Risk prediction for advanced neoplasia using longitudinal adherence measures to fecal immunochemical test-based colorectal cancer screening programs.

BACKGROUND: Patterns of longitudinal adherence may predict advanced neoplasia (AN) detection in subsequent rounds of colorectal cancer (CRC) screening. However, after more than five rounds, it is important to obtain a simplified measure. The aim was to determine the best simplified measure of longitudinal adherence to predict AN detection in CRC screening. METHODS: Individuals with four invitations from a Dutch Fecal immunochemical testing (FIT-)based pilot study and two Italian FIT-based CRC screening programs were included. We calculated AN detection in the fourth round, stratified by prior adherence. Five simplified measures were compared to full information (permutations) using chi-squared goodness-of-fit: adherence previous invitation, consistency, frequency, frequency + adherence previous invitation, and proportion of invitations covered. RESULTS: AN detection in the fourth round was highly dependent on prior adherence behavior. For inconsistent adherence, detection in the fourth round was strongly dependent on frequency and time since last participation. The performance of the simplified measures to capture this variation differed considerably. 'Adherence previous invitation' scored worst in predicting AN detection. 'Frequency+adherence previous invitation' had lowest chi-squared goodness-of-fit. DISCUSSION: The simplified measure 'frequency+adherence previous invitation' is the best measure to reflect patterns of longitudinal adherence and could be used to emphasize to individuals the importance of CRC screening.

[Ureteric and testicular mestastasis 25 years after nephrectomy : Long-term survival with metastatic renal cell carcinoma]. / Harnleiter- und Hodenmetastase 25 Jahre nach Nephrektomie : Langjähriges Überleben mit einem metastasierten Nierenzellkarzinom.

A 70-year-old man with multiple metastasized renal cell carcinoma (RCC) presented himself in our clinic 25 years after initial diagnosis with newly developed hematuria and conspicuous right testis. The biopsy of the left ureter taken by ureterorenoscopy and the right orchiectomy show metastases of a clear cell RCC. This special case shows rare metastases in different organ systems. The individualized multimodal treatment led to a long-term survival with this metastasized disease. The presented case shows that late recurrences of RCC can occur years after initial diagnosis and should be considered at any time.

Carbon dioxide generation rates for building occupants.

Indoor carbon dioxide (CO2 ) concentrations have been used for decades to characterize building ventilation and indoor air quality. Many of these applications require rates of CO2 generation from the building occupants, which are currently based on approaches and data that are several decades old. However, CO2 generation rates can be derived from well-established concepts within the fields of human metabolism and exercise physiology, which relate these rates to body size and composition, diet, and level of physical activity. This paper reviews how CO2 generation rates have been estimated in the past and discusses how they can be characterized more accurately. Based on this information, a new approach to estimating CO2 generation rates is presented, which is based on the described concepts from the fields of human metabolism and exercise physiology. Using this approach and more recent data on body mass and physical activity, values of CO2 generation rates from building occupants are presented along with the variability that may occur based on body mass and activity data.

Increasing harvest maturity of whole-plant corn silage reduces methane emission of lactating dairy cows.

The objective of this study was to investigate the effects of increasing maturity of whole-plant corn at harvest on CH4 emissions by dairy cows consuming corn silage (CS) based diets. Whole-plant corn was harvested at a very early [25% dry matter (DM); CS25], early (28% DM; CS28), medium (32% DM; CS32), and late (40% DM; CS40) stage of maturity. In a randomized block design, 28 lactating Holstein-Friesian dairy cows, of which 8 were fitted with rumen cannula, received 1 of 4 dietary treatments designated as T25, T28, T32, and T40 to reflect the DM contents at harvest. Treatments consisted of (DM basis) 75% CS, 20% concentrate, and 5% wheat straw. Feed intake, digestibility, milk production and composition, energy and N balance, and CH4 production were measured during a 5-d period in climate respiration chambers after an adaptation to the diet for 12 d. Corn silage starch content varied between 275 (CS25) and 385 (CS40) g/kg of DM. Treatments did not affect DM intake (DMI), milk yield, or milk contents. In situ ruminal fractional degradation rate of starch decreased linearly from 0.098 to 0.059/h as maturity increased from CS25 to CS40. Apparent total-tract digestibility of DM, organic matter, crude protein, neutral detergent fiber, crude fat, starch, and gross energy (GE) decreased linearly with maturity. Treatments did not affect ruminal pH, volatile fatty acids, and ammonia concentrations, and volatile fatty acids molar proportions. The concentration of C18:3n-3 in milk fat decreased linearly, and the concentration of C18:2n-6 and the n-6:n-3 ratio increased linearly with maturity. A quadratic response occurred for the total saturated fatty acid concentration and total monounsaturated fatty acid concentration in milk fat. Methane production relative to DMI (21.7, 23.0, 21.0, and 20.1g/kg) and relative to GE intake (0.063, 0.067, 0.063, and 0.060 MJ/MJ; values for T25, T28, T32, and T40, respectively) decreased linearly with maturity. Also, CH4 emission relative to fat- and protein-corrected milk tended to decrease linearly with maturity (13.0, 13.4, 13.2, and 12.1g/kg of fat- and protein-corrected milk, for T25, T28, T32, and T40, respectively). Intake of GE and metabolizable energy, and energy retained, all expressed per unit of metabolic body weight, did not differ among treatments. Nitrogen intake, N use efficiency (milk N/N intake), and N balance were not influenced by treatments. Increasing maturity of whole-plant corn at harvest may offer an effective strategy to decrease CH4 losses with feeding CS without negatively affecting cow performance.

Comparison of fractionation methods for nitrogen and starch in maize and grass silages.

In in situ nylon bag technique, many feed evaluation systems use a washing machine method (WMM) to determine the washout (W) fraction and to wash the rumen incubated nylon bags. As this method has some disadvantages, an alternate modified method (MM) was recently introduced. The aim of this study was to determine and compare the W and non-washout (D+U) fractions of nitrogen (N) and/or starch of maize and grass silages, using the WMM and the MM. Ninety-nine maize silage and 99 grass silage samples were selected with a broad range in chemical composition. The results showed a large range in the W, soluble (S) and D+U fractions of N of maize and grass silages and the W, insoluble washout (W-S) and D+U fractions of starch of maize silages, determined by both methods, due to variation in their chemical composition. The values for N fractions of maize and grass silages obtained with both methods were found different (p < 0.001). Large differences (p < 0.001) were found in the D+U fraction of starch of maize silages which might be due to different methodological approaches, such as different rinsing procedures (washing vs. shaking), duration of rinsing (40 min vs. 60 min) and different solvents (water vs. buffer solution). The large differences (p < 0.001) in the W-S and D+U fractions of starch determined with both methods can led to different predicted values for the effective rumen starch degradability. In conclusion, the MM with one recommended shaking procedure, performed under identical and controlled experimental conditions, can give more reliable results compared to the WMM, using different washing programs and procedures.

Estimation of the in situ degradation of the washout fraction of starch by using a modified in situ protocol and in vitro measurements.

The in situ degradation of the washout fraction of starch in six feed ingredients (i.e. barley, faba beans, maize, oats, peas and wheat) was studied by using a modified in situ protocol and in vitro measurements. In comparison with the washing machine method, the modified protocol comprises a milder rinsing method to reduce particulate loss during rinsing. The modified method markedly reduced the average washout fraction of starch in these products from 0.333 to 0.042 g/g. Applying the modified rinsing method, the fractional degradation rate (k d ) of starch in barley, oats and wheat decreased from on average 0.327 to 0.144 h-1 whereas for faba beans, peas and maize no differences in k d were observed compared with the traditional washing machine rinsing. For barley, maize and wheat, the difference in non-fermented starch in the residue between both rinsing methods during the first 4 h of incubation increased, which indicates secondary particle loss. The average effective degradation of starch decreased from 0.761 to 0.572 g/g when using the new rinsing method and to 0.494 g/g when applying a correction for particulate matter loss during incubation. The in vitro k d of starch in the non-washout fraction did not differ from that in the total product. The calculated ratio between the k d of starch in the washout and non-washout fraction was on average 1.59 and varied between 0.96 for oats and 2.39 for maize. The fractional rate of gas production was significantly different between the total product and the non-washout fraction. For all products, except oats, this rate of gas production was larger for the total product compared with the non-washout fraction whereas for oats the opposite was observed. The rate of increase in gas production was, especially for grains, strongly correlated with the in vitro k d of starch. The results of the present study do not support the assumption used in several feed evaluation systems that the degradation of the washout fraction of starch in the rumen is much faster than that of the non-washout fraction.

A new approach to estimate the in situ fractional degradation rate of organic matter and nitrogen in wheat yeast concentrates.

In the classic in situ method, small particles are removed during rinsing and hence their fractional degradation rate cannot be determined. A new approach was developed to estimate the fractional degradation rate of nutrients in small particles. This approach was based on an alternative rinsing method to reduce the particulate matter loss during rinsing and on quantifying the particulate matter loss that occurs during incubation in the rumen itself. To quantify particulate matter loss during incubation, loss of small particles during the in situ incubation was studied using undegradable silica with different particle sizes. Particulate matter loss during incubation was limited to particles smaller than ~40 µm with a mean fractional particulate matter loss rate of 0.035 h-1 (first experiment) and 0.073 h-1 (second experiment) and an undegradable fraction of 0.001 and 0.050, respectively. In the second experiment, the fractional particulate matter loss rate after rinsing in a water bath at 50 strokes per minute (s.p.m.) (0.215 h-1) and the undegradable fraction at 20 s.p.m. (0.461) were significantly larger than that upon incubation in the rumen, whereas the fractional particulate matter loss rate (0.140 and 0.087 h-1, respectively) and the undegradable fraction (0.330 and 0.075, respectively) after rinsing at 30 and 40 s.p.m. did not differ with that upon rumen incubation. This new approach was applied to estimate the in situ fractional degradation rate of insoluble organic matter (OM) and insoluble nitrogen (N) in three different wheat yeast concentrates (WYC). These WYC were characterised by a high fraction of small particles and estimating their fractional degradation rate was not possible using the traditional washing machine rinsing method. The new rinsing method increased the mean non-washout fraction of OM and N in these products from 0.113 and 0.084 (washing machine method) to 0.670 and 0.782, respectively. The mean effective degradation (ED) without correction for particulate matter loss of OM and of N was 0.714 and 0.601, respectively, and significant differences were observed between the WYC products. Applying the correction for particulate matter loss reduced the mean ED of OM to 0.676 (30 s.p.m.) and 0.477 (40 s.p.m.), and reduced the mean ED of N to 0.475 (30 s.p.m.) and 0.328 (40 s.p.m.). These marked reductions in fractional degradation rate upon correction for small particulate matter loss emphasised the pronounced effect of correction for undegraded particulate matter loss on the fractional disappearance rates of OM and N in WYC products.

Maternal haemoglobin levels and cardio-metabolic risk factors in childhood: the Generation R study.

OBJECTIVE: To assess whether variations in maternal haemoglobin levels during pregnancy are associated with cardio-metabolic risk factors in school age children. DESIGN: Population-based prospective cohort study. SETTING: Rotterdam, The Netherlands, 2002-2012. POPULATION: Mothers and children (n = 5002) participating in the Generation R Study. METHODS: We obtained maternal haemoglobin levels during early pregnancy (median gestational age 14.6 weeks [95% range 10.3, 25.3]) from venous blood samples. Maternal anaemia and elevated haemoglobin levels were based on World Health Organization criteria. We measured childhood cardio-metabolic risk factors at age 6 years. MAIN OUTCOME MEASURES: Cardio-metabolic risk factors included body mass index, total fat mass percentage, android/gynoid fat mass ratio, systolic and diastolic blood pressure, left ventricular mass, and blood levels of cholesterol, insulin and C-peptide. RESULTS: Maternal haemoglobin levels were not associated with childhood body mass index, total fat mass percentage, android/gynoid fat mass ratio, systolic blood pressure, cholesterol or insulin levels. Compared with children with normal maternal haemoglobin levels, children from anaemic mothers had slightly higher diastolic blood pressures (difference 0.70 mmHg, 95% CI 0.12, 1.29) and lower C-peptide levels (difference factor 0.93, 95% CI 0.88, 0.98), and children of mothers with elevated haemoglobin levels had lower left ventricular masses (difference -1.08 g, 95% CI -1.88, -0.29). These associations attenuated after adjustment for multiple testing and were not consistent within linear models. CONCLUSION: These results do not strongly support the hypothesis that variations in maternal haemoglobin levels during pregnancy influence cardio-metabolic risk factors in childhood.

Making sense of how physician preceptors interact with medical students: discourses of dialogue, good medical practice, and relationship trajectories.

Work based learning and teaching in health care settings are complex and dynamic. Sociocultural theory addresses this complexity by focusing on interaction between learners, teachers, and their environment as learners develop their professional identity. Although social interaction between doctors and students plays a crucial role in this developmental process, socio-cultural research from the perspective of doctors is scarce. We performed discourse analysis on seven general practitioners' audio diaries during a 10-week general practice clerkship to study how they gave shape to their interaction with their students. Examination of 61 diary-entries revealed trajectories of developing relationships. These trajectories were initiated by the way respondents established a point of departure, based on their first impression of the students. It continued through the development of dialogue with their student and through conceptualizations of good medical practice. Such conceptualizations about what was normal in medical and educational practice enabled respondents to recognize qualities in the student and to indirectly determine students' desired learning trajectory. Towards the end, discursive turns in respondents' narratives signaled development within the relationship. This became evident in division of roles and positions in the context of daily practice. Although respondents held power in the relationships, we found that their actions depended strongly on what the students afforded them socially. Our findings address a gap in literature and could further inform theory and practice, for example by finding out how to foster constructive dialogue between doctors and students, or by exploring different discourses among learners and teachers in other contexts.

Field-scale Variation in Colloid Dispersibility and Transport: Multiple Linear Regressions to Soil Physico-Chemical and Structural Properties.

Water-dispersible soil colloids (WDC) act as carriers for sorbing chemicals in macroporous soils and hence constitute a significant risk for the aquatic environment. The prediction of WDC readily available for facilitated chemical transport is an unsolved challenge. This study identifies key parameters and predictive indicators for assessing field-scale variation of WDC. Samples representing three measurement scales (1- to 2-mm aggregates, intact 100-cm rings, and intact 6283 cm columns) were retrieved from the topsoil of a 1.69-ha agricultural field in a 15-m by 15-m grid to determine colloid dispersibility, mobilization, and transport. The amount of WDC was determined using (i) a laser diffraction method on 1- to 2-mm aggregates and (ii) an end-over-end shaking method on 100-cm intact rings. The accumulated amount of colloids leached from 20-cm by 20-cm intact columns was determined as a measure of the integrated colloid mobilization and transport. The WDC and the accumulated colloid transport were higher in samples from the northern part of the field. Using multiple linear regression (MLR) analyses, WDC or amount of colloids transported were predicted at the three measurement scales from 24 measured, geo-referenced parameters to identify parameters that could serve as indicator parameters for screening for colloid dispersibility, mobilization, and transport. The MLR analyses were performed at each sample scale using all, only northern, and only southern field locations. Generally, the predictive power of the regression models was best on the smallest 1- to 2-mm aggregate scale. Overall, our results suggest that different drivers controlled colloid dispersibility and transport at the three measurement scales and in the two subareas of the field.

Emotional reactivity at 12 months in very preterm infants born at <29 weeks of gestation.

The present study evaluated the socio-emotional development of very preterm born infants at 12 months corrected age. Forty-one infants born very preterm (<29 weeks of gestation) were compared to 22 infants born full term on a standardized behavioral assessment and a parental temperament questionnaire, both measuring emotional reactivity to joy, anger and fear, as well as sustained attention. The behavioral assessment showed that very preterm infants exhibited as much joy as full term infants during a joy-eliciting episode. However, they expressed a significantly higher reactivity in anger-eliciting situations and a reduced reactivity toward fear-eliciting situations. For all three emotion-eliciting situations, the preterm infants reacted with a higher level of motor activity. The preterm infants also exhibited a distinct attention pattern with a significantly higher initial attention level which declined rapidly throughout the episode. The questionnaire did not show any group differences. The clinical relevance of these results in terms of preliminary hallmarks of later behavioral difficulties such attention deficit/hyperactivity disorder are discussed as well as the inconsistencies observed between the questionnaire and the behavioral assessment.

A modified rinsing method for the determination of the S, W-S and D + U fraction of protein and starch in feedstuff within the in situ technique.

A modified rinsing method for the in situ technique was developed to separate, isolate and characterise the soluble (S), the insoluble washout (W-S) and the non-washout fractions (D + U) within one procedure. For non-incubated bags (t = 0 h), this method was compared with the conventional, Combined Fractionation (CF) method that measures the D + U and S fractions in separate steps and subsequently calculates the W-S fraction. The modified method was based on rinsing of nylon bags in a closed vessel containing a buffer solution (pH 6.2) during 1 h, where shaking speeds of 40, 100, and 160 strokes per minutes (spm) were evaluated, and tested for six feed ingredients (faba beans, maize, oats, peas, soya beans and wheat) and four forages (two ryegrass silages and two maize silages). The average recoveries as the sum of all fractions were 0.972 ± 0.041 for N and 0.990 ± 0.050 for starch (mean ± s.d.). The mean W-S fraction increased with increasing shaking speed and varied between 0.017 (N) and 0.083 (starch) at 40 spm and 0.078 (N) and 0.303 (starch) at 160 spm, respectively. For ryegrass silages, the W-S fraction was absent at all shaking speeds, but was present in the CF method. The modified method, in particular at 40 and 100 spm, reduced the loss of small particles during rinsing, resulting in lower W-S and higher D + U fractions for N and starch compared with the CF method. For soya beans and ryegrass silage, the modified method reduced the S fraction of N compared with the CF method. The results obtained at 160 spm showed the best comparison with those from the CF method. The W-S fraction of the feedstuff obtained at 160 spm contained mainly particles smaller than 40 µm (0.908 ± 0.086). In most feedstuff, starch was the most abundant chemical component in the W-S fraction and its content (726 ± 75 g/kg DM) was higher than in the D + U fraction (405 ± 177 g/kg DM). Alkaline-soluble proteins were the dominant N-containing components in the W-S fraction of dry feed ingredients and its relative content (0.79 ± 0.18 of total N in W-S) was higher than in the D + U fraction (0.59 ± 0.07 of total N in D + U) for all feedstuff except maize. The molecular weight distribution of the alkaline-soluble proteins differed between the W-S and the D + U fractions of all dry feed ingredients, except soya beans and wheat.

Inverse relationship of food and alcohol intake to sleep measures in obesity.

BACKGROUND: Short sleep and weight gain are inversely related. Sleep deprivation acutely increases food intake but little is known about eating behavior in chronically sleep-deprived, obese individuals. OBJECTIVE: To characterize the relationship between sleep, food intake and alcohol consumption under free-living conditions in obese, chronically sleep-deprived individuals. DESIGN: Cross-sectional study of a cohort of obese men and premenopausal women. SUBJECTS: A total of 118 obese subjects (age: 40.3±6.7 years; 91 females/27 males; body mass index 38.7±6.4 kg m(-2)). MEASUREMENTS: Energy, macronutrient, alcohol and caffeine intake assessed by 3-day food records. Sleep duration estimated by actigraphy. Respiratory disturbance index assessed by a portable device. RESULTS: SUBJECTS slept 360.7±50.2 min per night and had a total energy intake of 2279.1±689 kcal per day. Sleep duration and energy intake were inversely related (r=-0.230, P=0.015). By extrapolation, each 30-min deficit per day in sleep duration would translate to an ∼83 kcal per day increase in energy intake. In addition, sleep apnea was associated with a shift from carbohydrate to fat intake. Alcohol intake in subjects consuming >3.5 g of alcohol per day (N=41) was inversely related to sleep duration (r=-0.472, P=0.002). CONCLUSIONS: Shorter sleep duration and obstructive sleep apnea are associated with higher energy, fat and alcohol intakes in obese individuals. The importance of this study relies on the population studied, obese subjects with chronic sleep deprivation. These novel findings apply to the large segment of the US population who are obese and sleep-deprived.

[Psychotropic drugs dispensed on the island of Bonaire]. / Psychofarmacaverstrekkingen op Bonaire.

BACKGROUND: Up till now little is known about psychiatric disorders in relation to the use of psychotropics drugs on the Dutch Antilles, with the exception of Curaçao. AIM: To map the quantity and type of psychotropics prescribed for Bonairians in 2009. METHOD: We performed a retrospective data analysis of the antipsychotics dispensed by the pharmacies on Bonaire in 2009. Our analysis focused on the benzodiazepines and related compounds, antipsychotics, lithium, antidepressants and ADHD- and narcolepsy-medication. With regard to antipsychotics and antidepressants, we also investigated 'the age distribution of the persons to whom the psychotropics were dispensed'. In addition, we mapped the frequency with which the drugs were dispensed: once only, infrequently, regularly. RESULTS: At least one psychotropic drug was delivered to 18.37% of (N=2365) Bonairians in 2009. Benzodiazepines and related compounds in particular were the most commonly dispensed drugs. CONCLUSION: One in five Bonairians received at least one prescription for psychotropic drugs in 2009.

Chronic sleep deprivation and seasonality: implications for the obesity epidemic.

Sleep duration has progressively fallen over the last 100 years while obesity has increased in the past 30 years. Several studies have reported an association between chronic sleep deprivation and long-term weight gain. Increased energy intake due to sleep loss has been listed as the main mechanism. The consequences of chronic sleep deprivation on energy expenditure have not been fully explored. Sleep, body weight, mood and behavior are subjected to circannual changes. However, in our modern environment seasonal changes in light and ambient temperature are attenuated. Seasonality, defined as cyclic changes in mood and behavior, is a stable personality trait with a strong genetic component. We hypothesize that the attenuation in seasonal changes in the environment may produce negative consequences, especially in individuals more predisposed to seasonality, such as women. Seasonal affective disorder, a condition more common in women and characterized by depressed mood, hypersomnia, weight gain, and carbohydrate craving during the winter, represents an extreme example of seasonality. One of the postulated functions of sleep is energy preservation. Hibernation, a phenomenon characterized by decreased energy expenditure and changes in the state of arousal, may offer useful insight into the mechanisms behind energy preservation during sleep. The goals of this article are to: a) consider the contribution of changes in energy expenditure to the weight gain due to sleep loss; b) review the phenomena of seasonality, hibernation, and their neuroendocrine mechanisms as they relate to sleep, energy expenditure, and body weight regulation.

Prevalence of dietitian burnout.

BACKGROUND: Burnout is the result of unmanaged stress that has been shown to affect those working in the healthcare professions. Although much research has been conducted on burnout among nurses, physicians and other health professionals, there is limited documentation on the phenomenon among dietitians. The purpose of this study was to establish the prevalence of burnout among dietitians in Ontario, Canada, determine the demographic variables associated with burnout, and compare these results with burnout data for other healthcare professionals. METHODS: The Maslach Burnout Inventory-Human Services Survey and a demographic questionnaire were emailed to registered dietitians. RESULTS: The dietitians surveyed experienced a moderate amount of emotional exhaustion (mean = 19.96), a low level of depersonalisation (mean = 4.31) and a moderate sense of personal accomplishment (mean = 38.61). Statistically significant relationships were found between years as a dietitian and personal accomplishment (r = 0.16; P = 0.05), age and personal accomplishment (r = 0.15; P = 0.01), hours worked per week and emotional exhaustion (r = 0.17; P = 0.01) and hours worked per week and depersonalisation (r = 0.14; P = 0.01). There were no significant differences in mean burnout scores across the five areas of practice. Over 57% of dietitians had scores indicative of moderate to high levels of burnout overall. CONCLUSIONS: Although dietitians have lower levels of burnout compared to other healthcare professionals, moderate levels of emotional exhaustion and only moderate levels of personal accomplishment remain workplace issues for this professional group.

Effect of a 3-day high-fat feeding period on carbohydrate balance and ad libitum energy intake in humans.

OBJECTIVE: A reduction in glycogen after the switch to an isoenergetic high-fat diet (HFD) might promote a compensatory increase in food intake to reestablish carbohydrate balance. We assessed the effect of an isoenergetic switch from a 49%-carbohydrate to 50%-fat diet on nutrient balance and ad libitum food intake. We hypothesized that carbohydrate balance would be inversely related to ad libitum energy intake. METHODS: In 47 men and 11 women (22.6+/-0.4 years; 26.1+/-0.5 kg m(-2)), fuel balance was measured in a respiration chamber over 4 days. During the first day, an isoenergetic, high-carbohydrate diet was provided followed by a 3-day isoenergetic, HFD. At the end of this period and after 16 h of fasting, three options of foods (cookies, fruit salad and turkey sandwich) were offered ad libitum for 4 h. The relationships between post-chamber ad libitum intake and macronutrient oxidation and balance measured day-to-day and over the 4-day respiration chamber stay were studied. RESULTS: After switching to a HFD, 24-h respiratory quotient decreased from 0.87+/-0.02 to 0.83+/-0.02 (P<0.0001) resulting in a 4-day cumulative carbohydrate, fat and protein balances of -183+/-368, 342+/-480 and 65+/-267 kcal, respectively. Cumulative energy balance (224+/-362 kcal per 4 days) did not influence ad libitum energy intake. However, we detected that 4-day carbohydrate balance was a positive and independent predictor of post-chamber ad libitum energy intake (R (2)=0.10; P=0.01), whereas no significant influence of fat and protein balances was found. CONCLUSION: In response to an isoenergetic change from a high-carbohydrate to HFD, higher carbohydrate balance related to increased energy intake.

Subtyping obesity with microarrays: implications for the diagnosis and treatment of obesity.

OBJECTIVE: Obese patients respond differently to weight loss interventions. No efficient diagnostic tool exists to separate obese patients into subtypes as a means to improve prediction of response to interventions. We aimed to separate obese subjects into distinct subgroups using microarray technology to identify gene expression-based subgroups to predict weight loss. DESIGN: A total of 72 obese men and women without family history of diabetes were enrolled in the study; 52 were treated with ephedra and caffeine (E+C) and 20 with placebo for 8 weeks. Adipose and skeletal muscle tissue biopsies were performed at baseline. RNA sample pairs were labeled and hybridized to oligonucleotide microarrays. Quantile normalization and gene shaving were performed, and a clustering algorithm was then applied to cluster subjects based on their gene expression profile. Clusters were visualized using heat maps and related to weight changes. RESULTS: Cluster analysis of gene expression data revealed two distinct subgroups of obesity and predicted weight loss in response to the treatment with E+C. One cluster ('red') decreased to 96.87+/-2.35% body weight, and the second cluster ('green') decreased to 95.59+/-2.75% body weight (P<0.05). 'Red' cluster had less visceral adipose tissue mass (2.77+/-1.08 vs 3.43+/-1.49 kg; P<0.05) and decreased size of the very large fat cells (1.45+/-0.61 vs 2.16+/-1.74 microl; P<0.05) compared to 'green' cluster. Gene expression for both skeletal muscle and adipose tissue was also different between clusters. CONCLUSIONS: Our study provides the first evidence that the combined approach of gene expression profiling and cluster analysis can identify discrete subtypes of obesity, these subtypes have different physiological characteristics and respond differently to an adrenergic weight loss therapy. This brings us that into an era of personalized treatment in the obesity clinic.

Access surgery for hemodialysis in the Cayman Islands: Preliminary results of a vascular access service.

OBJECTIVE: In the Cayman Islands, a vascular access service was created in 2005 to facilitate the creation of vascular access for hemodialysis by local surgeons. The present retrospective audit aims to establish the outcomes of this practice in the Cayman Islands. METHODS: Data from the operative log of the Cayman Islands Hospital was collected over a period of 36 months. The data were analyzed using SPSS version 12.0 (SPSS Inc, USA). Statistical analyses were performed using Student's t tests and Fisher's exact tests. RESULTS: A total of 19 operative procedures were performed to create vascular accesses in 12 men and seven women. Thirteen procedures (68%) created autogenous arteriovenous fistulas (AVFs) and six (32%) involved the insertion of a prosthetic arteriovenous graft (AVG). There were six incident dialysis patients, all of whom had an AVF created. The remaining 13 prevalent dialysis patients had new accesses in the form of AVFs (n=7) or AVGs (n=6). The statistical analyses were limited by sample size, but with AVFs, there were trends toward reduced incidence of secondary failure (four of 13 versus four of six), thrombosis (four of 13 versus two of six), infectious morbidity (zero versus two of six) and less demand for interventions to maintain patency (one of 13 versus two of six) with AVFs. There were also trends toward superior primary (461 days versus 227 days) and secondary (803 days versus 205 days) patency rates for AVFs. CONCLUSIONS: In this setting, the rate of AVF creation exceeds the goals set by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative and the Fistula First Breakthrough Initiative. To ensure continued delivery of modern quality care, further audits of the local practice will be required at regular intervals.