Initial weight loss goals: have they changed and do they matter?

OBJECTIVE: Nearly 20 years ago, participants in behavioural weight loss programmes reported goals that greatly exceeded the amount of weight typically produced by these programmes. Whether having unrealistic weight loss goals impacts weight loss or attrition is unclear. The intent of the current study was to revisit current weight loss goals and examine whether goals impact outcomes. METHODS: Adults (N = 308, BMI = 33.7 ± 4.2 kg/m2) participated in a 12-month behavioural weight management programme and completed questionnaires about their goals. RESULTS: Participants' weight loss goal was 19.8 ± 7.9% of their body weight, and 90.4% selected a goal ≥10%. Weight goals were not associated with weight loss at 3 (p = 0.75) or 12 months (p = 0.47), or from 3 to 12 months (p = 0.55). Weight loss goals were not related to attrition at 3 (p = 0.91) or 12 months (p = 0.86). Participants believed that weight reduction would positively impact their health and psychosocial functioning. CONCLUSION: Weight loss goals have decreased, but still greatly exceed what can be expected by most. Unrealistic goals, however, had no impact on weight loss or attrition. These results question the utility of counseling people with obesity to set more realistic weight loss goals, which is typically practiced in behavioural weight management.

Electronically captured, patient-reported physical function: an important vital sign in obesity medicine.

OBJECTIVES: Impaired physical function (i.e., inability to walk 200 feet, climb a flight of stairs or perform activities of daily living) predicts poor clinical outcomes and adversely impacts medical and surgical weight management. However, routine assessment physical function is seldom performed clinically. The PROMIS Physical Function Short Form 20a (SF-20a) is a validated questionnaire for assessing patient reported physical function, which includes published T-score percentiles adjusted for gender, age and education. However, the effect that increasing levels of obesity has on these percentiles is unclear. We hypothesized that physical function would decline with increasing level of obesity independent of gender, age, education and comorbidity. MATERIALS AND METHODS: This study included 1,627 consecutive weight management patients [(mean ± SEM), 44.7 ± 0.3 years and 45.1 ± 0.2 kg/m2] that completed the PROMIS SF-20a during their initial consultation. We evaluated the association between obesity level and PROMIS T-score percentiles using multiple linear regression adjusting for gender, age, education and Charlson Comorbidity Index (CCI). RESULTS: Multiple linear regression T-score percentiles were lower in obesity class 2 (-12.4%tile, p < 0.0001), class 3 (-17.0%tile, p < 0.0001) and super obesity (-25.1%tile, p < 0.0001) compared to class 1 obesity. CONCLUSION: In patients referred for weight management, patient reported physical function was progressively lower in a dose-dependent fashion with increasing levels of obesity, independent of gender, age, education and CCI.

18-month outcomes of a community-based treatment for childhood obesity.

BACKGROUND: Few studies have evaluated community-based interventions for childhood obesity and even fewer provide efficacy data 1 year later. OBJECTIVES: This study assessed changes in relative weight 1 year after a 6-month treatment for childhood obesity. METHODS: Participants were 155 overweight/obese children/adolescents and their caregivers. The primary outcome was change in child percent over body mass index (BMI) from 6 to 18 months. The primary outcome was also assessed from 0 to 18 months and changes in secondary outcomes (BMI z-score, guardian weight, health-related quality of life [HRQoL]) were examined from 6-18 to 0-18 months. RESULTS: From 6 to 18 months, there were no significant changes in any outcome. From 0 to 18 months, there were improvements in BMI z-score (P < 0.001), HRQoL (P < 0.001) and guardian weight (P = 0.02). CONCLUSIONS: Changes in relative weight and HRQoL observed after 6 months persisted 1 year later. The programme produced reductions in BMI z-score and obesity prevalence but not in percent over BMI from 0 to 18 months.

The morbidity of treatment for patients with Stage I endometrial cancer: results from a randomized trial.

PURPOSE: To compare the treatment complications for patients with Stage I endometrial cancer treated with surgery and pelvic radiotherapy (RT) or surgery alone in a multicenter randomized trial. METHODS AND MATERIALS: The Postoperative Radiation Therapy in Endometrial Carcinoma (PORTEC) trial included patients with endometrial cancer confined to the uterine corpus, either Grade 1 or 2 with more than 50% myometrial invasion, or Grade 2 or 3 with less than 50% myometrial invasion. Surgery consisted of an abdominal hysterectomy and oophorectomy, without lymphadenectomy. After surgery, patients were randomized to receive pelvic RT (46 Gy), or no further treatment. A total of 715 patients were randomized. Treatment complications were graded using the French-Italian glossary. RESULTS: The analysis was done at a median follow-up duration of 60 months. 691 patients were evaluable. Five-year actuarial rates of late complications (Grades 1-4) were 26% in the RT group and 4% in the control group (p < 0.0001). Most were Grade 1 complications, with 5-year rates of 17% in the RT group and 4% in the control group. All severe (Grade 3-4) complications were observed in the RT group (3%). Most complications were of the gastrointestinal tract. The symptoms resolved after some years in 50% of the patients. Grade 1-2 genitourinary complications occurred in 8% of the RT patients, and 4% of the controls. Bone complications occurred in 4 RT patients (1%). Seven patients (2%) discontinued their RT due to acute RT-related symptoms. Patients with acute morbidity had an increased risk of late RT complications (p = 0.001). The 4-field box technique was associated with a lower risk of late complications (p = 0.06). CONCLUSION: Pelvic RT increases the morbidity of treatment in Stage I endometrial cancer. In the PORTEC trial, severe complications occurred in 3% of treated patients, and over 20% experienced mild (mostly Grade 1) symptoms. Patients with acute RT-related morbidity had an increased risk of late complications. As pelvic RT in Stage I endometrial carcinoma was shown to significantly reduce the rate of locoregional recurrence, but without a survival benefit, its use in the adjuvant setting requires careful patient selection (treating those at increased risk of relapse), and the use of treatment schemes with the lowest risk of morbidity.

Metastasectomy, a feasible treatment in selected cases with gynecologic malignancy.

We present the course of six gynecological patients who underwent surgical intervention because of a solitary metastasis. After a considerable follow-up period five patients are alive without evidence of disease and with a good quality of life. Metastasectomy should play a role in the management of gynecologic malignancies.

Surgery and postoperative radiotherapy versus surgery alone for patients with stage-1 endometrial carcinoma: multicentre randomised trial. PORTEC Study Group. Post Operative Radiation Therapy in Endometrial Carcinoma.

BACKGROUND: Postoperative radiotherapy for International Federation of Gynaecology and Obstetrics (FIGO) stage-1 endometrial carcinoma is a subject of controversy due to the low relapse rate and the lack of data from randomised trials. We did a multicentre prospective randomised trial to find whether postoperative pelvic radiotherapy improves locoregional control and survival for patients with stage-1 endometrial carcinoma. METHODS: Patients with stage-1 endometrial carcinoma (grade 1 with deep [> or =50%] myometrial invasion, grade 2 with any invasion, or grade 3 with superficial [<50%] invasion) were enrolled. After total abdominal hysterectomy and bilateral salpingo-oophorectomy, without lymphadenectomy, 715 patients from 19 radiation oncology centres were randomised to pelvic radiotherapy (46 Gy) or no further treatment. The primary study endpoints were locoregional recurrence and death, with treatment-related morbidity and survival after relapse as secondary endpoints. FINDINGS: Analysis was done according to the intention-to-treat principle. Of the 715 patients, 714 could be evaluated. The median duration of follow-up was 52 months. 5-year actuarial locoregional recurrence rates were 4% in the radiotherapy group and 14% in the control group (p<0.001). Actuarial 5-year overall survival rates were similar in the two groups: 81% (radiotherapy) and 85% (controls), p=0.31. Endometrial-cancer-related death rates were 9% in the radiotherapy group and 6% in the control group (p=0.37). Treatment-related complications occurred in 25% of radiotherapy patients, and in 6% of the controls (p<0.0001). Two-thirds of the complications were grade 1. Grade 3-4 complications were seen in eight patients, of which seven were in the radiotherapy group (2%). 2-year survival after vaginal recurrence was 79%, in contrast to 21% after pelvic recurrence or distant metastases. Survival after relapse was significantly (p=0.02) better for patients in the control group. Multivariate analysis showed that for locoregional recurrence, radiotherapy and age below 60 years were significant favourable prognostic factors. INTERPRETATION: Postoperative radiotherapy in stage-1 endometrial carcinoma reduces locoregional recurrence but has no impact on overall survival. Radiotherapy increases treatment-related morbidity. Postoperative radiotherapy is not indicated in patients with stage-1 endometrial carcinoma below 60 years and patients with grade-2 tumours with superficial invasion.

The medical and legal risks of the electronic fetal monitor.

Electronic fetal heart monitoring (EFM) is the most widely used method of monitoring the fetal heartbeat for possible signs of distress during delivery. Soon after its development in the 1960s, EFM replaced intermittent auscultation as the standard of care in the obstetrical community. However, Margaret Lent argues that the widespread use of EFM is both medically and legally unsound. Lent points to a series of clinical trials that demonstrate that EFM does not reduce fetal mortality, morbidity, or cerebral palsy rates. These studies suggest that EFM has a very high false positive rate, and that EFM usage correlates strongly with a rise in cesarean section rates. Similarly, EFM provides no protection in the courtroom. Though obstetricians believe that they should use EFM because its status as the standard of care will protect them from liability, Lent argues that it may in fact expose them to liability given its failings. Instead, she argues that auscultation is equally, if not more, safe and effective, and is more likely to protect physicians from liability. Lent concludes that obstetricians have an obligation to their patients and to themselves to adopt auscultation as the new standard of care.

High tissue factor concentration in the omentum, a possible cause of its hemostatic properties.

The hemostatic properties of the pedicled omentoplasty turned out to be helpful in difficult hemorrhages in extensive surgery. As suggested by others, a high concentration of tissue factor (TF) in the omentum could be responsible for this favourable property. The authors investigated the nature of that property in 11 patients who underwent laparotomy. In omentum and striated muscle (controls) the TF-concentrations in both tissues were estimated by the ELISA method. A significant difference between TF-concentration in omentum and striated muscle could be demonstrated.

The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer.

BACKGROUND: Although the value of primary cytoreductive surgery for epithelial ovarian cancer is beyond doubt, the value of debulking surgery after induction chemotherapy has not yet been defined. In this randomized study we investigated the effect on survival of debulking surgery. METHODS: Eligible patients had residual lesions measuring more than 1 cm in diameter after primary surgery. After three cycles of cyclophosphamide and cisplatin, these patients were randomly assigned to undergo either debulking surgery or no surgery, followed by further cycles of cyclophosphamide and cisplatin. The study end points were progression-free and overall survival. At surgery 65 percent of the patients had lesions measuring more than 1 cm. In 45 percent of this group, the lesions were reduced surgically to less than 1 cm. RESULTS: Of the 319 patients who underwent randomization, 278 could be evaluated (140 patients who underwent surgery and 138 patients who did not). Progression-free and overall survival were both significantly longer in the group that underwent surgery (P = 0.01). The difference in median survival was six months. The survival rate at two years was 56 percent for the group that underwent surgery and 46 percent for the group that did not. In the multivariate analysis, debulking surgery was an independent prognostic factor (P = 0.012). Overall, after adjustment for all other prognostic factors, surgery reduced the risk of death by 33 percent (95 percent confidence interval, 10 to 50 percent; P = 0.008). Surgery was not associated with death or severe morbidity. CONCLUSIONS: Debulking surgery significantly lengthened progression-free and overall survival. The risk of death was reduced by one third, after adjustment for a variety of prognostic factors.

Results of decentralized in-vitro fertilization treatment with transport and satellite clinics.

The results of in-vitro fertilization (IVF) treatments carried out in a university IVF centre are compared with those obtained following 15-40 min transportation of oocytes from a transport IVF clinic to the central IVF laboratory of the university centre. Moreover, treatment results following monitoring of ovarian stimulation in satellite clinics, combined with ovum retrieval at the transport clinic and transport of oocytes to the central IVF laboratory, are described. In a total of 5540 IVF treatment cycles, 24-26% of viable pregnancies per embryo transfer were found in the three groups. Comparison of results, obtained with the three different treatment modalities, showed no negative influences of transporting oocytes from transport clinic to IVF laboratory and of monitoring ovarian stimulation in satellite clinics. It is concluded that decentralization of the clinical phase of IVF treatment is possible. This leads to a more optimal use of existing laboratory facilities in large urban areas. It is stressed that good communication between satellite clinic, transport clinic and IVF laboratory is necessary for a decentralized IVF programme. To obtain good quality assurance, both the satellite clinic and the transport clinic must adhere to the same protocol.

The omentoplasty: a neglected ally in gynecologic surgery.

Although the omentum is extensively used in general, reconstructive and thoracic surgery as a pedicled omentoplasty, little information exists about the utility of such a procedure in general and radical gynecologic surgery. In this paper we review the properties of the omentum which may be useful in gynecologic surgery. The omentum is highly vasculated and rich in thromboplastin, an excellent property for treating difficult to handle abdominal or pelvic abscesses and for inducing hemostasis. Furthermore, it appears that the omentum has a trophical effect on the surrounding tissue, making it very useful in reconstruction procedures. Moreover, elevating the small intestines out of the true pelvis paves the way for high dose (brachy)radiotherapy with less radiation enteritis. The technique of the pedicled omentoplasty is straightforward and takes 20-30 min extra operating time. We use pedicled omentoplasty for covering large operating fields instead of reperitonealization, to prevent radiation enteritis, as a matrix for grafting, to treat serious intraperitoneal infections and to facilitate hemostasis. Our experience of 48 omentoplasty procedures in gynecology is described.

The pedicled omentoplasty, a simple and effective surgical technique to acquire a safe pelvic radiation field; theoretical and practical aspects.

A substantial number of patients need radiotherapy after surgery for pelvic malignancy. Approximately 15% of them will experience radiation enteritis. After omentoplasty, reduction of irradiated bowel volume may be obtained. We evaluated the pedicled omentoplasty during gynaecologic surgery as a technique to improve safe irradiation of the pelvic region.

EMG profiles of ACL-deficient patients during walking: the influence of mild fatigue.

The purpose of this study was to determine muscle activities after ACL rupture during walking and running and to investigate the influence of mild fatigue (10 min walking) on these activities. A group of 12 patients with ACL-ruptures was compared with a control group (healthy volunteers) of 15 persons. Linear envelopes of EMG-activity from vastus medialis, vastus lateralis, biceps femoris and medial hamstrings were measured. Patients and control persons walked on a treadmill at speeds of 1.2 m/s (samples at t = 2 min and t = 12 min) and 2.8 m/s i.e. running (sample at t = 15 min). The patient group showed significantly lower muscle activities of vastus lateralis (p < 0.001) and medial hamstrings (p < 0.05) for both the injured and uninjured leg during running compared to the control group. After 10 minutes walking, the mean-EMG of biceps femoris (p < 0.05) and medial hamstrings (p < 0.01) decreased as did the activity time of biceps femoris (p < 0.05), medial hamstrings (p < 0.01) and vastus medialis (p < 0.001) for the injured leg of the patient group. Control persons showed no significant changes. Thus, mild fatigue did effect only the EMG-pattern of the patients. Patients with ACL-ruptures should be trained not only on strength and stabilisation, but also on endurance. A decrease in hamstrings activity during walking might be a sensitive measure for evaluation of the rehabilitation process, as those muscles may be able to substitute ACL-deficiency.

Results of curettage for postmenopausal vaginal bleeding in women treated with tamoxifen and megestrol acetate for progressive metastatic breast carcinoma.

Tamoxifen and megestrol acetate are used as a hormonal treatment for metastatic breast carcinoma. It is suggested that the use of tamoxifen may induce endometrial cancer. In this article we describe nine patients under hormonal treatment for metastatic breast cancer with, firstly, tamoxifen and, later, megestrol acetate. These nine patients all had symptoms of postmenopausal vaginal blood loss during therapy with megestrol acetate, an indication to perform a diagnostic dilatation and curettage. By histopathological examination the curettings showed a decidualized stroma with an infiltration of lymphocytes, some plasma cells and many eosinophils. In none of the patients was atypical hyperplasia or malignancy found. The dilatation and curettage had also a therapeutic effect, since only one of the patients still had complaints, while the other eight did not complain of postmenopausal bleeding again. We review the literature and discuss the value of a diagnostic dilatation and curettage.

Ovarian cysts, cytology and histology: a conflicting story.

Ovarian cysts from 27 selected patients were examined cytologically as well as histologically. The aspirates were obtained by means of ultrasound or laparoscopy. Cytological examination in 17 of the cases did not show malignancy, but histological examination demonstrated malignancy in 5 of these patients. The fluid of the other 10 cysts indicated malignancy, which was confirmed histologically in only 4 cases. From this study we conclude that cytological examination has little to offer in diagnosing the true nature of ovarian cysts.

Watch and wait after careful surgical treatment and staging in well-differentiated early ovarian cancer.

Patients with well-differentiated epithelial ovarian cancer Stages Ia, Ib, Ic, and IIa (FIGO 1976) were observed after surgical treatment without adjuvant therapy. Careful surgical staging was required, and the extent of the staging procedure was assessed in each individual patient. There were 107 patients entered in the study by nine Dutch oncology centers. Of these 107, 21 did not fulfill all of the inlet criteria of the study and were excluded. Central pathologic review was performed in the remaining 86 cases, revealing that there was borderline tumor in seven patients, moderately or poorly differentiated tumor in nine patients, and tumor of nonepithelial histologic cell type in one patient. In two cases, no material for histologic review was available. After exclusion of these 19 cases, 67 patients were further analyzed. None of these 67 patients was lost during the follow-up period that ranged from 19 to 99 months (mean, 50 months). Tumor recurrence was found in four patients after 11, 25, 34, and 34 months of follow-up, all of whom died shortly after diagnosis of the recurrence without satisfactory response to secondary treatment. For the patients who underwent the most extensive staging procedure, disease-free 5-year survival was 100%. For the patients who were inaccurately staged, disease-free 5-year survival was 88%. It was concluded that well-differentiated early stage (Ia-IIa) ovarian cancer carries an excellent prognosis after surgical treatment and complete surgical staging, with the possible exception of patients with Stage Ic disease with malignant peritoneal washings. Furthermore, it was considered that the application of more objective and consistent ways of assessing tumor grade should be encouraged. Surgical staging should be regarded as the golden standard in defining subsets of low-risk patients and should be included and clearly defined in future trials on early ovarian cancer.

Carboplatin and cyclophosphamide salvage therapy for ovarian cancer patients relapsing after cisplatin combination chemotherapy.

30 ovarian cancer patients with a relapse after prior cisplatin combination chemotherapy were treated in a phase II study with cyclophosphamide 100 mg/m2 orally on days 1-7 and carboplatin 300 mg/m2 intravenously on day 8. Treatment was well tolerated. The major side-effect was thrombocytopenia. 28 patients were evaluable for response. The response was 5 CRs (18%), 4 PRs (14%) 15 SDs (53%) and 4 PDs (14%), for an overall response rate of 32%. The overall progression-free survival lasted from 2 to 23 months, median 8 months. Overall survival ranged from 2 to 35+ months, median 12 months. Patients with a therapy-free interval of more than 1 year showed a higher response rate (46%) than patients with a shorter therapy-free interval (20%). It is concluded that platinum containing second-line chemotherapy, after treatment that already contained cisplatin, is only warranted to palliate symptoms.