Insights into the challenges and facilitators to physical activity among brooklyn teens enroled in a weight management programme.

PURPOSE: A qualitative study was carried out to explore obese adolescents' understanding of physical activity, perceptions of the ideal body type and to identify facilitators of and barriers to physical activity. METHODS: Twenty-two adolescents 12-18 years of age and 14 of their parents were recruited from an obesity intervention programme in Brooklyn, New York, from June to November 2017. Data were collected using focus groups and individual semi-structured interviews, followed by interpretative phenomenological analysis of the transcripts. RESULTS: The adolescents wanted to 'lose some weight', but not to be 'thin' or 'look hungry'. Most females desired a 'slim-thick' figure, which was 'a flat stomach with big thighs, and curvy'. Fun and support from parents, peers and programme staff facilitated achieving their physical activity goals. Barriers included low self-efficacy, inactive families, fear of neighbourhood gangs and crime and perceptions that the parks were small and overcrowded, with limited physical activity options for adolescents. CONCLUSION: These findings highlight the need to consider local norms concerning body image when designing obesity interventions. To effectively reduce childhood obesity in New York City, policy should prioritize the promotion of public safety, improvement of neighbourhood parks and increase options for physical activity. PATIENT OR PUBLIC CONTRIBUTION: The voices and narratives of patients and their families informed this study.

Healthcare utilization in patients with first-time implantable cardioverter defibrillators (data from the WEBCARE study).

BACKGROUND: Knowledge of the level of healthcare utilization (HCU) and the predictors of high HCU use in patients with an implantable cardioverter defibrillator (ICD) is lacking. We examined the level of HCU and predictors associated with increased HCU in first-time ICD patients, using a prospective study design. METHODS: ICD patients (N = 201) completed a set of questionnaires at baseline and 3, 6, and 12 months after inclusion. A hierarchical multiple linear regression with three models was performed to examine predictors of HCU. RESULTS: HCU was highest between baseline and 3 months postimplantation and gradually decreased during 12 months follow-up. During the first year postimplantation, only depression (ß = 0.342, P = 0.002) was a significant predictor. Between baseline and 3 months follow-up, younger age (ß = -0.220, P < 0.01), New York Heart Association class III/IV (ß = 0.705, P = 0.01), and secondary indication (ß = 0.148, P = 0.05) were independent predictors for increased HCU. Between 3 and 6 months follow-up, younger age (ß = -0.151, P = 0.05) and depression (ß = 0.370, P < 0.001) predicted increased HCU. Between 6 and 12 months only depression (ß = 0.355, P = 0.001) remained a significant predictor. CONCLUSIONS: Depression was an important predictor of increased HCU in ICD patients in the first year postimplantation, particularly after 3 months postimplantation. Identifying patients who need additional care and provide this on time might better meet patients' needs and lower future HCU.

Development of the Patient's Experience and Attitude Colposcopy Eindhoven Questionnaire (PEACE-q).

BACKGROUND: No validated instruments for the evaluation of patient satisfaction in colposcopy do exist. Therefore, this study reports on the development of a Patient's Experience and Attitude to Colposcopy questionnaire. METHODS: Patients who recently received colposcopy participated in a focus group. A panel of experts evaluated the transcriptions and agreed on a 15-item draft questionnaire. The draft questionnaire was completed by 68 women who subsequently came for a colposcopy. For construct validation, Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were performed as well as reliability analysis. Concurrent validity was assessed with the 4-item Patient Health questionnaire (PHQ-4). RESULTS: Construct validation resulted in an 8-item patient perception scale with good psychometric properties (Cronbach's alpha: 0.76) and excellent model fit. Two subscales could be discriminated: patient procedure perception scale (alpha: 0.89) and caregiver attitude perception scale (alpha: 0.71). Both subscales intercorrelated moderately (r = 0.28, p = 0.045). The subscale patient perception correlated significantly with the PHQ-4 scale and its anxiety subscale, not with the depression subscale. CONCLUSIONS: We developed a Patient's Experience and Attitude to Colposcopy questionnaire with adequate psychometric properties. Future application in out-patient clinics should further evaluate its clinical relevance.

Regional variation in the management of metastatic gastric cancer in Ontario.

BACKGROUND: Geographic variation in cancer care is common when clear clinical management guidelines do not exist. In the present study, we sought to describe health care resource consumption by patients with metastatic gastric cancer (gc) and to investigate the possibility of regional variation. METHODS: In this population-based cohort study of patients with stage iv gastric adenocarcinoma diagnosed between 1 April 2005 and 31 March 2008, chart review and administrative health care data were linked to study resource utilization outcomes (for example, clinical investigations, treatments) in the province of Ontario. The study took a health care system perspective with a 2-year time frame. Chi-square tests were used to compare proportions of resource utilization, and analysis of variance compared mean per-patient resource consumption between geographic regions. RESULTS: A cohort of 1433 patients received 4690 endoscopic investigations, 12,033 computed tomography exams, 12,774 radiography exams, and 5059 ultrasonography exams. Nearly all patients were seen by a general practitioner (98%) and a specialist (99%), and were hospitalized (95%) or visited the emergency department (87%). Fewer than half received chemotherapy (43%), gastrectomy (37%), or radiotherapy (28%). The mean number of clinical investigations, physician visits, hospitalizations, and instances of patient accessing the emergency department or receiving radiotherapy or stent placement varied significantly by region. CONCLUSIONS: Variations in health care resource utilization for metastatic gc patients are observed across the regions of Ontario. Whether those differences reflect differential access to resources, patient preference, or physician preference is not known. The observed variation might reflect a lack of guidelines based on high-quality evidence and could partly be ameliorated with regionalization of gc care to high-volume centres.

E-health to manage distress in patients with an implantable cardioverter-defibrillator: primary results of the WEBCARE trial.

UNLABELLED: The Web-based distress management program for patients with an implantable cardioverter-defibrillator (ICD; WEBCARE) was developed to mitigate distress and enhance health-related quality of life in ICD patients. This study investigated the treatment effectiveness at 3-month follow-up for generic and disease-specific outcome measures. METHODS: Consecutive patients implanted with a first-time ICD from six hospitals in the Netherlands were randomized to either the "WEBCARE" or the "usual care" group. Patients in the WEBCARE group received a 12-week fixed, six-lesson behavioral treatment based on the problem-solving principles of cognitive behavioral therapy. RESULTS: Two hundred eighty-nine patients (85% response rate) were randomized. The prevalence of anxiety and depression ranged between 11% and 30% and 13% and 21%, respectively. No significant intervention effects were observed for anxiety (ß = 0.35; p = .32), depression (ß = -0.01; p = .98) or health-related quality of life (Mental Component Scale: ß = 0.19; p = .86; Physical Component Scale: ß = 0.58; p = .60) at 3 months, with effect sizes (Cohen d) being small (range, 0.06-0.13). There were also no significant group differences as measured with the disease-specific measures device acceptance (ß = -0.37; p = .82), shock anxiety (ß = 0.21; p = .70), and ICD-related concerns (ß = -0.08; p = .90). No differences between treatment completers and noncompleters were observed on any of the measures. CONCLUSIONS: In this Web-based intervention trial, no significant intervention effects on anxiety, depression, health-related quality of life, device acceptance, shock anxiety, or ICD-related concerns were observed. A more patient tailored approach targeting the needs of different subsets of ICD patients may be warranted. TRIAL REGISTRATION: clinicaltrials.gov. Identifier: NCT00895700.

Disease management for co-morbid depression and anxiety in diabetes mellitus: design of a randomised controlled trial in primary care.

BACKGROUND: Depression and anxiety are common co-morbid health problems in patients with type 2 diabetes. Both depression and anxiety are associated with poor glycaemic control and increased risk of poor vascular outcomes and higher mortality rates. Results of previous studies have shown that in clinical practice, treatment of depression and anxiety is far from optimal as these symptoms are frequently overlooked and undertreated. METHODS/DESIGN: This randomised controlled trial will examine the effectiveness of a disease management programme treating symptoms of depression and anxiety in primary care patients with Type 2 diabetes. Patients will be randomized on patient level in 1:1 ratio. Random block sizes of 2 and 4 are used. The disease management programme consists of screening, stepped treatment and monitoring of symptoms (n = 80). This will be compared to care as usual (n = 80). DISCUSSION: The disease management model for co-morbid depression and anxiety in primary care patients with diabetes is expected to result in reduced symptoms of depression and anxiety, improved quality of life, reduced diabetes specific distress and improved glyceamic control, compared to care as usual. TRIAL REGISTRATION: Dutch Trial Register NTR2626.

Rules on informed consent and advance directives at the end-of-life: the new Italian law.

End-of-life decisions are an emergent issue for bioethical debates and practical concerns among health professionals. On December 2017, Italy enacted a new law named "Rules about informed consent and advance directives", which promotes the relationship of care in a fiduciary sense through the implementation of a correct and exhaustive information. It is also prescribed to record in writing all the patients' decisions about consent or refusal. Furthermore, the law explicitly forbids unreasonable therapeutic obstinacy for terminal patient, legitimizing deep palliative sedation. Finally, the law establishes the use of "advance directives" as a written document by which adults and capable people can express their wishes regarding health treatments and diagnostic tests in anticipation of a possible future incapacity. The law provides that doctors must comply with these directives, unless they appear clearly incongruous or not corresponding to the patient's current clinical condition.

A rare case of Spinal Epidural Abscess following mesotherapy: a challenging diagnosis and the importance of clinical risk management. Considerations concerning uncommon risk factor for development of Spinal Epidural Abscess and its prevention.

Spinal Epidural Abscess (SEA) is a rare pyogenic infection localized between dura mater and vertebral periostium. The development of SEA is associated with the presence of medical co-morbidities and risk factors that facilitate bacterial dissemination. It is possible distinguish two type of SEA: primary SEA due to pathogen hematogenous dissemination and secondary SEA resulting from direct inoculation of pathogen. This entity, very uncommon, shows a prevalence peak between the 5th and the 7th decade of life with predominance in males. The case is a 44 years old Caucasian man with chronic low back pain, treated with physiotherapy and anti-inflammatory drugs. Following an episode of acute severe exacerbation of pain, the patient underwent four session of dorsal and lumbo-sacral area mesotherapy. One month after the last session, the patient experienced acute sever lumbar pain, radiated to left lower limb and accompanied by fever and vomiting. During hospitalization, elevated levels of white blood cells and C Reactive Protein (CRP) were found. Moreover, a vertebral magnetic resonance imaging revealed the presence of intramedullary lesion. Furthermore, methicillin sensitive staphylococcus aureus was isolated from three blood cultures and antibiotic therapy was performed. In our case the patient had the typical SEA onset, without any specific risk factors excepting the execution of four session of mesotherapy. Aim of this study is to explain risk factors for the SEA development and to clarify how act as preventive measure, because also acupuncture can promote bacterial infection.

Hungarian hospital antibiotic consumption at the regional level, 1996-2005.

BACKGROUND: Regional variations in antibiotic consumption in outpatients have been reported previously, but nothing is as yet known about the regional distribution of antibiotic consumption in the hospital sector in Hungary. This study was designed to explore regional variations and investigate determinants of antibiotic consumption in hospital care in Hungary. MATERIALS AND METHODS: Regional distribution-based antibiotic sales data were obtained for a 10-year period (1996-2005) for the 20 Hungarian counties. Systemic antibacterial use (Anatomical Therapeutic Chemical code: J01) was expressed as the number of defined daily doses (DDD) per 100 patient-days. The multiple linear regression model was applied to investigate the determinants of regional differences in hospital antibiotic consumption. Independent variables related to health care access, utilization of hospital resources, doctors' workload, type of hospital care provided, and patient's characteristics and infections were considered as possible determinants, and data on these variables were obtained for 2 years (2004, 2005). We also tested the association between hospital and ambulatory care antibiotic consumption in Hungarian regions using the Pearson correlation test. RESULTS: For each year during the 1996-2005 study period, there were large and stable variations in total hospital antibiotic consumption (e.g., min-max(1996): 16.0-28.2; min-max(2005): 15.2-32.2 DDD per 100 patient-days) depending on the region. In the two developed models (Model 1 and Model 2), the number of reported infections accounted for 53% of the observed regional variations in hospital antibiotic consumption (Model 1), and the number of reported infections together with the case-mix index were responsible for 61% (Model 2) . Total antibiotic consumption in hospitals showed a positive correlation (R = 0.71, p = 0.002) with total antibiotic consumption in ambulatory care. CONCLUSION: The case-mix index and the number of reported infections explained some of the observed regional variations. However, the moderate value of the models in explaining these regional variations suggest that determinants which could not be explored in this preliminary study may also contribute to regional differences. Future studies should aim at collecting data for each individual hospital as well as data on possible determinants for hospital antibiotic consumption.

Identification of an essential cysteine in the reaction catalyzed by aspartate-beta-semialdehyde dehydrogenase from Escherichia coli.

The enzyme L-aspartate-beta-semialdehyde dehydrogenase from Escherichia coli has been studied by oligonucleotide-directed mutagenesis. The focus of this investigation was to examine the role of a cysteine residue that had been previously identified by chemical modification with an active site directed reagent (Biellmann et al. (1980) Eur. J. Biochem. 104, 59-64). Substitution of this cysteine at position 135 with an alanine results in complete loss of enzyme activity. However, changing this cysteine to a serine yields a mutant enzyme with a maximum velocity that is 0.3% that of the native enzyme. This C135S mutant has retained essentially the same affinity for substrates as the native enzyme, and the same overall conformation as reflected in identical behavior on gel electrophoresis and in identical fluorescence spectra. The pH profile of the native enzyme shows a loss in catalytic activity upon protonation of a group with a pKa value of 7.7. The same activity loss is observed at this pH with the serine-135 mutant, despite the differences in the pKa values for a cysteine sulfhydryl and a serine hydroxyl group that have been measured in model compounds. This observed pKa value may reflect the protonation of an auxiliary catalyst that enhances the reactivity of the active site cysteine nucleophile in the native aspartate-beta-semialdehyde dehydrogenase.

Chemical and kinetic mechanisms of aspartate-beta-semialdehyde dehydrogenase from Escherichia coli.

The chemical and kinetic mechanisms of purified aspartate-beta-semialdehyde dehydrogenase from Escherichia coli have been determined. The kinetic mechanism of the enzyme, determined from initial velocity, product and dead end inhibition studies, is a random preferred order sequential mechanism. For the reaction examined in the phosphorylating direction L-aspartate-beta-semialdehyde binds preferentially to the E-NADP-Pi complex, and there is random release of the products L-beta-aspartyl phosphate and NADPH. Substrate inhibition is displayed by both Pi and NADP. Inhibition patterns versus the other substrates suggest that Pi inhibits by binding to the phosphate subsite in the NADP binding site, and the substrate inhibition by NADP results from the formation of a dead end E-beta-aspartyl phosphate-NADP complex. The chemical mechanism of the enzyme has been examined by pH profile and chemical modification studies. The proposed mechanism involves the attack of an active site cysteine sulfhydryl on the carbonyl carbon of aspartate-beta-semialdehyde, with general acid assistance by an enzyme lysine amino group. The resulting thiohemiacetal is oxidized by NADP to a thioester, with subsequent attack by the dianion of enzyme bound phosphate. The collapse of the resulting tetrahedral intermediate leads to the acyl-phosphate product and liberation of the active site cysteine.

Crystallization and preliminary crystallographic analysis of aspartate-beta-semialdehyde dehydrogenase from Escherichia coli.

Aspartate-beta-semialdehyde dehydrogenase catalyzes the NADPH-mediated reductive dephosphorylation of beta-aspartylphosphate at a branch point in the biosynthesis of several amino acids. The enzyme from Escherichia coli has been crystallized by the vapor diffusion method from Tris buffer (pH 8.5) using polyethylene glycol 4000 as a precipitant. The crystals are orthorhombic and have the symmetry of space group P222(1), with unit cell dimensions of a = 177.8 A, b = 59.9 A, c = 118.65 A, and alpha = beta = gamma = 90 degrees. The dimensions and space group are indicative of two enzyme dimers (40 kDa per subunit) in the asymmetric unit. The crystals show strong diffraction, and a native data set has been collected to 2.5 A resolution.

Crystallization and preliminary X-ray studies of L-aspartase from Escherichia coli.

Single crystals of L-aspartate ammonia-lyase (L-aspartase) from Escherichia coli have been obtained by microdialysis at room temperature using polyethylene glycol 3350 and sodium acetate as co-precipitants. The crystals exhibit the symmetry of space group P2(1)2(1)2 with a = 156.5 A, b = 147.6 A, c = 102.5 A and diffract at least to 2.8 A.

Structure of aspartate-beta-semialdehyde dehydrogenase from Escherichia coli, a key enzyme in the aspartate family of amino acid biosynthesis.

Aspartate beta-semialdehyde dehydrogenase (ASADH) lies at the first branch point in an essential aspartic biosynthetic pathway found in bacteria, fungi and the higher plants. Mutations in the asd gene encoding for ASADH that produce an inactive enzyme are lethal, which suggests that ASADH may be an effective target for antibacterial, herbicidal and fungicidal agents. We have solved the crystal structure of the Escherichia coli enzyme to 2.5 A resolution using single isomorphous replacement and 3-fold non-crystallographic symmetry. Each monomer has an N-terminal nucleotide-binding domain and a dimerisation domain. The presence of an essential cysteine locates the active site in a cleft between the two domains. The functional dimer has the appearance of a butterfly, with the NADP-binding domains forming the wings and the dimerisation domain forming the body.A histidine residue is identified as a likely acid/base catalyst in the enzymic reaction. Other amino acids implicated in the enzymic activity by mutagenesis are found in the active site region and define the substrate binding pocket.

Attitudes of terminally ill patients toward euthanasia and physician-assisted suicide.

BACKGROUND: In jurisdictions that permit euthanasia or physician-assisted suicide, patients with cancer comprise the largest group to die by these methods. We investigated the personal attitudes toward these practices of patients receiving palliative care for advanced cancer. METHODS: Seventy patients (32 men and 38 women; median survival, 44.5 days) took part in a survey using in-depth semistructured interviews. The interviews were audiotaped for transcription and content analysis of themes. RESULTS: Most participants (73%) believed that euthanasia or physician-assisted suicide should be legalized, citing pain and the individual's right to choose as their major reasons. Participants who were opposed to legalization cited religious and moral objections as their central concerns. Forty (58%) of the 69 participants who completed the entire interview also believed that, if legal, they might personally make a future request for a hastened death, particularly if pain or physical symptoms became intolerable. Eight of these individuals (12%) would have made such a request at the time of the interview. These 8 participants differed from all others on ratings of loss of interest or pleasure in activities, hopelessness, and the desire to die (Ps<.02). They also had a higher prevalence of depressive disorders (P<.05). However, they did not differ on ratings of pain severity. CONCLUSIONS: Many patients with advanced cancer favor policies that would allow them access to both euthanasia and physician-assisted suicide if pain and physical symptoms became intolerable. For patients who would actually make requests for a physician-hastened death, however, psychological considerations may be at least as salient as physical symptoms.

A new model for evaluating corneal wound strength in the rabbit.

Presented in this report is a new model to evaluate corneal wound strength quantitatively by using an Instron 1125 tensiometer with video monitoring. Twenty-six rabbits received full thickness 8 mm central corneal incisions that were marked with sutures at each end and dressed with collagen shields. Animals were killed and corneas were harvested from 3-30 d postoperatively. Tensile test specimens, of rectangular (n = 9) or hourglass (n = 17) planform geometry, were prepared. Uniaxial tension tests were performed on these specimens parallel to the long dimension and perpendicular to the incision. Specimens were processed for light microscopy. Individual specimen load and displacement records were normalized to yield geometry independent stress and strain data sets. Maximum wound strength was determined as peak tissue stress on loading. Maximum tissue stiffness (inverse compliance) was derived from the peak slope of the stress-strain profile. Tissue fracture toughness was calculated as the total area under the stress-strain profile from the onset of loading to total wound failure. Data points at 3, 5, 10, 18, and 30 d show maximum wound strength increasing from 15.2 to 832 kilopascals (KPa), maximum stiffness increasing from 0.20 to 11.4 megapascals, and fracture toughness increasing from 1.82 to 87.7 KPa. Histological observations correlate well with tensiometry deductions. These data suggest enhanced mechanical load bearing with time, indicative of enhanced collagen fiber formation and cross-linking.

Noncross-linked collagen discs and cross-linked collagen shields in the delivery of gentamicin to rabbits eyes.

Using fluorescent polarization immunoassay, in vitro absorption and elution of gentamicin by noncross-linked collagen discs was measured. This technique was compared with that of cross-linked collagen shields and topical drops to provide adequate gentamicin levels in the cornea and aqueous humor of the rabbit eye. In vitro results showed that the noncross-linked collagen discs absorbed increased gentamicin with prolonged soaking time. All 2-hr presoaked discs completely dissolved within 6 min after being placed in the lower fornix of the rabbit eye. The presoaked discs released most of their gentamicin load within 0.5 hr of elution. Gentamicin levels in the cornea and aqueous humor, using 2-hr presoaked discs, were similar to those obtained with a single drop (P greater than 0.05) of topical solution and significantly lower than those obtained by applying a collagen shield at all intervals (P less than 0.01) and by hourly drops measured at 4- and 6-hr intervals (P less than 0.01). These results suggest that, in their current formulation, the presoaked collagen discs may not be an effective alternative to collagen shields or topical drops for gentamicin delivery because of their rapid dissolution in the eye.