Gastrostomy tube placement in head and neck cancer patients undergoing radiotherapy

Background: In head and neck cancer (HNC) patients, the side effects of radiotherapy (RT) often lead to patients being unable to consume adequate nutrition and fluid (Chencharick and Mossman, 1983). Gastrostomy tube placement prior to RT can reduce incidence of severe weight loss and hospitalization during treatment (Beaver et al., 2001). However, gastrostomy tube usage is dependant upon HNC site and area of RT. The aims of the study were to identify the characteristics of those HNC patients who will require gastrostomy tube feeding during RT and utilize these data to target future patients for prophylactic tube placement prior to commencing RT and to write guidelines for the placement of feeding tubes. Method: Data were collected retrospectively regarding diagnosis, surgery and area of RT on all HNC patients who had had a prophylactic gastrostomy placed prior to RT between April 2000 and April 2002. Outcome measurements in terms of utilization of gastrostomy, body weight and nutrition related emergency admissions were recorded. Results: Thirty‐five patients had a prophylactic gastrostomy placed [26 male, nine female; mean age 62 (range 26–84) years]. Of these, 26 utilized their tube for feeding or fluids during RT. The sites of radiotherapy were: bilateral RT to the oro‐ or nasopharynx and neck (20 patients), bilateral RT to the neck (five) and RT to the left oropharynx and neck (one). The mean weight loss during RT in patients who utilized their prophylactic gastrostomy was 3.3 (range 0–11.5%) compared to 8 (5.5–12.0%) in patients who did not have a prophylactic gastrostomy. Only one of the patients with a prophylactic gastrostomy had a hospital admission (length of stay 11 days) compared to four patients who did not [mean length of stay 21 days (range 14–29)]. Six of the nine patients who did not utilize their gastrostomy for feeding and were able to maintain their nutrition orally, received bilateral RT to the neck only. Discussion: Most of the patients who received bilateral RT to the oro‐ or nasopharynx required gastrostomy feeding during RT, which is consistent with findings of Beaver et al. (2001) who reported the highest incidence of weight loss in patients receiving RT to the nasopharynx or base of the tongue. Conclusion: In view of the association between the site of RT and gastrostomy utilization, hospital admissions, length of stay and weight loss, HNC patients with planned bilateral RT to the oro‐ or nasopharynx or with existing dysphagia should be targeted for gastrostomy tube placement prior to starting treatment. References: Beaver, M.E., Matheny, K.E., Roberts, D.B. & Myers, J.N.(2001) Predictors of weight loss during radiation therapy. Otolaryngol. Head Neck Surg. 125 , 645–648. Chencharick, J.D. & Mossman, K.L. (1983) Nutritionalconsequences of the radiotherapy of head and neck cancer. Cancer 51 , 811–815.     

Nutritional Intervention for Nonsurgical Head and Neck Cancer Patients Treated with Radiation Therapy: Results from a Prospective Stepped-Wedge Clinical Protocol

Aim: To evaluate the impact on weight loss (WL) of a standardized nutritional stepped-wedge protocol on consecutive head and neck cancer (HNC) patients treated with curative radiotherapy (RT).

Methods: We prospectively collected data of patients followed by a trained dietitian and treated according to a pre-defined stepped-wedge protocol. Patients with swallowing defect at the baseline and WL >10% 3 months prior to the beginning of RT were excluded from the analysis. Nutritional status was assessed at the baseline and weekly during the course of RT. Fluid and caloric intake were assessed through a 24-h recall.

Results: Between May 2010 and March 2011, 42 patients treated were evaluated. Median overall treatment time was 52.5 days. WL per CTCAE 4.03 was G0, G1 and G2 in 23 (55%), 14 (33%) and 5 (12%) patients, respectively. Thirty-five (83%) patients did not require enteral nutrition. About 90% of patients completed RT without interruption of oral feeding.

Conclusions: Despite the high toxicity profile of curative RT in HN, we proposed a standardized stepped-wedge protocol allowing to prevent severe WL in most of our patients. Further larger prospective studies are warranted to validate our approach and to achieve consensus on nutritional intervention in this subset of patients.     

Factors Associated With Weight Loss,Low BMI,and Malnutrition Among Nursing Home Patients: A Systematic Review of the Literature

BackgroundWeight loss and poor nutrition are important quality measures in long term care. Long term care professionals need to identify factors associated with weight loss and poor nutrition to target high-risk patients.MethodsThe authors systematically searched Medline and CINAHL databases and included English language studies with more than 100 subjects analyzed, published after January 1, 1990, with data on factors associated with at least one of the following: weight loss, low body mass index (BMI), low Mini-Nutritional Assessment (MNA) score, or other standard measure of malnutrition. Data from all studies were systematically extracted onto a matrix table. The Critical Appraisal Skills Programme (CASP) questions were used to compare the quality of evidence extracted. Data from each article were then sorted and arranged into tables of factors associated with weight loss, low BMI, and malnutrition.ResultsSixteen studies met the inclusion criteria for the review. The factors most consistently associated with weight loss were depression, poor oral intake, swallowing issues, and eating/chewing dependency. Staffing factors were associated with weight loss in most studies. The factors most consistently associated with low BMI included immobility, poor oral intake, chewing problems, dysphagia, female gender, and older age. The factors most consistently associated with poor nutrition included impaired function, dementia, swallowing/chewing difficulties, poor oral intake, and older age.ConclusionPotentially modifiable factors consistently associated with increased likelihood of weight loss, low BMI, or poor nutrition included depression, impaired function, and poor oral intake. Nursing home medical directors may wish to target quality improvement efforts toward patients with these conditions who are at highest risk for weight loss and poor nutrition.     

Extended Outpatient Civil Commitment and Treatment Utilization

Summary

Objective: This study considers four hypotheses regarding the impact of extended involuntary outpatient commitment orders on services utilization.

Method: All Victorian Psychiatric Case Register (VPCR) patients who had extended (180+ day) outpatient commitment orders in the nine year study period and a matched treatment compliant comparison group with extended periods of outpatient care (N = 1182), both with at least two years of post-episode experience, were evaluated. Pre/post episode utilization was compared via paired t tests with individuals as their own controls. Logistic and OLS regression as well as repeated measures ANOVA via the GLM SPSS program and post hoc t tests were used to evaluate between group and across time differences.

Results: Extended episodes of care for both groups were associated with reduced use of hospitalization and increases in outpatient services. Extended orders did not promote voluntary participation in the post-period. Outpatient services during the extended episode for those on orders were raised to the level experienced by the treatment compliant comparison group and maintained at that level via subsequent renewal of orders throughout the patients' careers. OLS regression results indicate that approximately six community care service days were required for those on orders to achieve a one-day reduction in hospital utilization following the extended episode.

Conclusion: Outpatient commitment for those on extended orders in the Victorian context enables a level of community-based services provision, unexpected in the absence of this delivery system, which provides an alternative to hospitalization.     

Impact of United States 2017 Immigration Policy changes on missed appointments at two Massachusetts Safety-Net Hospitals

Introduction

Studies have shown mixed findings regarding the impact of immigration policy changes on immigrants’ utilization of primary care.

Methods

We used a difference-in-differences analysis to compare changes in missed primary care appointments over time across two groups: patients who received care in Spanish, Portuguese, or Haitian Creole, and non-Hispanic, white patients who received care in English.

Results

After adjustment for age, sex, race, insurance, hospital system, and presence of chronic conditions, immigration policy changes were associated with an absolute increase in the missed appointment prevalence of 0.74 percentage points (95% confidence interval: 0.34, 1.15) among Spanish, Portuguese and Haitian-Creole speakers. We estimated that missed appointments due to immigration policy changes resulted in lost revenue of over $185,000.

Conclusions

We conclude that immigration policy changes were associated with a significant increase in missed appointments among patients who receive medical care in languages other than English.

     

Hospitalists’ utilization of weight loss resources with discharge texts and primary care contact: a feasibility study

Objectives: Obesity affects a large proportion of the U.S. population, and hospitalizations may serve as an opportunity to promote weight loss. We sought to determine if multidisciplinary patient-centered inpatient weight loss intervention that included counseling, consults, post-discharge telephone text messages, and primary care follow up was feasible.

Methods: We conducted a feasibility study focusing on 25 obese hospitalized patients to understand the issues related to rolling out an intensive intervention. Actual weight loss was a secondary outcome and we compared these 25 patients to 28 control patients who were exposed to usual care; weight change was assessed at 1 and 6 months.

Results: Ninety-six percent (24/25) of nutritional consults and 92% (23/25) of physical therapy consults were submitted by hospital providers. All of these doctors were also reminded to counsel their patients about the detrimental health consequences. Fifty-two percent (13/25) and 40% (10/25) were actually seen and counseled by nutrition and physical therapy services respectively, before being discharged. Sixty-eight percent (17/25) received a motivational interviewing counseling session from the principal investigator. All patients were sent text messages and followed with their primary care provider after discharge who received the personalized weight loss discharge instructions that had been given to the patient. The feasibility group lost a mean of 3.0 kg at 6 months and the control group gained an average of 0.20 kg at 6 months post discharge (p = 0.03).

Conclusion: Executing a multifaceted weight loss intervention for hospitalized obese patients is feasible, and there may be associated persistent improvements in weight status over time.     

The role of intimate partner violence, race, and ethnicity in help-seeking behaviors

Objective . Women experiencing intimate partner violence (IPV) have multiple health and social service needs but many, especially Hispanic, women may not access these resources. This research sought to examine the relationship between IPV and health and social services utilization (help-seeking behaviors), with a focus on racial and ethnic disparities.

Design . Case-control study from an urban US emergency department population in which cases (women with IPV) and controls (women without IPV) were frequency matched by age group and race/ethnicity. Logistic regression analyses were performed to examine the relationship between IPV and help-seeking behaviors and between help-seeking behaviors and race/ethnicity among abused women. In addition, a stratified analysis was conducted to examine the relationship between acculturation and help-seeking behaviors among Hispanic women.

Results . The sample included 182 cases and 147 controls. Among the health services, alcohol program, emergency department, and hospital utilization were significantly increased among IPV victims compared to non-victims after taking demographic and substance use factors into account. Similarly, IPV victims were more likely to access social/case worker services and housing assistance compared to non-victims. Specific help-seeking behaviors were significantly associated with race and ethnicity among IPV victims, with non-Hispanic white and black women more likely to use housing assistance and emergency department services and black women more likely to use police assistance compared to Hispanic women. Among all Hispanic women, low acculturation was associated with decreased utilization of social services overall and with any healthcare utilization, particularly among abused women.

Conclusions . Social service and healthcare workers should be alerted to and screen for IPV among all clients. The need for increased outreach and accessibility of services for abused women in Hispanic communities in the USA should be addressed, with cultural and language relevance a key component of these efforts.     

Nutritional Status and Information Needs of Medical Oncology Patients Receiving Treatment at an Australian Public Hospital

This study aimed to identify 1) the prevalence of malnutrition according to the scored Patient Generated-Subjective Global Assessment (PG-SGA), 2) utilization of available nutrition resources, 3) patient nutrition information needs, and 4) external sources of nutrition information. An observational, cross-sectional study was undertaken at an Australian public hospital on 191 patients receiving oncology services. According to PG-SGA, 49% of patients were malnourished, and 46% required improved symptom management and/or nutrition intervention. Commonly reported nutrition-impact symptoms included peculiar tastes (31%), no appetite (24%), and nausea (24%). External sources of nutrition information were accessed by 37%, with popular choices being media/Internet ( n = 19) and family/friends ( n = 13). In a subsample ( n = 65), 32 patients were aware of the available nutrition resources, 23 thought the information sufficient, and 19 patients had actually read them. Additional information on supplements and modifying side effects was requested by 26 patients. Malnutrition is common in oncology patients receiving treatment at an Australian public hospital, and almost half require improved symptom management and/or nutrition intervention. Patients who read the available nutrition information found it useful; however, awareness of these nutrition resources and the provision of information on supplementation and managing symptoms requires attention.     

COPD: Does Inpatient Education Impact Hospital Costs and Length of Stay?

Background: Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in the United States and costs approximately $50 billion in annual healthcare costs. Certain interventions such as COPD inpatient education programs have demonstrated effectiveness in reducing healthcare utilization and reducing healthcare associated costs.

Purpose: To assess the effectiveness of chronic obstructive pulmonary disease (COPD) inpatient education using existing respiratory therapy staff in an academic health system.

Methodology/Approach: This retrospective observational study employed a matched case-control design. Inpatients admitted with a COPD related condition in this study received self-management interventions from Registered Respiratory Therapists (RTs). The sample includes retrospective administrative and medical record data on 84 inpatients with a diagnosis of COPD admitted in 2016 through 2017. Patients received self-management interventions at the bedside by trained RTs while admitted to acute care areas, progressive care units and intermediate care units. Effectiveness of inpatient education was compared before and after the interventions. Hospitalization costs and length of stay (LOS) are the primary outcome measures.

Results: Statistical analyses revealed that inpatient COPD education appears to reduce hospital length of stay and associated costs. Post hoc regression analyses revealed that age, gender, marital status, and number of visits were significantly associated with LOS; whereas, smoking, LOS, and number of visits were significantly associated with hospitalization costs.

Practice Implications: COPD patient education may be an effective strategy at reducing hospital costs and healthcare utilization overall. Empowering patients to take responsibility for their own health outcomes by improving self-efficacy has proven to demonstrate value.     

Effects of a Texture-Modified,Enriched, and Reshaped Diet on Dietary Intake and Body Weight of Nursing Home Residents with Chewing and/or Swallowing Problems: An Enable Study

Abstract

This proof-of-concept study investigated the effects of an innovative nutrition concept, comprising texture modification, enrichment, and reshaping, on dietary intake and nutritional status of 16 nursing home residents with chewing and/or swallowing problems (mean age 86.5?±?7.4 years) in a pre-test post-test design. During 6?weeks with usual texture-modified diet (P1) energy and protein intake were constant. After the implementation of the innovative diet, daily energy intake increased by 204.2 (median) [interquartile range 95.8–444.4] kcal (P?=?0.011), and protein intake by 18.3 [9.9–26.3] g (P?<?0.001) and remained constant during the following 6?weeks (P2). Body weight decreased during P1 (–0.5 [–1.4 to 0.2] kg), and increased during P2 (+1.1 [0.0 to 1.7] kg, P?=?0.004). The present nutrition concept turned out to be a promising strategy for nutritional management of chewing and/or swallowing problems, however, the effects need to be confirmed in larger studies.     

Cachexia and Cognitive Function in the Community-Dwelling Older Adults: Mediation Effects of Oral Health

Background

Cognitive impairment and poor oral health are common problems in older adults and are associated with malnutrition. However, it is unclear how they are related to cachexia in community-dwelling older adults. The aim of this study was to examine the relationships among cachexia, cognitive function, and oral health in community-dwelling older adults.

Methods

This study is a secondary analysis of a data-set. Data were collected in the community setting on older adults who applied for government-funded long-term care services in Hong Kong in 2017. Subjects were community-dwelling and aged ≥60 years. The outcome variable was cachexia. The predictors were cognitive function and oral health. The covariates included demographics and comorbidities associated with cachexia or malnutrition. Path analysis was employed to examine the associations among cachexia, cognitive function, and oral health using the software SAS/STAT and Mplus.

Results

This analysis included 12,940 subjects. The prevalence of cachexia was 1.3%. Cognitive function was also found to have a direct effect on the oral health indicators of chewing problems (OR=1.073, p<0.001), brushing teeth problems (OR=1.349, p<0.001), and swallowing problems (coeff.=0.177, p<0.001). Oral health indicators with a direct effect on cachexia included dry mouth (OR=1.250, p<0.001), brushing teeth problems (OR = 1.185, p<0.01), and swallowing problems (OR=1.231, p<0.001). Cognitive function had no significant direct effect, but had a significant indirect effect on cachexia (OR=1.100, p<0.001) which is mediated by brushing teeth problems (OR=1.052, p<0.001) and swallowing problems (OR=1.038, p<0.001).

Conclusion

Cognitive impairment causes cachexia indirectly through poor oral health. This study recommends adding cognitive function when screening community-dwelling older adults for cachexia. Health policymakers should stress regular oral health screening and interventions, and encourage increased utilization of oral health services by community-dwelling older adults with cognitive problems.

     

Diet,Nutrition, and Cancer: From Basic Research to Policy Implications

Objective: This study was designed to obtain baseline data regarding desired body weight, weight satisfaction, self-perceived weight categories, approaches to weight loss of female college students in Taiwan. The characteristics of subjects who are dieting were also assessed.

Methods: One thousand, fifty-seven female college students participated in this study. Written questionnaires were used for data collection. Students’ height and weight were also measured. Simple frequency and one-way analysis of variance (ANOVA) were used to analyze data. Post hoc analyses were performed with the LSD test when the F ratio for the ANOVA was significant at p<0.05.

Results: In general, subjects perceived themselves as being heavier than their actual weight categories. The percentage of subjects who perceived they were overweight or obese was much higher than the percentage of subjects who were actually in these categories (51.4% vs. 16.2%). Above 20% of subjects in both severely underweight and underweight categories use some methods to lose weight. More than 60% of subjects in acceptable weight categories still want to lose weight. A higher percentage of subjects chose exercise than dieting as the major weight-loss method. Subjects in the DS/D (dissatisfied/dieting) group did not score higher points for knowledge and attitude in nutrition, and they tended to measure their body weight more frequently (p<0.05), spent more time for exercise (p<0.05) and for reading nutrition information (p<0.05); they also skipped lunch (p<0.05) more frequently than others.

Conclusions: The results indicate that risk factors leading to eating disorders are common among Taiwanese college females. Dietitians, physicians and other health professionals should be on the alert to identify patients with eating disorders.     

Determinants of healthcare utilization in Greece: Implications for decision-making

Objective: To explore factors influencing the utilization of primary and secondary healthcare in Greece. Methods: A national, geographically stratified sample was randomly selected. From November 2001 to March 2002, 5000 questionnaires were mailed, 4427 were actually received, and 1819 were completed and returned (response rate 41%). The questionnaire investigated respondents’ characteristics and their health services utilization. A number of potential utilization determinants were explored, such as region, gender, age, education, income, insurance coverage, number of family members, self-rated health status, country of birth, and parents’ country of birth. Results: The utilization of primary healthcare services depended on self-rated health status, age, income, gender, and region. Individuals with moderate and poor self-rated health, older people, women, and residents of the region of Epirus showed increased utilization of primary healthcare services. Income was a factor affecting the utilization of primary healthcare only at lower income levels. The frequency of visits for primary healthcare was negatively correlated with self-rated health status and increased as self-evaluation of health status worsened. Hospitalization was associated with self-rated health and insurance coverage for primary healthcare. Individuals with better self-rated health status, as well as those who were covered by health insurance for primary care, showed decreased hospital care utilization. The frequency of hospitalization depended on region and lower evaluations of health status.

Conclusion: The findings of our research are encouraging, since they suggest that the utilization of health services in Greece is mostly determined by health status rather than other socioeconomic factors. It is believed that similar studies should be conducted in the country, since they can improve health service planning and reinforce decision-making towards healthcare resource allocation according to healthcare needs.     

Maternal Nutrition and Birth Size among Urban Affluent and Rural Women in India

Background: Varying results of worldwide intervention programs to pregnant mothers necessitate the need to understand the relationship between maternal nutrition and birth size among well nourished and undernourished mothers.

Objective: To examine this relationship among urban affluent mothers and to compare the findings with those on rural Indian mothers.

Subjects: Data collected on urban affluent mothers (n = 236) was compared with rural mothers (n = 633).

Design: Mothers were contacted at 18 ± 2 and 28 ± 2 wk of gestation for anthropometry, dietary intakes [24-hr recall, Food Frequency Questionnaire (FFQ)] and after delivery for neonatal anthropometry.

Results: Despite large differences in nutritional status of urban and rural mothers ( pre-pregnant weight 55.9 ± 9.2 Vs 41.5 ± 5.2 kg, respectively) maternal fat intakes at 18 wk were associated with birth weight (p < 0.05), length (p < 0.01) and triceps skin fold thickness (p < 0.05) of the newborn in urban and rural mothers. Consumption of fruits was associated with birth length (p < 0.05) in urban (18wk) and with birth weight (p < 0.01) and length (p < 0.01) in rural (28wk) mothers, when their energy intakes were low. Maternal consumption of milk too, was associated with newborn's triceps (p < 0.01) in urban (28wk) while with birth weight (p < 0.05) and length (p < 0.05) in rural (18wk) mothers. The findings mainly underscore the importance of consumption of micronutrient rich foods, when energy intakes are limiting during pregnancy, for improving birth size.

Conclusions: Creating nutritional awareness and motivating rural mothers for consuming micronutrient rich foods like green leafy vegetables and seasonal fruits that are easily available in rural areas, will be a much affordable solution for combating the problem of low birth weight rather than waiting for improvement in the existing nationwide programs for pregnant women.     

A Comparison of Meal Replacements and Medication in Weight Maintenance after Weight Loss

Objective: To compare the use of meal replacements or medication during weight maintenance subsequent to weight loss using a very low-energy diet (VLED) in overweight or obese adults.

Design: Participants followed a liquid VLED of 2177 kJ for 12 weeks followed by 4 weeks of re-orientation to solid foods. Participants were randomized at week 16 to receive either meal replacements or Orlistat both combined with a structured meal plan containing an energy value calculated to maintain weight loss.

Subjects: Sixty-four women (age = 49.9 ± 10 y, weight = 101.6 ± 17.1 kg, height = 164.9 ± 6.0 cm, BMI = 36.7 ± 5.4 kg/m²) and 28 men (age = 53.7 ± 9.6 y, weight = 121.8 ± 16.0 kg, height = 178.7 ± 5.6 cm, BMI = 37.8 ± 4.9 kg/m²) completed a 1 year weight management program. Behavioral weight management clinics included topics on lifestyle, physical activity (PA), and nutrition. Participants met for 90 min weekly for 26 weeks, and then biweekly for the remaining 26 weeks.

Outcomes: Minutes of PA, fruits and vegetables (FV), and pedometer steps were recorded on a daily basis and reported at each group meeting. Body weight was obtained at each group meeting.

Results: During VLED, the MR group decreased body weight by 22.8 ± 6.1 kg and the Orlistat group decreased body weight by 22.3 ± 6.1 kg. During weight maintenance, there was no significant group by time interaction for body weight, PA, FV consumption, or pedometer steps. At week 16, the meal replacement group had a body weight of 85.4 ± 14.3 kg that increased to 88.1 ± 16.5 kg at 52 weeks (p < 0.05). At week 16, the Orlistat group had a body weight of 85.7 ± 17.9 kg that increased to 88.5 ± 20.3 kg at 52 weeks (p < 0.05).

Conclusions: Subsequent to weight loss from a VLED, meal replacements and Orlistat treatments were both effective in maintaining weight significantly below baseline levels over a 52 week period of time. Meal replacements may be a viable alternative strategy to medications for weight maintenance.     

Do HMOs Have Monopsony Power?

Objective: To determine whether health maintenance organizations (HMOs) have monopsony power in the markets for ambulatory care and inpatient hospital services. Data Sources: A pooled time-series of data on all HMOs operating in the United States from 1985 through 1997. Information reported to InterStudy on HMO market areas and enrollment is linked to financial data reported to state regulators and county characteristics from the Area Resource File (ARF). Study Design: We use a two-stage design to test for the existence of monopsony power. First, we estimate regression equations for the prices paid by HMOs for ambulatory visits and inpatient hospital days. The key independent variable is a measure of the importance of an individual HMO as a buyer of ambulatory care or hospital services. Second, we estimate regressions for the utilization of ambulatory visits and inpatient hospital days per HMO enrollee, as a function of HMO buying power and other variables. Principal Findings: Increased HMO buying power is associated with lower price and higher utilization of hospital services. Buying power is not related to ambulatory visit price or utilization per member. Conclusions: Our findings are not consistent with the monopsony hypothesis. They suggest that managed care organizations have contributed to a welfare-increasing breakup of hospital monopoly power. The role of HMOs as buyers of ambulatory services is more complex. We discuss possible reasons why buying power may not affect price or utilization of ambulatory visits.     

Weight Loss Is More Important Than the Diet Type in Improving Adiponectin Levels Among Overweight/Obese Adults

Objective: The study objective was to compare the effect of a standard calorie- and fat-restricted diet (STD-D) and a calorie- and fat-restricted lacto-ovo-vegetarian diet (LOV-D) on total and high-molecular-weight (HMW) adiponectin levels after 6 months of behavioral intervention.

Design: This study is an ancillary study to a randomized clinical trial.

Subjects: Subjects included 143 overweight/obese adults (STD-D = 79; LOV-D = 64).

Intervention: Both groups received the same standard behavioral intervention; the only difference was that LOV-D participants were instructed to eliminate meat, poultry, and fish from their diet.

Measures: Weight, dietary intake with the 3-day food diary, and total and HMW adiponectin levels were measured.

Results: Both groups significantly increased total (STD-D +7.2 ± 17.8%; LOV-D +9.4 ± 21.8%) and HMW adiponectin levels (STD-D +18.5 ± 32.9%; LOV-D +15.8 ± 34.5%; ps < 0.05) with no significant differences between the groups. We found significant associations between weight loss and increases in total (β (SE) = ?.071(.27); p = 0.003) and HMW adiponectin (β (SE) = ?1.37(.47); p = 0.001) levels independent of the diet type. Weight loss at the higher quartile was associated with improvements of adiponectin levels (p < 0.05).

Conclusion: Weight loss was associated with increased total and HMW adiponectin levels regardless of the diet type. Enhancing weight loss may be a means to improve adiponectin levels.     

Comprehensive Planning and ‘Partnership for Health’: I

Abstract

Background: Current clinical practice guidelines recommend dual antiplatelet therapy with aspirin and clopidogrel or prasugrel for patients with acute coronary syndrome (ACS). Ticagrelor, an experimental antiplatelet therapy, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Patients with ACS presenting with dyspnea require additional medical attention to rule out possible heart failure or other serious diagnoses. This study used real-world data to quantify the direct medical costs of dyspnea among patients with a history of ACS. Objective: To determine the clinical and economic impact of a dyspnea episode for patients with a history of ACS using commercial and Medicare supplemental claims data. Methods: Patients with an emergency room (ER) visit with a primary diagnosis of dyspnea (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] diagnosis code, 786.0x) in 2008 or 2009 were identified using Thomson Reuters MarketScan® Research Databases. Patients were required to have 6 months of continuous medical enrollment prior to an ER visit and a history of ACS (ie, ≥ 1 inpatient claim, ≥ 1 ER visit, or ≥ 2 outpatient claims, with an ICD-9-CM diagnosis code for ACS [410.xx or 411.1x] in any position on the outpatient claim during either the baseline period or on the index date). An episode of dyspnea was defined as all ER and outpatient services on the day of an ER claim with a primary diagnosis of dyspnea, and any inpatient admissions occurring on the day of or day following the ER visit. Procedure utilization and expenditures were evaluated for the ER visit and associated outpatient services, as well as the proportion of ER visits that led to an inpatient stay. Costs were allowed charges (ie, provider payment plus member cost-share) adjusted to 2009 US constant dollars. Results: A total of 8433 ER visits for dyspnea were identified during 2008 to 2009 from these databases of approximately 74 million beneficiaries. The average cost per dyspnea episode was $6958, of which $1621 were outpatient costs associated with the ER visit (standard deviation, $3269). Along with physician services, assessment of dyspnea often included electrocardiogram (71.3%), chest radiograph (75.9%), and, occasionally, a B-type natriuretic peptide test (14.9%) or chest computed axial tomography scan (12.2%). More than one-fourth (25.8%) of dyspnea ER visits preceded an inpatient stay, with an average cost of $20 693 per patient. Conclusions: Dyspnea is a significant event associated with high medical resource utilization and hospital costs. Ticagrelor, an experimental antiplatelet agent not yet available on the market, has been shown to be associated with significantly higher rates of dyspnea than clopidogrel in clinical trials. Considering that the increased risk of dyspnea for ticagrelor is well documented, these costs may be important to health plan decision-makers when evaluating costs associated with each antiplatelet therapy.     

Body Composition and Energy Expenditure after Weight Loss Following Bariatric Surgery

Objectives: To assess the effectiveness of biliopancreatic diversion (BPD) in the treatment of morbid obesity and to evaluate how the procedure affects body weight.

Subjects: Fourteen morbidly obese subjects studied before and 30 months after BPD and fifteen healthy volunteers matched for age, sex and height (controls).

Methods: Comparison of the following parameters were made in the study groups before surgery and 30 months after BPD and with those of the controls group: fat mass, fat-free mass, non-protein substrate oxidation, basal metabolic rate, plasma glucose, insulin and free fatty acid concentrations.

Results: Obese subjects lost 60.38±10.71 kg of weight during 18 months following surgery and then remained stable for another 12 months, when this study was performed. Weight loss was substantially due to a loss of fat mass (FM: 60.13±13.01 kg before and 19.02±8.61 kg after BPD; p<0.001). FM were not statistically different between post-obese subjects and controls; however, post-obese patients retained significantly more fat free mass (FFM) than controls. Subsequently, basal metabolic rates of post-obese subjects were higher than those of the control group (p<0.05). Fasting non-protein respiratory quotient (npRQ) was significantly lower before BPD than 30 months after the surgery (0.798±0.04 vs. 0.90±0.048, p<0.001), suggesting that, while obese, patients oxidized more lipids than carbohydrates. Moreover, fasting and two-hour plasma glucose and insulin concentrations decreased significantly after BPD to values comparable to those of the control group.

Conclusion: Weight loss in obese patients after BPD is mainly due to lipid malabsorption, but increased energy expenditure associated with retaining a high FFM in physically active post-obese subjects may also play a role, enabling them to maintain long-term reduced body weights.     

The combined effect of creatine and resistance training on doxorubicin-induced muscle dysfunction

Abstract

Background: Doxorubicin (DOX) is associated with profound skeletal muscle dysfunction. Resistance training (RT) and creatine (Cr) monohydrate have been independently shown to protect against DOX-induced muscle dysfunction. However, no investigation has examined their combined effects on DOX-induced muscle dysfunction.

Methods: Male Sprague-Dawley rats were randomly assigned to a RT or sedentary group. After 6?wk of training, the soleus (SOL) and extensor digitorum longus (EDL) were excised and placed in a tissue bath containing Krebs buffer (K) or a K containing Cr (25?mM) for 30?min. The buffers were refreshed with new K or K containing DOX (24?μM) and incubated for 30?min. Muscles were then subjected to maximal twitch and fatigue testing.

Results: DOX-induced fatigue occurred at 40?s in the SOL and EDL. RT delayed DOX-induced fatigue by 20?s in the SOL and 10?s in the EDL. Cr treatment delayed the onset of DOX-induced fatigue by 10?s in the EDL. The combination of RT and Cr delayed DOX-induced fatigue by 50?s in the SOL and 20?s in the EDL.

Conclusion: This study showed that a combined treatment with RT and Cr minimized DOX-induced fatigue in the SOL and EDL.