Identification and Management of Children and Adolescents with Obesity Referred to a General Paediatric Outpatient Department.

Aims To identify all children and adolescents with overweight or obesity attending the outpatient department and audit our processes in their identification and management against NICE standards. Methods A retrospective chart review was performed. BMI charts were used to identify children and adolescents with overweight/obesity. The patient journey was audited to ascertain if overweight/obesity was identified by the clinician, whether this was communicated to the child or adolescent/their carer and whether intervention was offered. Results There were 669 scheduled appointments and 27.3%(n=127) of children 2 years and adolescents were identified with overweight/obesity. Children and adolescents referred for reasons not primarily related to obesity management were identified (90.6% (n=115)) and this group was analysed. Height and weight and/or BMI were communicated in 13.9% (n=16) of referral letters. A record of discussing growth was observed in 15.7% (n=18) of cases. Growth measurements were included in the post-clinic correspondence to the primary care physician in 56.8% (n=63) of letters. Discussion Further research is required to ascertain what barriers exist to the discussion of growth. Additional education of healthcare providers is necessary to develop standardised procedures around processes related to child and adolescent growth.

How to Investigate the Origins of Novelty: Insights Gained from Genetic, Behavioral, and Fitness Perspectives.

Biologists are drawn to the most extraordinary adaptations in the natural world, often referred to as evolutionary novelties, yet rarely do we understand the microevolutionary context underlying the origins of novel traits, behaviors, or ecological niches. Here we discuss insights gained into the origins of novelty from a research program spanning biological levels of organization from genotype to fitness in Caribbean pupfishes. We focus on a case study of the origins of novel trophic specialists on San Salvador Island, Bahamas and place this radiation in the context of other rapid radiations. We highlight questions that can be addressed about the origins of novelty at different biological levels, such as measuring the isolation of novel phenotypes on the fitness landscape, locating the spatial and temporal origins of adaptive variation contributing to novelty, detecting dysfunctional gene regulation due to adaptive divergence, and connecting behaviors with novel traits. Evolutionary novelties are rare, almost by definition, and we conclude that integrative case studies can provide insights into this rarity relative to the dynamics of adaptation to more common ecological niches and repeated parallel speciation, such as the relative isolation of novel phenotypes on fitness landscapes and the transient availability of ecological, genetic, and behavioral opportunities.

Como Investigar as Origens da Novidade: Ideias Obtidas a Partir de Perspectivas da Genética, do Comportamento e de Fitness (How to Investigate the Origins of Novelty: Insights Gained from Genetic, Behavioral, and Fitness Perspectives) Biólogos são atraídos pelas adaptações mais extraordinárias do mundo natural, muitas vezes chamdas de novidades evolutivas, mas raramente entendemos o contexto microevolutivo subjacente às origens de novas características, novos comportamentos ou nichos ecológicos. Aqui discutimos ideias obtidas sobre as origens da novidade evolutiva a partir de um programa de pesquisa abrangendo níveis biológicos de organização de genótipo para fitness em pupas do Caribe. Nós nos concentramos em um estudo de caso sobre as origens de novos especialistas tróficos na ilha de São Salvador, Bahamas, e colocamos essa radiação no contexto de outras radiações rápidas. Destacamos questões que podem ser abordadas sobre as origens da novidade evolutiva em diferentes níveis biológicos, como medir o isolamento de novos fenótipos no cenário adaptativo, localizando as origens espaciais e temporais da variação adaptativa que contribuem para a novidade evolutiva, detectando a regulação gênica disfuncional devido à divergência adaptativa, e conectando comportamentos com novas características. As novidades evolutivas são raras, quase por definição, e concluímos que estudos de caso integrativos podem fornecer ideias sobre essa raridade em relação à dinâmica de adaptação a nichos ecológicos mais comuns e especiação paralela repetitiva, como o relativo isolamento de novos fenótipos em cenários adaptativos e a disponibilidade transitória de oportunidades ecológicas, genéticas, e comportamentais. Translated to Portuguese by G. Sobral (gabisobral@gmail.com).

Psychological characteristics, eating behavior, and quality of life assessment of obese patients undergoing weight loss interventions.

BACKGROUND AND AIMS: Bariatric surgery is the most effective treatment for obesity. However, not all patients have similar weight loss following surgery and many researchers have attributed this to different pre-operative psychological, eating behavior, or quality-of-life factors. The aim of this study was to determine whether there are any differences in these factors between patients electing to have bariatric surgery compared to less invasive non-surgical weight loss treatments, between patients choosing a particular bariatric surgery procedure, and to identify whether these factors predict weight loss after bariatric surgery. MATERIAL AND METHODS: This was a prospective study of 90 patients undergoing gastric bypass, vertical sleeve gastrectomy, or adjustable gastric banding and 36 patients undergoing pharmacotherapy or lifestyle interventions. All patients completed seven multi-factorial psychological, eating behavior, and quality-of-life questionnaires prior to choosing their weight loss treatment. Questionnaire scores, baseline body mass index, and percent weight loss at 1 year after surgical interventions were recorded. RESULTS AND CONCLUSIONS: Surgical patients were younger, had a higher body mass index, and obesity had a higher impact on their quality of life than on non-surgical patients, but they did not differ in the majority of eating behavior and psychological parameters studied. Patients opting for adjustable gastric banding surgery were more anxious, depressed, and had more problems with energy levels than those choosing vertical sleeve gastrectomy, and more work problems compared to those undergoing gastric bypass. Weight loss after bariatric surgery was predicted by pre-operative scores of dietary restraint, disinhibition, and pre-surgery energy levels. The results of this study generate a number of hypotheses that can be explored in future studies and accelerate the development of personalized weight loss treatments.

An evaluation of the nurse practitioner role in a major rural emergency department.

The purpose of this pilot study was to investigate whether nurse practitioners are able to provide a level of primary health service applicable to remote/isolated settings in wound management and treatment of blunt limb trauma. It was hypothesized that there would be no significant difference in the quality of care, or the level of client satisfaction, provided by the medical officers and the nurse practitioners in the study. Two groups participated in the study, nurse practitioners and medical officers. The study used a randomized trial design. Data were collected using quantitative and qualitative methods. Two hundred and thirty-two clients participated in the study. Of this number 63 were supervised cases in the pilot trial. In the randomized trial participants were distributed between nurse practitioners and medical officers (n = 169), of which 91 were randomized to medical officers and 78 to nurse practitioners. Telephone interviews were conducted to evaluate client satisfaction. The majority of study participants were surveyed for client satisfaction (n = 132). This represents approximately 78% of the randomized sample and multivariate analysis was carried out on the data. Study results indicate that there were no significant differences between the two groups in relation to client satisfaction. Very positive outcomes of treatment were consistent across groups in the study. The study also found that there was strong support for the role of the nurse practitioner in the rural emergency setting. Recommendations include further research to measure the efficacy of nurse practitioners utilizing the selected competencies in remote/isolated settings.

Physicians in rural West Virginia emergency departments: residency training and board certification status.

OBJECTIVE: To describe the training and certification of physicians who staff small EDs in rural West Virginia. METHODS: A survey of rural hospital-based EDs was performed. The authors chose to study all hospitals in counties with populations of <30,000 and in which the hospital was the only one in the county. Interviews were conducted with the medical director of the ED or the hospital administrator, depending on who was available at the time of interview. Data collected describing the emergency physicians (EPs) employed at each facility included: medical school and residency training, specialty board certification, and certification in a variety of life support courses. General information about each ED, such as census and hospital resources, was also obtained. Interview data were collected on a survey form and subsequently entered into a database. Descriptive analyses were performed. RESULTS: 20 hospitals met rural criteria for inclusion in the study and all were included. The median number of full-time physicians per ED was 2 (IQR 2-4). 98 part-time doctors were identified; 28 (29%) of these were residents in training. 13/40 (33%) of full-time and 37/98 (38%) of part-time physicians were foreign medical graduates. Only 3/40 (7.5%) of full-time EPs completed residency training in emergency medicine (EM). Only 4/98 (4%) of part-time EPs were residency-trained in EM. 50% of full-time EPs were board-certified in a primary care specialty. Only 5/42 (12%) of full-time EPs were board-certified in EM. One third of full-time and the majority of part-time EPs were not board-certified in any specialty whatsoever. The majority of EPs had been certified in Advanced Cardiac Life Support, but fewer had been certified in Advanced Trauma Life Support and/or Pediatric Advanced Life Support/Advanced Pediatric Life Support. CONCLUSIONS: The majority of physicians staffing small rural EDs in West Virginia are neither residency-trained nor board-certified in EM. Further studies are warranted to determine the most efficient and effective way to maximize the skills and availability of emergency care providers in rural settings.

Blood lead of intravenous drug users.

OBJECTIVE: A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may result in methamphetamine grossly contaminated with lead. Three reports have documented outbreaks of acute lead poisoning in intravenous methamphetamine users. METHODS: This study measured blood lead concentrations in intravenous drug users of methamphetamine, cocaine or heroin presenting to the emergency department to determine the prevalence of subclinical lead poisoning in intravenous methamphetamine users. RESULTS: Mean blood leads for methamphetamine users (n = 92) were 6.22 micrograms/dL or 0.30 mumol/L (range 0.10-1.15, SD 0.20) and 7.25 micrograms/dL or 0.35 mumol/L (0.10-0.80, SD 0.15) for the nonmethamphetamine users (n = 53) with no significant difference between groups. CONCLUSIONS: The data suggest that previous outbreaks of acute intravenous lead poisoning among methamphetamine users were probably related to episodic contamination of methamphetamine. Subclinical lead poisoning was not found among the methamphetamine users presenting to the emergency department.

Airway compromise and delayed death following attempted central vein injection of propylhexedrine.

Propylhexedrine is a potent alpha-adrenergic drug available as a nasal decongestant, which drug abusers sometimes extract and inject into a central vein. A 25-year-old white male presented to a local emergency department 32 h after attempting to inject his right internal jugular vein with "home-made crank." Following injection, he noted right neck pain, followed by fever and chills. On emergency department admission, he had inspiratory stridor and respiratory distress. Massive edema of his right neck extended from his anterior chest to the right parotid. Neck radiographs showed extensive paracervical swelling with displacement of the trachea. The patient was taken to surgery for nasotracheal intubation with fiberoptic guidance and surgical exploration. The neck contained extensive necrotic tissue that was surgically debrided. In spite of treatment with antibiotics, he developed progressive renal failure and hypotension unresponsive to fluid therapy, followed by cardiopulmonary arrest and death.

The effect of phenylephrine on excretion of fluid and electrolytes by the parotid and mandibular glands of the rat.

The effect has been investigated of the alpha-adrenergic agonist, phenylephrine, on excretion of water and electrolytes (Na, K, and HCO3) by the parotid and mandibular glands of the rat. In the mandibular glands the agonist was as effective as acetylcholine (or parasympathetic nerve stimulation) in stimulating secretion, and the electrolyte excretory patterns seen in the two modes of stimulation were similar. In the parotid gland, phenylephrine was only one-fifth as potent as acetylcholine (or parasympathetic nerve stimulation) in evoking a secretory response but, when due allowance for flow rate differences is made, the electrolyte excretion patterns were similar. In both glands the secretory response to phenylephrine was totally different, in magnitude and in electrolyte excretion pattern, to that evoked by the beta-adrenergic agonist, isoprenaline. It is concluded, as has already been established for secretion of exportable protein, that alpha-adrenergic agonists have very similar effects to muscarinic agonists both on endpiece and on duct cells and that these actions are completely different from those evoked by activation of beta-adrenergic receptors.