Analysing experienced and inexperienced cyclists' attentional focus and self-regulatory strategies during varying intensities of fixed perceived effort cycling: A mixed method study.

Using a think aloud approach during fixed perceived effort exercise is a unique method to explore the decision-making processes that guide the self-regulation of perceived effort during endurance-based activity. In a two-part study, authors investigated the attentional focus and self-regulatory strategies associated with: Part A - perceived effort corresponding to (RPEGET) and above gas exchange threshold (RPE+15%GET); Part B - between experienced and inexperienced cyclists during fixed perceived effort cycling tasks. Eighteen (15 male, 3 female) healthy, active individuals completed three visits (visit 1 - ramped incremental test and familiarisation, visit 2 and 3-30-min fixed perceived effort cycling). During which, power output, heart rate, lactate, think aloud, and perceptual markers were taken. Random-intercepts linear mixed-effects models assessed the condition, time, and condition × time interactions on all dependent variables. Power output, heart rate, lactate and instances of internal sensory monitoring (t195=2.57,p=.011,ß=0.95[0.23,1.68]) and self-regulation (t195=4.14,p=.001,ß=1.69[0.89,2.49]) were significantly higher in the RPE+15%GET versus RPEGET trial. No significant differences between inexperienced and experienced cyclists for internal sensory monitoring (t196=-1.78,p=.095,ß=-1.73[-3.64,0.18]) or self-regulatory thoughts (t196=-0.39,p=.699,ß=-1.06[-6.32,4.21]) were noted but there were significant condition × time interactions for internal monitoring (t196=2.02,p=.045,ß=0.44[0.01,0.87]) and self-regulation (t196=3.45,p=.001,ß=0.85[0.37,1.33]). Seemingly, experienced athletes associatively attended to internal psychophysiological state and subsequently self-regulate their psychophysiological state at earlier stages of exercise than inexperienced athletes. This is the first study to exhibit the differences in attentional focus and self-regulatory strategies that are activated based on perceived effort intensity and experience level in cyclists.

'Doing school food!': a practical toolkit for adopting a whole school food approach.

AIMS: The dietary intake and reported eating behaviours of adolescents in the UK are a public health concern. Schools are identified as an ideal 'place' setting to promote health and improve young peoples' nutrition outcomes. A gap in the understanding of how healthy secondary school food policy can be implemented, sustainable and effective, may hamper progress to improving school food provision and nutrition education in the UK. Research was conducted to understand the factors which influence healthy school food provision and the adolescent's food choice to inform and develop a practical framework for schools. METHODS: This research involves the development of a practical toolkit which synthesises evidence generated from a mixed methods study and a systematic review. This was informed by an exploration of the secondary school food environment as a potentially 'obesogenic' setting, the effectiveness of school food interventions and policy in Europe and UK, included young people's (11-18 years of age) eating behaviours and priorities in food choice. A pragmatic approach was taken in the integration of evidence, using ecological and behaviour change theory, and joint display principles. RESULT: A six-phase practical toolkit is presented, guided by 'What Good Looks Like' and 'Whole Systems Approach to Obesity' principles which can be used to translate the evidence from this research into good school food practice. CONCLUSION: Improving secondary school food provision across the school day and having a coherent whole school food approach to healthy eating have the potential to significantly improve a young person's food choice, therefore impacting the nutrient intake of adolescents in the UK. This toolkit helps working towards operationalising this idea.

Regulatory mechanisms to create healthier environments: planning appeals and hot food takeaways in England.

AIMS: To explore existing regulatory mechanisms to restrict hot food takeaway (HFT) outlets through further understanding processes at local and national levels. METHODS: The Planning Appeals Portal was utilised to identify recent HFT appeal cases across England between December 2016 and March 2020. Eight case study sites were identified using a purposive sampling technique and interviews carried out with 12 professionals involved in planning and health to explore perceptions of and including factors that may impact on the HFT appeal process. Additionally, documents applicable to each case were analysed and a survey completed by seven Local Authority (LA) health professionals. To confirm findings, interpretation meetings were conducted with participants and a wider group of planning and public health professionals, including a representative from the Planning Inspectorate. RESULTS: Eight case study sites were identified, and 12 interviews conducted. Participants perceived that LAs would be better able to work on HFT appeal cases if professionals had a good understanding of the planning process/the application of local planning policy and supplementary planning documents; adequate time and capacity to deal with appeals cases; access to accurate, robust, and up to date information; support and commitment from elected members and senior management; good lines of communication with local groups/communities interested in the appeal; information and resources that are accessible and easy to interpret across professional groups. CONCLUSIONS: Communication across professional groups appeared to be a key factor in successfully defending decisions. Understanding the impact of takeaway outlets on health and communities in the long term was also important. To create a more robust appeals case and facilitate responsiveness, professionals involved in an appeal should know where to locate current records and statistical data. The enthusiasm of staff and support from senior management/elected officials will play a significant role in driving these agendas forward.

The impact of COVID-19 on the hot food takeaway planning regulatory environment: perspectives of local authority professionals in the North East of England.

BACKGROUND & AIMS: Planning regulations have been used to prevent the over-proliferation of hot food takeaways, minimising the impact of local obesogenic environments. To help mitigate the effects of lockdown, the UK government introduced temporary changes in March 2020 to Planning Regulations for England, allowing food retailers to open for takeaway services beyond 'ancillary' level without needing to apply for planning permission through permitted development rights (PDR). Businesses are required to notify their local authority (LA) when they implement PDRs. To better understand the impact of regulations on the policy and practice of key professional groups, Public Health England commissioned Teesside University to undertake scoping research in the North East of England. METHODS: A focus group and interviews were conducted with 15 professionals from 7 of 12 North East LAs. Professions included Planners, Public Health Leads, Environmental Health Officers and Town Centre Managers. Data were analysed using a codebook thematic analysis approach. An interpretation meeting with some participants was conducted. RESULTS: LAs were not aware of most businesses notifying them of new regulation adherence despite taking up PDRs, but were considered low-priority with many lacking formal recording procedures. There were concerns about health consequences of the changes, and consensus relating to ongoing issues with capacity across all professional groups, largely due to the continuing pandemic and absence of a strategy out of temporary measures. Concerns existed around ensuring cessation of restaurants trading as takeaways, and hygiene inspections backlog. Many (personally) saw new takeaways as a lifeline, offering broader menus and preserving local economies. CONCLUSION: Lack of information around the number of restaurants/pubs using PDR to trade as takeaway services, ongoing capacity issues of LAs and, at the time, the absence of a strategy post regulation changes, meant there were high levels of uncertainty regarding the impacts of these temporary measures.

Exploring the fast food and planning appeals system in England and Wales: decisions made by the Planning Inspectorate (PINS).

BACKGROUND: The National Planning Policy Framework advocates the promotion of 'healthy communities'. Controlling availability and accessibility of hot food takeaways is a strategy which the planning system may use to promote healthier environments. Under certain circumstances, for example, local authorities can reject applications for new hot food takeaways. However, these decisions are often subject to appeal. The National Planning Inspectorate decide appeals - by upholding or dismissing cases. The aim of this research is to explore and examine the National Planning Inspectorate's decision-making. METHODS: The appeals database finder was searched to identify hot food takeaway appeal cases. Thematic analysis of appeals data was carried out. Narrative synthesis provided an overview of the appeals process and explored factors that were seen to impact on the National Planning Inspectorate's decision-making processes. RESULTS: The database search identified 52 appeals cases. Results suggest there is little research in this area and the appeals process is opaque. There appears to be minimal evidence to support associations between the food environment and health and a lack of policy guidance to inform local planning decisions. Furthermore, this research has identified non-evidence-based factors that influence the National Planning Inspectorate's decisions. CONCLUSION: Results from this research will provide public health officers, policy planners and development control planners with applied public health research knowledge from which they can draw upon to make sound decisions in evaluating evidence to ensure they are successfully equipped to deal with and defend hot food takeaway appeal cases.

A mixed method evaluation of adult tier 2 lifestyle weight management service provision across a county in Northern England.

Adult obesity in the UK remains a public health priority. Current guidance recommends local areas provide multicomponent interventions to treat adults with overweight and obesity; however, there is currently a dearth of published evidence on the evaluation of these programmes. This study reports on a mixed method evaluation of seven tier 2 weight management programmes funded by a local authority in the North of England through their public health grant (a lifestyle multicomponent weight management programme for the treatment of adults with overweight and obesity, but not severe obesity, or obesity with severe co-morbidities). Data collected from over 2000 participants demonstrated that the proportion of participants achieving 5% initial body weight loss was comparable to that reported in recent UK weight management trials. Two services exceeded national criteria of 30% of participants achieving 5% initial body weight loss at 12 weeks, although long term data was limited. Greater weight loss was also observed in participants aged 35-44 and those without co-morbidities. This study provides important learning points for improvements in real world weight management services, these include: standardised data collection and management tools; staff training and communication requirements; the importance of programmes that are joined up to wider support services; and the importance of providing ongoing peer and provider support, continuous monitoring and feedback, and physical activities tailored to user needs.

Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review.

Specialist weight management services provide a treatment option for severe obesity. The objective of the study is to review the characteristics, impact and practice implications of specialist weight management services for adults in the UK. Systematic review: EMBASE, MEDLINE and PsycINFO were searched from January 2005 to March 2016 with supplementary searches. Adults with a body mass index of ≥40 kg m-2 , or ≥35 kg m-2 with comorbidity or ≥30 kg m-2 with type 2 diabetes and any study of multicomponent interventions, in any UK or Ireland setting, delivered by a specialist multidisciplinary team are the inclusion criteria. Fourteen studies in a variety of settings were included: 1 randomized controlled trial, 3 controlled and 10 observational studies. Mean baseline body mass index and age ranged from 40 to 54 kg m-2 and from 40 to 58 years. The studies were heterogeneous making comparisons of service characteristics difficult. Multidisciplinary team composition and eligibility criteria varied; dropout rates were high (43-62%). Statistically significant reduction in mean body mass index over time ranged from -1.4 to -3.1 kg m-2 and mean weight changes ranged from -2.2 to -12.4 kg. Completers achieving at least 5% reduction of initial body weight ranged from 32 to 51%. There was evidence for improved outcomes in diabetics. Specialist weight management services can demonstrate clinically significant weight loss and have an important role in supporting adults to manage severe and often complex forms of obesity. This review highlights important variations in provision and strongly indicates the need for further research into effective approaches to support severely obese adults.

Glucocorticoid exposure and fracture risk in patients with new-onset rheumatoid arthritis.

Retrospective claims analysis indicated that high levels of daily and cumulative doses of systemic glucocorticoids were associated with elevated fracture risk in a large cohort of new RA patients under age 65. Heightened risk began to decline within months of discontinuation. Findings were similar among patients age <50 years. INTRODUCTION: We evaluated the impact of systemic glucocorticoid exposure on fracture risk among relatively young patients with new-onset rheumatoid arthritis (RA). METHODS: Using administrative data, we identified 42,127 RA patients diagnosed January 1, 2005-December 31, 2012, age 18-64 years, with benefits coverage for ≥12 months before RA diagnosis. Follow-up extended to clinical fracture, cancer diagnosis, or December 31, 2012. Glucocorticoid users were new to therapy. Fracture incidence rates (IR) were stratified by glucocorticoid exposure expressed as prednisone equivalent doses. Cox's proportional hazards models estimated fracture risk adjusted for demographics and baseline clinical characteristics to assess dose-response relationships with current (daily) and prior (cumulative) dose, and by time since discontinuation. RESULTS: Most patients (85 %) had glucocorticoid exposure. Exposed and unexposed patients were demographically similar (74 % female; mean age 49.7 and 48.8 years); 1 % had prior fracture. Fracture IRs (95 % confidence intervals) were 5 to 9 per 1000 person-years at doses <15 mg/day, 16.0 (11.0, 22.6) at doses ≥15 mg/day, and 13.4 (10.7, 16.7) at cumulative doses ≥5400 mg. Adjusted fracture risk was approximately 2-fold higher at highest dose levels compared with 0 mg/day current daily dose and <675 mg cumulative dose, respectively. Fracture risk was 29 % lower at 60-182 days post-discontinuation compared with ongoing use and was similar to unexposed patients by 12 months. Findings were similar among patients age <50 years. CONCLUSIONS: Among younger, new-onset RA patients, fracture risk was significantly elevated at high levels of daily and cumulative dose, and was similar to unexposed patients by 12 months post-discontinuation.

Determinants of sugar-sweetened beverage consumption in young children: a systematic review.

Sugar-sweetened beverage (SSB) consumption is associated with adverse health outcomes. Improved understanding of the determinants will inform effective interventions to reduce SSB consumption. A total of 46,876 papers were identified through searching eight electronic databases. Evidence from intervention (n = 13), prospective (n = 6) and cross-sectional (n = 25) studies on correlates/determinants of SSB consumption was quality assessed and synthesized. Twelve correlates/determinants were associated with higher SSB consumption (child's preference for SSBs, TV viewing/screen time and snack consumption; parents' lower socioeconomic status, lower age, SSB consumption, formula milk feeding, early introduction of solids, using food as rewards, parental-perceived barriers, attending out-of-home care and living near a fast food/convenience store). Five correlates/determinants were associated with lower SSB consumption (parental positive modelling, parents' married/co-habiting, school nutrition policy, staff skills and supermarket nearby). There was equivocal evidence for child's age and knowledge, parental knowledge, skills, rules/restrictions and home SSB availability. Eight intervention studies targeted multi-level (child, parents, childcare/preschool setting) determinants; four were effective. Four intervention studies targeted parental determinants; two were effective. One (effective) intervention targeted the preschool environment. There is consistent evidence to support potentially modifiable correlates/determinants of SSB consumption in young children acting at parental (modelling), child (TV viewing) and environmental (school policy) levels.

Further reductions in nonvertebral fracture rate with long-term denosumab treatment in the FREEDOM open-label extension and influence of hip bone mineral density after 3 years.

UNLABELLED: Limited data exist on the efficacy of long-term therapies for osteoporosis. In osteoporotic postmenopausal women receiving denosumab for 7 years, nonvertebral fracture rates significantly decreased in years 4-7 versus years 1-3. This is the first demonstration of a further benefit on fracture outcomes with long-term therapy for osteoporosis. INTRODUCTION: This study aimed to evaluate whether denosumab treatment continued beyond 3 years is associated with a further reduction in nonvertebral fracture rates. METHODS: Participants who completed the 3-year placebo-controlled Fracture REduction Evaluation of Denosumab in Osteoporosis every 6 Months (FREEDOM) study were invited to participate in an open-label extension. The present analysis includes 4,074 postmenopausal women with osteoporosis (n = 2,343 long-term; n = 1,731 cross-over) who enrolled in the extension, missed ≤1 dose during their first 3 years of denosumab treatment, and continued into the fourth year of treatment. Comparison of nonvertebral fracture rates during years 1-3 of denosumab with that of the fourth year and with the rate during years 4-7 was evaluated. RESULTS: For the combined group, the nonvertebral fracture rate per 100 participant-years was 2.15 for the first 3 years of denosumab treatment (referent) and 1.36 in the fourth year (rate ratio [RR] = 0.64; 95 % confidence interval (CI) = 0.48 to 0.85, p = 0.003). Comparable findings were observed in the groups separately and when nonvertebral fracture rates during years 1-3 were compared to years 4-7 in the long-term group (RR = 0.79; 95 % CI = 0.62 to 1.00, p = 0.046). Fracture rate reductions in year 4 were most prominent in subjects with persisting low hip bone mineral density (BMD). CONCLUSIONS: Denosumab treatment beyond 3 years was associated with a further reduction in nonvertebral fracture rate that persisted through 7 years of continuous denosumab administration. The degree to which denosumab further reduces nonvertebral fracture risk appears influenced by the hip bone density achieved with initial therapy.

Fracture incidence in a large cohort of men age 30 years and older with osteoporosis.

UNLABELLED: In this large retrospective study of men with presumed osteoporosis, we estimate the rate of osteoporosis-related fractures in men age ≥30 years. Our results suggest that spine and hip fractures continue to be a considerable disease burden for osteoporotic men of all ages. INTRODUCTION: The purposes of this study were to describe a cohort of men with presumed osteoporosis and estimate the incidence rates of fractures by age. METHODS: Using US administrative claims data, we identified 43,813 men ≥30 years old with an osteoporosis diagnosis or use of an osteoporosis medication. Men were followed for a minimum of 12 months after diagnosis or treatment of osteoporosis (index date), until the earliest of fracture (hip, spine, pelvis, distal femur, humerus, wrist, forearm), disenrollment, or study end date. RESULTS: During the study period, there were 3834 first fractures following the index date and 3303 fractures in the 6-month period prior to the diagnosis/treatment of osteoporosis. Incidence rates of osteoporosis-related fracture, estimated from the index date onward, increased with age, although did not significantly differ from one another in younger age groups (30-49 and 50-64 years). Spine fractures had the highest incidence rate in men across all age groups, increasing from 10.8 per 100,000 person-years (p-yrs) (95% confidence interval (CI) 9.1, 12.7), 12.2 per 100,000 p-yrs (95% CI 11.2, 13.3), and 15.3 per 100,000 p-yrs (95% CI 13.8, 16.9) in men 30-49, 50-64, and 65-74 years to 33.4 per 100,000 p-yrs (95% CI 31.5, 35.4) in men ≥75 years. Hip fractures were the second most common, with the incidence rate reaching 16.2 per 100,000 (95% CI 14.9, 17.6) in the ≥75-year group. CONCLUSION: These incidence rates suggest that spine and hip fractures are a considerable disease burden for men of all ages diagnosed and/or treated for osteoporosis.

Risk factors for fracture among current, persistent users of bisphosphonates.

SUMMARY: Bisphosphonate therapy reduces fracture risk but does not eliminate fracture occurrence. We determined the fracture incidence and risk factors for fractures among 14,674 bisphosphonate users in a community setting. Bisphosphonate users remained at risk of fracture, and additional measures to prevent fractures in these patients would be beneficial. INTRODUCTION: Bisphosphonate therapy reduces but does not eliminate fracture occurrence. The incidence of fracture and risk factors for fractures among persistent, current users of bisphosphonates in a community setting have not been well studied. METHODS: We conducted a retrospective cohort study of 14,674 bisphosphonate users in a health maintenance organization. Patients were followed until a 3-month gap in therapy, creating a pool of highly compliant [mean medication possession ratio (MPR) of 94%] current users. We used Cox proportional hazards models to identify risk factors for fractures among these persistent, current users. RESULTS: There were 867 fractures over the period of observation or 3.7 fractures per 100 users per year. Older patients who take multiple medications, have lower bone mineral density, have a history of prior fracture, and suffer from particular comorbidities (i.e., dementia, chronic kidney disease, and rheumatoid arthritis) are at higher risk of fracture while taking bisphosphonates. CONCLUSION: Persistent, current bisphosphonate users remain at risk of fracture, and additional measures to prevent fractures in these patients would be of benefit.

Introduction of oesophageal Doppler-guided fluid management in a laparoscopic colorectal surgery enhanced recovery programme: an audit of effect on patient outcome.

Morbidity after colorectal surgery can be reduced with intraoperative oesophageal Doppler monitor (ODM) guided fluid therapy. We audited the effect of introducing ODM-guided fluid therapy in enhanced recovery laparoscopic colorectal surgery. ODM group (n = 40) outcomes (toleration of diet, Post Operative Morbidity Survery (POMS) score, complications) were compared to matched patients (n = 40) who had the same surgery using a conventional approach to fluid management. Mean (SD) time to tolerate diet was shorter in the ODM group (2.3 (1.6) days vs 3.8 (2.4) days, p = 0.003). The ODM group had a lower mean (SD) POMS score on post-operative day 1 (2 (1.4) vs 4 (1.1), p = 0.001), fewer postoperative complications (14 patients vs 20, p = 0.009) and a lower rate of unplanned critical care area admission (1 vs 6, p= 0.001). Introduction of intraoperative ODM-guided stroke volume optimization was associated with improved outcomes in patients undergoing enhanced recovery laparoscopic colorectal surgery.

Multimorbidity in women with and without osteoporosis: results from a large US retrospective cohort study 2004-2009.

UNLABELLED: To determine the incidence of comorbidities in women with and without osteoporosis, incidence rates per 1,000 person-years were calculated using electronic health records from an integrated healthcare system. The overall comorbidity burden and health service utilization were greater in women with osteoporosis than in the controls. INTRODUCTION: This retrospective cohort study describes the incidence of an array of comorbidities in women with and without osteoporosis (OP). METHODS: Using electronic health records from an integrated healthcare system, we identified 22,414 women aged 55-89 years with OP and 22,414 age-matched controls without OP. Incidence rates (IRs) per 1,000 person-years (P-Y) were calculated and 95% confidence intervals (CI) were estimated. RESULTS: Women with OP had significantly more comorbidities, medications, hospitalizations, and outpatient visits than the controls. Most cardiac comorbidity rates were 20-25% lower in the OP cohort than in the control cohort. Hypertension had the largest rate difference; the IR was 42.0 per 1,000 P-Y (95% CI 40.2-44.0) in the OP cohort compared to 94.0 (95% CI 90.7-97.4) in the control cohort. Rates for cerebrovascular disease were similar for both cohorts at 26 per 1,000 P-Y. Bronchitis, sinusitis, and cystitis were each 55 per 1,000 P-Y in the OP cohort, whereas they ranged from 28 to 34 per 1,000 P-Y in the controls. The OP cohort had decreased incidence of ovarian, uterine, colorectal, and liver cancers and increased incidence of lung cancer, breast cancer, and multiple myeloma, compared to the non-OP cohort. Falls, depression, vision, and musculoskeletal issues were higher for the OP cohort than the controls. CONCLUSIONS: This study demonstrates the high disease burden in women with OP. This knowledge may help guide the clinical management of this population and may aid in the interpretation of adverse events in randomized clinical trials of OP therapies.

Estimating prevalence of osteoporosis: examples from industrialized countries.

UNLABELLED: In nine industrialized countries in North America, Europe, Japan, and Australia, country-specific osteoporosis prevalence (estimated from published data) at the total hip or hip/spine ranged from 9 to 38 % for women and 1 to 8 % for men. In these countries, osteoporosis affects up to 49 million individuals. PURPOSE: Standardized country-specific prevalence estimates are scarce, limiting our ability to anticipate the potential global impact of osteoporosis. This study estimated the prevalence of osteoporosis in several industrialized countries (USA, Canada, five European countries, Australia, and Japan) using the World Health Organization (WHO) bone mineral density (BMD)-based definition of osteoporosis: BMD T-score assessed by dual-energy x-ray absorptiometry ≤-2.5. METHODS: Osteoporosis prevalence was estimated for males and females aged 50 years and above using total hip BMD and then either total hip or spine BMD. We compiled published location-specific data, using the National Health and Nutrition Examination Survey (NHANES) III age and BMD reference groups, and adjusted for differences in disease definitions across sources. Relevant NHANES III ratios (e.g., male to female osteoporosis at the total hip) were applied where data were missing for countries outside the USA. Data were extrapolated from geographically similar countries as needed. Population counts for 2010 were used to estimate the number of individuals with osteoporosis in each country. RESULTS: For females, osteoporosis prevalence ranged from 9 % (UK) to 15 % (France and Germany) based on total hip BMD and from 16 % (USA) to 38 % (Japan) when spine BMD data were included. For males, prevalence ranged from 1 % (UK) to 4 % (Japan) based on total hip BMD and from 3 % (Canada) to 8 % (France, Germany, Italy, and Spain) when spine BMD data were included. CONCLUSIONS: Up to 49 million individuals met the WHO osteoporosis criteria in a number of industrialized countries in North America, Europe, Japan, and Australia.

A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery.

Intra-operative oesophageal Doppler monitor-guided fluid management has been associated with improved postoperative length of hospital stay and morbidity in gastrointestinal and orthopaedic surgery. We designed a randomised controlled trial to test the hypothesis that this approach to intra-operative fluid management in major elective open gynaecological surgery would shorten the length of postoperative stay, defined as time to readiness for hospital discharge. Postoperative morbidity was evaluated as a secondary outcome. The oesophageal Doppler monitor group underwent intra-operative fluid management using an oesophageal Doppler-guided stroke volume optimisation algorithm. Control group (conventional fluid therapy) intra-operative fluid management was based on conventional haemodynamic indices. In a single centre, 102 patients were randomly assigned: 51 to the oesophageal Doppler monitor group (51 analysed) and 51 to the control group (50 analysed). Evaluators who were blinded to patient assignment collected postoperative outcome data. There was no difference in the length of postoperative hospital stay between the groups: median (IQR [range]) number of days until ready for discharge was 6 (5-8 [4-25]) days in the oesophageal Doppler monitor group compared with 7 (5-9 [4-42]) days in the control group, p = 0.5. There was no difference between the groups in postoperative morbidity survey scores on postoperative days 1, 3 or 5. Seven patients in the oesophageal Doppler monitor group and 11 in the control group experienced postoperative complications (p = 0.41). These findings question whether intra-operative oesophageal Doppler-guided fluid therapy is of benefit in patients undergoing open gynaecological surgery.

Primary non-adherence to bisphosphonates in an integrated healthcare setting.

UNLABELLED: We estimated primary non-adherence to oral bisphosphonate medication and examined the factors associated with primary non-adherence. Nearly 30% of women did not pick up their new bisphosphonate within 60 days. Identifying barriers and developing interventions that address patients' needs and concerns at the time a new medication is prescribed are warranted. INTRODUCTION: To estimate primary non-adherence to oral bisphosphonate medications using electronic medical record data in a large, integrated healthcare delivery system and to describe patient and prescribing provider factors associated with primary non-adherence. METHODS: Women aged 55 years and older enrolled in Kaiser Permanente Southern California (KPSC) with a new prescription for oral bisphosphonates between December 1, 2009 and March 31, 2011 were identified. Primary non-adherence was defined as failure to pick up the new prescription within 60 days of the order date. Multivariable logistic regression models were used to investigate patient factors (demographics, healthcare utilization, and health conditions) and prescribing provider characteristics (demographics, years in practice, and specialty) associated with primary non-adherence. RESULTS: We identified 8,454 eligible women with a new bisphosphonate order. Among these women, 2,497 (29.5%) did not pick up their bisphosphonate prescription within 60 days of the order date. In multivariable analyses, older age and emergency department utilization were associated with increased odds of primary non-adherence while prescription medication use and hospitalizations were associated with lower odds of primary non-adherence. Prescribing providers practicing 10 or more years had lower odds of primary non-adherent patients compared with providers practicing less than 10 years. Internal medicine and rheumatology providers had lower odds of primary non-adherent patients than primary care providers. CONCLUSION: This study found that nearly one in three women failed to pick up their new bisphosphonate prescription within 60 days. Identifying barriers and developing interventions aimed at reducing the number of primary non-adherent patients to bisphosphonate prescriptions are warranted.

An observational study of the prevalence and incidence of comorbid conditions in older women with breast cancer.

BACKGROUND: Longitudinal analyses of comorbid conditions in women with breast cancer are few. METHODS: Using Surveillance, Epidemiology, and End Results-Medicare data, we included 51,950 women aged≥66 years with in situ and stage I to IV breast cancer diagnosed in 1998-2002. We identified the prevalence and incidence of 34 comorbid conditions in these women, as well as in a matched cohort without cancer whose rates were standardized to the age and race/ethnicity distribution of the cancer patients. We also estimated rates of office encounters and diagnostic or testing procedures during the 12 months before diagnosis. RESULTS: The prevalence of most conditions at diagnosis was comparable among breast cancer and noncancer patients. New conditions after diagnosis were more common in breast cancer patients, and the incidence rates increased with higher stage at diagnosis. Before diagnosis, women presenting with stage IV disease had 41% [95% confidence interval (CI) 38% to 43%] fewer physician encounters and 34% (95% CI 24% to 31%) fewer unique diagnostic tests than women diagnosed with carcinoma in situ. CONCLUSIONS: Many comorbid conditions are identified as a consequence of the breast cancer diagnosis. There appears to be an important contribution from a lack of interaction with the health care system before diagnosis.