disturbances were assessed by the Munich Composite International Diagnostic Interview (M-CIDI) and a psychiatric-psychosomatic examination.

RESULTS

In all but one patients emotional disturbances (F-codes of the ICD-10) were diagnosed by the M-CIDI and the psychiatric-psychosomatic examination. The diagnoses of the M-CIDI and the psychiatric-psychosomatic examination often did not match. MCS was ruled out in seven patients.

CONCLUSIONS

According to the criteria defined by Cullen (5), emotional disturbances must be ruled out before MCS is diagnosed. Therefore, an examination by a specialist in psychiatry or psychosomatics is mandatory because evaluation solely based on the M-CIDI is insufficient. Performing a routine psychiatric-psychosomatic examination, MCS could be ruled out much more often than previously.

Pituitary resistin gene expression is upregulated in vitro and in vivo by dexamethasone but is unaffected by rosiglitazone

A physiological role for the adipose-derived hormone, resistin, remains unsolved and its putative involvement in insulin resistance is largely controversial. Like leptin and other adipokines, we detected resistin in the rodent hypothalamic-pituitary system. In addition, the pituitary corticotrope cell line, AtT20, is also a source of resistin. These data suggested that resistin could be involved in diverse physiological processes in non-adipose tissue. Initial studies indicated that pituitary resistin gene expression was regulated in a nutritional (fed>fasted), age- (young>old) and gender-specific manner (male>female). In the present work we hypothesized that pituitary resistin expression should be regulated through signalling pathways similar to those reported for adipose tissue. For example, dexamethasone (DEX) potently stimulates production of resistin in murine adipose tissue, whereas thiazolidinediones such as rosiglitazone (ROSI), acting via peroxisome proliferator-activated receptor (PPAR)gamma, reportedly inhibit or stimulate resistin expression. Using quantitative real-time RT-PCR we determined that injection of DEX (10 and 50 microg) yielded 7- and 9-fold increases in pituitary resistin gene expression in prepubertal, but not adult mice. In addition, adrenalectomy attenuated pituitary resistin gene expression, which was restored by DEX (10 microg). In AtT20 cells, exposure to corticosterone (10(-7) and 10(-6)M; 24 h) and DEX (10(-9)-10(-6)M) stimulated resistin mRNA more than 65% (p<0.05) and 115% (p<0.0001), respectively. In contrast, ROSI, injected (5 and 20 mg/kg s.c. for 14 days) or given orally (3 mg/kg/day to 10 mg/kg/day for up to 7 weeks), failed to alter pituitary resistin gene expression in healthy male CD1 mice. Treatment of AtT20 cells with ROSI (10(-5)-10(-10)M; 24 h or 96 h) or the PPARgamma agonist GW 1929 (10(-9) and 10(-5)M; 24 h) had no effect on resistin mRNA. The PPARgamma antagonist GW 9662 (10(-6) and 10(-5)M) was also ineffective. In conclusion, pituitary resistin mRNA levels are robustly stimulated by corticosteroids, particularly at the time of puberty. This is consistent with our previous suggestion that resistin may be involved in maturation of the hypothalamic-pituitary axis. In contrast, pituitary resistin gene expression appears to be PPARgamma-independent and therefore different from the situation in adipose tissue.

Hypothalamic resistin immunoreactivity is reduced by obesity in the mouse: co-localization with alpha-melanostimulating hormone

Resistin is a new adipokine expressed in mouse, rat and human adipose tissue. Resistin may be an important link between obesity and insulin resistance, though this controversial view is complicated by the discovery of multiple sites of resistin expression, including human macrophages, placenta and pancreas. In previous studies we demonstrated that the mouse hypothalamo-pituitary system was also a site of resistin production. Pituitary resistin is developmentally regulated, reduced in the ob/ob mouse and severely down-regulated by food deprivation (24 h). An unexpected finding was that hypothalamic resistin mRNA remained unaffected by fasting. The present experiments examined the localization and possible regulation of hypothalamic resistin protein. Using immunohistochemistry we observed a complex network of resistin+ fibres extending rostrally from the arcuate nucleus of the hypothalamus (ARC) to the preoptic area. Labelled cell bodies occurred only in the ARC and in a periventricular region of the dorsal hypothalamus. Hypothalamic resistin immunoreactivity (ir) was unaffected by fasting (48 h) or by a high fat diet, but the periventricular staining was greatly increased in the lactating mouse. Marked reductions in resistin+ fibres were seen in brain tissue from: (a) ob/ob mice, (b) young mice made underweight for their age by raising them in large litters (20 pups per litter) and (c) mice with hypothalamic lesions induced by monosodium glutamate (MSG) or gold thioglucose (GTG). We speculate that the resistin-ir deficit in genetically obese mice, and in severely underweight mice, could be due to low or absent leptin. In contrast, though MSG- and GTG-treated mice have high levels of circulating leptin, in the presence of excessive visceral fat deposits, we hypothesize that damage to the ARC destroys the resistin+ cell bodies. This latter supposition led us to an additional hypothesis, that resistin-ir would be contained in neurons expressing the proopiomelanocortin (POMC) gene. This proved to be correct. Double label immunofluorescence histochemistry revealed that alpha-MSH-ir, a marker for POMC neurons, was co-localized with resistin-ir. In conclusion, our data reveal a second example of an adipocytokine co-localized with a hypothalamic neuropeptide. We reported previously that leptin was co-localized with oxytocin and vasopressin. RT-PCR analysis confirmed that resistin mRNA is readily detectable in ARC, but further work is required to determine whether the resistin gene is expressed in POMC neurons or if resistin is specifically accumulated by these cells. Nonetheless, our data suggest that the hypothalamus is a target tissue for resistin.

Suizidmethoden?ein Vergleich zwischen Ost- und Westdeutschland

A comparative study of the means of suicide in West and East Germany is extremely difficult both because of the data stock and the methodological questions that arise. This examination analyses means of suicide used during the following years: 1962-1964, 1987-1989 and 2000-2002. Accordingly, there is a similar pattern in both East and West for type of suicide committed and distinct developmental parallelism in applying the suicide methods. Certain means of suicide are more prominent (e. g. "hanging", "falling from a height") while others decrease in significance (e. g. "drowning"). No link was found between means of suicide and "society order". The use of a certain means of suicide depends on "availability", "existence" or "accessibility" of opportunities to commit suicide in the everyday environment. The same trend towards an increase of "hard" means of suicide was noted. The ways in which suicide is committed are becoming increasingly alike, but in the East it is apparent that people adhere more to "traditional" means of suicide.

Extra-adipocyte leptin release in human obesity and its relation to sympathoadrenal function

The link between the human sympathoadrenalmedullary system and the adipocyte hormone leptin is controversial. We measured total and regional norepinephrine spillover, epinephrine secretion rate, and extra-adipocyte leptin release in 22 lean [body mass index (BMI) < 26] and 20 obese (BMI > 28) normotensive men who underwent arterial and central venous catheterization. Because plasma clearance of leptin is primarily by renal removal, for men at steady state we could estimate whole body leptin release to plasma from renal plasma leptin extraction. Whole body leptin release was 1,950 +/- 643 (means +/- SE) ng/min in obese men and 382 +/- 124 ng/min in lean men (P < 0.05). Total and renal norepinephrine spillover rates correlated directly with whole body leptin secretion rate. Leptin is released from multiple nonadipocyte sites, which we tested by use of simultaneous arteriovenous blood sampling. We found a surprisingly large contribution of brain leptin release to the plasma leptin pool, 529 +/- 175 ng/min (> 40% whole body leptin release), with greater leptin release in obese than in lean men, 935 +/- 321 vs. 160 +/- 59 ng/min (P = 0.045). In parallel with leptin measurements, we also quantified brain serotonin turnover and jugular overflow of neuropeptide Y (NPY). Brain serotonin turnover was higher in obese than in lean men, 227 +/- 112 vs. 21 +/- 14 ng/min (P = 0.019), as was overflow of NPY from the brain, 12.9 +/- 1.4 vs. 5.3 +/- 2.2 ng/min (P = 0.042). These results suggest that leptin is released within the brain and at an increased rate in obese humans, in whom activation of brain serotonergic and NPY mechanisms also exists.

Pituitary resistin gene expression: effects of age, gender and obesity

Resistin is a new adipocytokine which is expressed in rat, mouse and possibly human adipose tissue. Its putative role as a mediator of insulin resistance is controversial. We hypothesized that resistin, like leptin, would have multiple roles in non-adipose tissues and we reported that resistin is expressed in mouse brain and pituitary. Moreover, resistin expression in female mouse pituitary is developmentally regulated and maximal expression occurs peripubertally. Although the role of endogenous resistin in mouse brain and pituitary has not been determined, our data suggest that resistin could be important in the postnatal maturation of the hypothalamic-pituitary system. In the present study we compared the ontogeny of resistin gene expression in the pituitary of male and female mice using semi-quantitative RT-PCR analysis. We show that resistin expression is developmentally regulated in the pituitary of male and female CD1 mice. However, significant gender differences were evident (male > female at postnatal day 28 and 42) and this was not modified by neonatal treatment of female pups with testosterone. Since resistin expression in adipose tissue is also influenced by obesity, we evaluated resistin expression in fat, brain and pituitary of the obese ob/ob mouse. Resistin mRNA was significantly increased in both visceral and subcutaneous adipose depots in postnatal day 28 ob/ob mice compared to controls, but pituitary resistin expression was significantly reduced. In contrast to the prepubertal levels, and in agreement with other reports, adipose resistin expression was reduced in adult ob/ob mice. In a third set of experiments we examined the influence of food deprivation on pituitary and fat resistin mRNA. Resistin gene expression was severely down-regulated by a 24-hour fast in adipose and pituitary tissue but not in hypothalamus. In conclusion, pituitary resistin expression is age- and gender-dependent. In ob/ob mice, and in fasted mice, resistin is regulated in a tissue-specific manner. Thus in visceral fat obesity increases but starvation decreases resistin mRNA. In contrast, pituitary levels are decreased in the presence of both high (ob/ob) and low (fasting) adipose stores. Further studies are required to define the unexpected hormonal regulation of resistin gene expression in the pituitary.

Lebenserwartung, vorzeitig verlorene Lebensjahre und vermeidbare Sterblichkeit im Ost-West-Vergleich

The dynamics of convergence between East and West Germany in the life-prolonging process continued undiminished from 1990 until 2001. The regional differences in premature and avoidable mortality were clearly reduced, both between East and West and between the individual federal states. In the East and in the West there was an increase in life expectancy in all age groups and for both sexes, whereby the increase in life expectancy was considerably greater in East Germany and in all of the East German federal states. Also, the standardized potential years of life lost before the age of 65 decreased more intensively in East Germany. The women in East Germany achieved a lower premature mortality due to illness in the year 2001 than those in West Germany. In the initial year of 1990, the years of life lost were 27.2% greater. Unnatural premature mortality (especially due to accidents) was also relatively high in East Germany in the year 2001, but it is clearly being reduced. The avoidable mortality has been more than cut in half in all East German federal states since 1990. An almost complete alignment between East and West in regard to avoidable mortality was achieved in the year 2001. The phase of economic stagnation that can be observed in East Germany since 1997 has up to now not led to a worsening in the constitutive health references presented above.

Food restriction regulates adipose-specific cytokines in pituitary gland but not in hypothalamus

White adipose tissue is now recognized as the source of a growing list of novel adipocyte-specific factors, or adipokines. These factors regulate energy homeostasis, including the response to food deprivation. We hypothesized that the brain and pituitary gland would also express adipokines and their regulatory factors and subsequently demonstrated that the rodent brain-pituitary system expresses mRNA and protein for leptin and resistin. We now report that the adipokines FIAF and adiponutrin, as well as the nuclear hormone receptor PPAR gamma, are expressed in pituitary, brain and adipose tissue. In pituitary gland, 24 h of food restriction reduced PPAR gamma expression by 54% whereas both adiponutrin and FIAF were increased 1.7 and 2.3 fold, respectively. These changes in expression were similar to those observed in fat, except for adiponutrin, which by contrast is dramatically reduced 95% by fasting. Furthermore, whereas PPAR gamma 2 is the main isoform affected by fasting in adipose tissue, our data suggest that only PPAR gamma 1 is present and downregulated by fasting in pituitary tissue. In contrast to the sensitivity of pituitary tissue to the effects of fasting, no significant change in expression was observed in basal hypothalamus for any of the genes studied. Overall, our data suggest that pituitary-derived adipokines may play an unexpected role in the neuroendocrine regulation of energy homeostasis.

Influence of leptin on neurotransmitter overflow from the rat brain in vitro

The 16-kDa polypeptide hormone, leptin along with the neurotransmitters noradrenaline and serotonin (5-HT) have important physiological roles in the regulation of a number of neuroendocrine actions particularly feeding. Leptin receptor mRNA and immunoreactivity has been reported in various brain regions, while recent studies suggest that leptin is released from the human brain. This study investigated the interactions between leptinergic and neurotransmitter systems of the rat brain in vitro. Techniques were established to simultaneously monitor the release of endogenous noradrenaline and its metabolite 3,4 dihydroxyphenylglycol (DHPG), and 5-HT and its metabolite 5-hydroxyindoleacetic acid (5-HIAA) from the rat brain. The neuromodulatory action of leptin (0.2 and 3 nM) on the overflow of noradrenaline and DHPG from the medulla and hypothalamus was examined. The effect of leptin on 5-HT and 5-HIAA overflow from the hypothalamus was also investigated. Administration of 0.2 and 3 nM leptin significantly increased medullary noradrenaline overflow to 172% and 174% of basal levels, respectively. Leptin had no significant effect on hypothalamic noradrenaline overflow, while leptin perfusion induced a significant increase in 5-HIAA overflow from the hypothalamus. This study lends support to the notion of a complex interaction of the leptinergic and brain neurotransmitters involved in the control of feeding and energy metabolism.

Sympathetic nervous system and insulin resistance: from obesity to diabetes

As the world faces an obesity "epidemic," the mechanisms by which overweight is translated into insulin resistance, hypertension, and diabetes need to be better understood. Although the processes of transition remain uncertain, overactivity of the sympathetic nervous system appears pivotal. In obesity, there is stimulation of sympathetic outflow to the kidneys, evident in increased rates of spillover of noradrenaline into the renal veins, and to skeletal muscle vasculature, demonstrated with microneurography. The cause is unclear, but possibly involves the stimulatory action of leptin released from adipose tissue, or from within the brain, for which there is recent evidence in human obesity. The high renal sympathetic tone contributes to hypertension development by stimulating renin secretion and through promoting renal tubular reabsorption of sodium. Neurally mediated skeletal muscle vasoconstriction reduces glucose delivery and uptake in muscle. Impairment of glucose uptake by skeletal muscle is a hallmark of insulin resistance syndromes. Pharmacologic sympathetic nervous suppression within the central nervous system with imidazoline receptor-binding agents such as rilmenidine is a logical therapeutic approach for lowering blood pressure (BP) in patients with essential hypertension, in whom sympathetic activity is often increased. In addition, drugs of this class appear to have the capacity to favorably modify insulin sensitivity, which has particular relevance in the treatment of hypertensive diabetic patients. In the hypertension accompanying maturity onset obesity, with recent recommendations from advisory bodies setting lower goal BP, and with these lower targets often being reached only with combinations of antihypertensive agents, it is advisable that all drugs used in combination therapy have a favorable or at least a neutral effect on insulin resistance.