Evaluating steady-state resting energy expenditure using indirect calorimetry in adults with overweight and obesity.

BACKGROUND: Determining a period of steady state (SS) is recommended when estimating resting energy expenditure (REE) using a metabolic cart. However, this practice may be unnecessarily burdensome and time-consuming in the research setting. AIM: The aim of the study was to evaluate the use of SS criteria, and compare it to alternative approaches in adults with overweight and obesity. METHODS: In this cross-sectional, ancillary analysis, participants enrolled in a bariatric (study 1; n = 13) and lifestyle (study 2; n = 51) weight loss intervention were included. Indirect calorimetry was performed during baseline measurements using a metabolic cart for 25 min, including a 5-min stabilization period at the start. SS was defined as the first 5-min period with a coefficient of variation (CV) ≤10% for both VO2 and VCO2 (hereafter REE5-SS). Body composition was measured using bioelectrical impedance analysis in study 2 participants only. REE5-SS was compared against the lowest CV (REECV-lowest), 5-min time intervals (REE6-10, REE11-15, REE16-20, REE21-25), 4-min and 3-min SS intervals (REE4-SS and REE3-SS), and time intervals of 6-15, 6-20 and 6-25 min (REE6-15, REE6-20, and REE6-25) using repeated measures ANOVA and Bland-Altman analysis to test for bias, limits of agreement and accuracy (±6% measured REE). RESULTS: Participants were 54 ± 13 years old, mostly women (75%) and had a BMI of 35 ± 5 kg/m2. Overall, 54/63 (84%) of participants reached REE5-SS, often (47/54, 87%) within the first 10-min (6-15 min). Alternative approaches to estimating REE had a relatively low bias (-16 to 13 kcals), narrow limits of agreement and high accuracy (83-98%) when compared to REE5-SS, in particular, outperforming standard prediction equations (e.g., Mifflin St. Joer). CONCLUSION: Indirect calorimetry measurements that utilize the 5-min SS approach to estimate REE are considered the gold-standard. Under circumstances of non-SS, it appears 4-min and 3-min SS periods, or fixed time intervals of atleast 5 min are accurate and practical alternatives for estimating REE in adults with overweight and obesity. However, future trials should validate alternative methods in similar populations to confirm these findings.

Delayed immune-related adverse events in assessment for dose-limiting toxicity in early phase immunotherapy trials.

BACKGROUND: Immunotherapy (IO) agents can cause late-onset immune-related adverse events (irAEs). In phase I trials, observation for dose-limiting toxicities (DLTs) is typically limited to the first cycle. The incidence of delayed-onset DLTs and their potential impact on dose determination have not been fully elucidated. PATIENTS AND METHODS: Consecutive patients enrolled in early phase IO trials at Princess Margaret Cancer Centre between August 2012 and September 2016 were retrospectively reviewed, applying trial-specific definitions for DLTs. A clinically significant AE (csAE) was defined as a treatment-related adverse event requiring corticosteroids, hormone replacement, IO delay or discontinuation. RESULTS: A total of 352 consecutive trial enrolments in 21 early phase clinical trials were included. Two-hundred seventy-eight patients (79%) received monotherapy and 74 (21%) received combination IO. Two hundred sixty (74%) patients experienced irAEs. There were two protocol-defined DLTs. Twenty (5.7%) patients had 24 csAEs qualifying as DLTs except for occurrence after the protocol-specified DLT period. One-hundred and six (10%) of irAEs were csAEs, including endocrine (26%), respiratory (14%), gastrointestinal (11%), general (10%), dermatological (8%), hepatic (8%), musculoskeletal (6%), pancreatic (6%), haematological, metabolic, neurological, cardiac (each 2%), infective and ocular (each 1%) events. The highest risk of first-onset csAE was during the first 4 weeks compared with the period from 4 weeks to end of treatment (odds ratio 3.13, 95% confidence interval 1.95-5.02). The median time to first onset csAE was significantly shorter with combination than monotherapy IO (32 vs. 146 days, P < 0.001). CONCLUSIONS: In our series of early phase IO trials, the risk of csAE was highest during the initial 4 weeks on IO treatment, supporting the use of the conventional DLT period for dose escalation decision. However, there were 24 clinically significant late-onset DLTs in 5.7% of patients. Combination IO was associated with greater risk of and also earlier onset for csAE, which may need to be considered for early phase trial design.

Safety comes first: are doctors attentive enough to their initial clinical assessment notes?

Accurate hospital admission/initial history and physical examination [H&P] notes are vital to support patient care. We aimed to assess the quality of H&P notes and to compare medical/surgical, and inpatient/outpatient H&P notes. A cross-sectional study examined 154 initial H&P notes for the adherence to a standard protocol in a tertiary referral hospital. 134 doctors (87.1%) adhered to the correct layout in accordance with the standard. Only 77 doctors (50%) recorded the names of the patient's medications. 106 (68.8%) documented the allergy status. Six doctors (3.9%) omitted an objective record of their own identity. Surgeons were superior at recording admission type (p = 0.0001) and past surgical history (p = 0.002) only. The data in this study show that the standard o completeness of the H&P documentation among doctors is suboptimal. We recommend the introduction of a standardised H&P template to reduce errors.

Dental practitioners with a special interest in periodontics: the West Sussex experience.

The experience of a pilot service involving practitioners with a special interest in periodontics is described. The service functioned as a clinical network between the primary and secondary sector and featured consultant outreach. Between June 2006 and May 2007 it experienced 441 referrals. It improved patient access to periodontal care and was successful in targeting specific disease categories and in meeting key performance indicators. The service was non-surgical and emphasised patient self-efficacy. It produced highly effective clinical outcomes. It was well accepted by both patients and referring practitioners. It did not replace the need for a consultant-led service in the eyes of the referring practitioners. The BPE was used to identify suitable patients; audit indicated that there was a tendency for practitioners to underscore the level of periodontal disease.

Computer simulations of the growth of synthetic peptide fibres.

We present a coarse-grained computer model designed to study the growth of fibres in a synthetic self-assembling peptide system. The system consists of two 28 residue α-helical sequences, denoted AB and CD, in which the interactions between the half peptides, A, B, C and D, may be tuned individually to promote different types of growth behaviour. In the model, AB and CD are represented by double ended rods, with interaction sites distributed along their lengths. Monte Carlo simulations are performed to follow fibre growth. It is found that lateral and longitudinal growth of the fibre are governed by different mechanisms--the former is diffusion limited with a very small activation energy for the addition of units, whereas the latter occurs via a process of secondary nucleation at the fibre ends. As a result, longitudinal growth generally proceeds more slowly than lateral growth. Furthermore, it is shown that the aspect ratio of the growing fibre may be controlled by adjusting the temperature and the relative strengths of the interactions. The predictions of the model are discussed in the context of published data from real peptide systems.

Scrotal signs and symptoms in the general population, the value of testis self-examination and the pitfalls of a scrotal screening programme: is the two-week rule relevant?

PURPOSE: Testicular symptoms/lumps are a cause of concern, anxiety and possible diagnostic dilemma for patient and general practitioner. The majority of scrotal pathology is benign in nature and results in a huge workload. The main aim of this study was to determine the relationship between scrotal symptoms, previous scrotal surgery, testicular self-examination and awareness of scrotal abnormalities. Secondarily, we sought to determine the scrotal findings in men enrolled in a consultant urologist-directed screening programme. METHODS: There were 677 men surveyed on their performance of TSE. They were also asked about scrotal symptoms and prior surgery, before undergoing blinded physical examination by one of four consultant urologists. RESULTS: Among the participants, 9.8% of men had scrotal symptoms with 55% of these having a normal scrotal examination and the rest having benign pathology. A number of men who had undergone previous scrotal surgery (13%) had no clinical findings detected on scrotal examination. No subject was found to have testis cancer; 20.9% had a benign scrotal or inguinal condition detected with the majority (65%) not aware of the abnormality. Men who demonstrate a superior awareness of their scrotal abnormalities were more likely to perform TSE. CONCLUSIONS: Increased awareness of scrotal abnormalities combined with TSE may have a role in improving detection of significant testicular pathology. However, the high prevalence of benign scrotal conditions, of which most men were unaware, may serve to raise anxiety in the patient and general practitioner. We believe there is no role for a one-stop scrotal anxiety clinic, as the costs do not justify the benefits.

Team Objective Structured Bedside Assessment (TOSBA): a novel and feasible way of providing formative teaching and assessment.

It can be challenging to teach and assess medical students successfully in the setting of a hospital ward using real patients. We describe a novel method of providing weekly formative clinical assessment and teaching to final year students on an acute medical ward: The Team Objective Structured Bedside Assessment (TOSBA). The TOSBA involves three groups of five students rotating through three ward-based stations (each station consists of an inpatient and facilitator). Each group spends 25 minutes at a bedside station where the facilitator asks consecutive students to perform one of five clinical tasks. Every student receives a standardised grade and is provided with educational feedback at each of the three stations. We report our 15-month experience using the TOSBA format to assess and teach a large number of medical students on a weekly basis. We discuss the advantages and potential drawbacks of our approach.

Skin sensitization testing in potency and risk assessment.

The purpose of this article is to review, and make recommendations for, the use of relevant skin sensitization test methods, for the purposes of determination of relative potency and the threshold dose necessary for the induction of skin sensitization, and for risk assessment. In addressing the first area, the utility of three guinea pig tests (the guinea pig maximization test, the occluded patch test, and the open epicutaneous test) of the local lymph node assay (LLNA) and of human volunteer testing for the assessment of relative potency and identification of thresholds for sensitization were considered. The following conclusions were drawn. (1) Although attempts have been made to modify the guinea pig maximization test for the purposes of deriving dose-response relationships, this method is usually unsuitable for determination of relative sensitizing potency. (2) Guinea pig methods that do not require the use of adjuvant and which employ a relevant route of exposure (the occluded patch test and the open epicutaneous test) are more appropriate for the assessment of relative skin-sensitizing potency. (3) The LLNA is suitable for the determination of relative skin sensitizing potency, and the adaptation of this method for derivation of comparative criteria such as EC3 values (the estimated concentration of test chemical required to induce a stimulation index of 3 in the LLNA) provides an effective and quantitative basis for such measurements. (4) For all the methods identified above, potency is assessed relative to other chemical allergens of known skin sensitizing potential. The estimation of likely threshold concentrations is dependent upon the availability of suitable benchmark chemicals of known potency for human sensitization. (5) Human testing (and specifically, the Human Repeat Insult Patch Test) can provide information of value in confirming the absence of skin sensitizing activity of formulations and products under specific conditions of use and exposure. Based on the above, the following recommendations are made. (1) If results are already available from suitable guinea pig tests, then judicious interpretation of the data may provide information of value in assessing relative skin sensitizing potency. This option should be explored before other analyses are conducted. (2) The LLNA is the recommended method for new assessments of relative potency, and/or for the investigation of the influence of vehicle or formulation on skin sensitizing potency. (3) Whenever available, human skin sensitization data should be incorporated into an assessment of relative potency. With respect to risk assessment, the conclusion drawn is that all the available data on skin-sensitizing activity in animals and man should be integrated into the risk-assessment process. Appropriate interpretation of existing data from suitable guinea pig studies can provide valuable information with respect to potency, as the first step in the development of a risk assessment. However, for de novo investigations, the LLNA is the method favored for providing quantitative estimations of skin-sensitizing potency that are best suited to the risk assessment process. Finally, human testing is of value in the risk assessment process, but is performed only for the purposes of confirming product safety.

Developing a framework for comprehensive cancer prevention and control in the United States: an initiative of the Centers for Disease Control and Prevention.

The Division of Cancer Prevention and Control, Centers for Disease Control and Prevention, is working with state health agency staff and other stakeholders to develop a comprehensive and integrated approach to cancer control. To help stakeholders visualize the approach, a graphic model was developed based on stakeholder input and a literature review of existing models. Phases of the model include setting optimal objectives (data driven), determining optimal strategies (science driven), establishing feasible priorities (capacity driven), and implementing effective strategies (outcome driven). The model currently is being validated through case studies of state-level cancer planning in six states.

Development and validation of a measurement system for assessment of energy expenditure and physical activity in Prader-Willi syndrome.

OBJECTIVE: The morbid obesity associated with Prader-Willi syndrome (PWS) may result from either excessive energy intake or reduced energy expenditure (EE). In this report, we describe the development and validation of an Activity-Energy Measurement System (AEMS) to measure EE and physical activity components in an environment approximating free-living conditions. RESEARCH METHODS AND PROCEDURES: The AEMS consists of a live-in, whole-room indirect calorimeter equipped with a novel force platform floor system to enable simultaneous measurements of EE, physical activity, and work efficiency during spontaneous activities and standardized exercises. Free-living physical activity and estimated free-living EE are measured using portable triaxial accelerometers individually calibrated in each subject during their stay in the AEMS. RESULTS: Representative data from two PWS patients and two matched control (CTR) subjects displayed EE during their inactive lifestyles. DISCUSSION: This combination of methods will allow the quantification of daily EE and its components, the amount and energy cost of physical activity, and the relationships between body composition and EE, in order to determine their roles in the development and maintenance of the morbid obesity in PWS.

Intensive care unit bedside documentation systems. Realizing cost savings and quality improvements.

Automating intensive care unit (ICU) documentation saves time and assists in interpreting data and planning care. The current economic climate makes the cost of ICU computer systems prohibitive for many institutions. Any expenditure without a measurable return on investment will be scrutinized carefully. The literature describing ICU computer system benefits often is difficult to interpret. No two implementations, hospitals, or benefit study designs have been the same. Each implementation has many unique variables. These variables make study comparison and replication potentially impossible. The authors have concluded that replicating previous studies may not be relevant if the goal is to justify system cost. The objective is met by designing a study that evaluates changes in data management activities as well as issues unique to the study unit or institution. The purpose of this article is to review the findings of previous benefits studies related to ICU documentation systems and to suggest other measures to support cost justification for expensive bedside documentation systems.

A guide to nurse prescribing of insecticides and anthelmintics.

Several drug preparations are available to the nurse prescriber to treat parasitic infestations, most commonly head lice, scabies and threadworms. It is vital that the nurse has a thorough knowledge of the types of preparations available, together with an understanding of the non-pharmacological interventions to eradicate infestation. Many people may be treated without the intervention of a doctor, but the nurse prescriber should ensure that those who are affected receive appropriate referral to their GP if there are special circumstances, secondary infestation or a suspected infestation by roundworms.

Laxatives and rectal preparations.

This article is the second in a series looking at the knowledge needed for nurses to prescribe. It considers the use of drugs that have an effect on the digestive tract and incorporates essential knowledge from the biological sciences.

Fewer immigrants settle in nonmetro areas and most fare less well than metro immigrants.

"Recent attention to the issue of immigration in the United States has led to the addition of questions about immigration status to the Current Population Survey. Data from the March 1996 version show that Mexico has been the single largest source of immigration to the nonmetro United States, that a large proportion of nonmetro immigrants are children, and that nonmetro immigrants generally have lower earnings, higher unemployment, and higher poverty rates than metro immigrants and nonmetro natives. Fewer immigrants live in nonmetro areas than in metro, but they are concentrated in particular areas."

Eliciting the views of experienced midwives about the assessment of competence in midwifery.

OBJECTIVE: to investigate the views of the English National Board for Nursing, Midwifery and Health Visiting (ENB) Professional Midwifery Advisory Network (PMAN) members about the assessment of competence in midwifery. DESIGN: initial questionnaire followed by a group discussion of a summary of the data from the completed questionnaires. PARTICIPANTS: 54 PMAN midwives representing education, management, research, practice and supervision; plus six ENB Education Officers (midwifery). FINDINGS: the response rate to the questionnaires was 75%. In the group discussion the PMAN members commented particularly on: the large number of items identified as needing assessment in practice and by written work; lack of total agreement on the assessment in practice of normal delivery; differences in practitioners' perceptions of assessment; the number and range of areas to be assessed; differences in expectation of 'task' assessment versus 'holistic' assessment; lack of assessment in simulation; heavy reliance on written work in assessment. CONCLUSIONS: the group's discussion of the questionnaire data revealed further interesting data, which added considerably to the initial analysis and overview. Some participants had misinterpreted the instructions and found that what they had filled in did not accurately reflect their beliefs about assessment. General consensus was reached on the need for a national standard or framework for assessment and more emphasis to be placed on assessing students in the practice setting whilst ensuring this includes knowledge and understanding and not merely psycho-motor skills. The major implications include effective preparation of assessors and more teacher involvement in practice to support the midwife assessors.

Prospective assessment of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic vs conservative therapy.

PURPOSE: To determine whether subclinical cholesterol embolization is a frequent sequela of thrombolytic therapy. Case reports of catastrophic cholesterol embolization temporally associated with thrombolytic therapy in 19 patients have suggested a causal relationship. PATIENTS AND METHODS: We prospectively followed 60 patients with acute myocardial infarction who underwent coronary bypass surgery within 1 month. Twenty-nine received thrombolytic therapy for myocardial infarction; 31 were treated conservatively. Two muscle biopsy specimens and one skin biopsy specimen were obtained from the vein harvest site at the time of bypass surgery. Paraffin block and frozen sections from each biopsy specimen were analyzed for evidence of cholesterol embolization. RESULTS: Cholesterol emboli were found in biopsy specimens from 4 of 29 patients who had undergone thrombolytic therapy (14%) and in 3 of 31 patients who had not undergone thrombolytic therapy (10%, p = NS). Clinical evidence of cholesterol embolization occurred in one patient. Cholesterol emboli were distributed inhomogeneously; they were not observed in any skin biopsy specimen and were never present in more than one muscle biopsy specimen from each patient. CONCLUSIONS: The prevalence of cholesterol embolization in patients with acute myocardial infarction treated with thrombolytic therapy is not significantly higher than in those treated without thrombolytic therapy. The cholesterol embolization seen in 12% of our patients was mostly subclinical and was probably spontaneous and/or catheterization induced. Isolated case reports of severe cholesterol embolization temporally associated with thrombolytic therapy do not represent a phenomenon that has widespread subclinical occurrence.

Altered diaphragm function modifies neonatal lung growth: biologic morphometric assessment.

Thoracic volume relationships supported by the diaphragm are important mechanical components of neonatal lung growth. Alterations modify regional lung growth. We used stereologic morphometry to study effects of altered diaphragm function on alveolar growth in neonatal pigs. Nine piglets (1 mo) were divided into three groups: unilateral phrenectomy, noncompliant patch replacement of diaphragm, and sham. Seven days later lungs were fixed in situ with 2.5% glutaraldehyde by airway installation at 20 cm H2O. Five 1-mm cubes were cut from lung corresponding to apex/RUQ(A), base/RLQ(B), apex/LUQ(C), and base/LLQ(D) and prepared for light microscopy (n = 25/quad/animal). Stereologic morphometry involved point counting for air volume density and point intersect to determine the surface area density of the alveolar spaces. Results were analyzed for variance and by Tukey range testing. Variance of air volume % between groups-quadrants B, C, D had decreased air volume % in phrenectomy group compared with patch and sham group (P < .05). Variance of air volume % within groups, for phrenectomy group A (81.5%), is different from all others (B = 70.6%, C = 75.5%, D = 66.7%); C is different from D (P < .05). For patch and sham group, D (P = 74.8%, S = 80.7%) is different from A (P = 84.1%, S = 86.6%) and C (P = 86.2%, S = 84.4%). Variance of surface area density between groups--quadrant D had increased surface area density % in phrenectomy group compared to sham group (P < .05). Variance of surface area density % within groups, for phrenectomy group, A (37.9 mm-1) is different from D (55.7 mm-1).(ABSTRACT TRUNCATED AT 250 WORDS)

Geriatric rehabilitation nursing.

This article is derived from a statement initially developed by the author for the Gerontology Special Interest Group of the Association of Rehabilitation Nurses. It draws on the standards and scope of practice of rehabilitation nursing as established by the American Nurses Association and the Association of Rehabilitation Nurses. The article provides insight into the needs of the elderly individual in the healthcare system; ultimately, its focus is on the necessity of providing responsible rehabilitation nursing care for clients with varied gerontological problems by evaluating and promoting restorative function. Rehabilitation nursing joins with gerontology to assist elderly clients in meeting individual goals.