Prospective evaluation of 24-hour urine profiles following bariatric surgery in a modern comprehensive care bariatric clinic.

AIMS: To prospectively examine the effect of modern bariatric surgery on 24-hour urine parameters in a comprehensive care bariatric practice (CCBP). MATERIALS AND METHODS: 47 consecutive patients in our CCBP underwent serum and 24-hour urine analysis pre-operatively, and 30 returned at 12 months for repeat testing. Paired comparisons for serum metabolite and 24-hour urine measures were performed using a Wilcoxon signed-rank test for continuous variables and McNemar's test for categorical variables. Statistical tests were two-sided, with threshold of significance set at p = 0.05. RESULTS: All 30 patients with pre-operative and 12-month follow-up analysis were free of stone events. 20 (67%) had Roux-en-Y gastric bypass (RYGB), 6 (20%) had laparoscopic gastric banding (LGB), and 4 (13%)h ad laparoscopic sleeve gastrectomy (LSG). 24-hour urinary parameters were available for 27 patients. Median urine oxalate (mmol) was 0.29 pre-operatively and 0.21 at 12 months (p = 0.048). Median urine calcium (mg) was 143 pre-operatively and 180 at 12 months (p = 0.11). Median citrate excretion was 527 pre-operatively and 782 at 12 months (p = 0.22). Median serum creatinine was 0.7 pre-operatively and 0.8 at 12 months (p < 0.001). These trends were preserved with the exclusion of LGB and LSG patients. CONCLUSIONS: Modern bariatric surgery (RYGB, LGB, and LSG) as part of a CCBP can still demonstrate alterations of select urinary parameters (particularly oxalate and citrate) in select patients associated with an increased risk of urolithiasis at 1 year follow-up.

A pilot investigation of a multidisciplinary quality of life intervention for men with biochemical recurrence of prostate cancer.

OBJECTIVE: This pilot project evaluated the acceptability and estimated the effect size of a tailored multidisciplinary quality of life (MQOL) intervention for men who have biochemical recurrence of prostate cancer. METHODS: Participants included 57 men with localized prostate cancer with biochemical recurrence (Median=76 years; 89% White). Participants were randomized to wait list control which offered the intervention upon conclusion of the study (n=27) or to an eight-session group-based, MQOL (n=30) intervention. Assessments were completed at baseline, end of treatment, and 6 months post-treatment. RESULTS: MQOL was acceptable as indicated by favorable participant retention (100% retained), treatment compliance (97% attended > 6 treatment sessions), and high ratings of helpfulness (80% rated helpfulness > 4 on 5-point scale). MQOL had a favorable impact on the mental health composite score of the Short Form-36 at the end of treatment but not at 6 months (effect size=0.52 and -0.04); health-related QOL as measured by the Functional Assessment of Cancer Therapy-Prostate at the end of treatment and 6 months (effect size=0.14 and 0.10); and prostate cancer specific anxiety as measured by the Memorial Anxiety Scale for Prostate Cancer at the end of treatment and 6 months (effect size=0.45 and 0.23). CONCLUSIONS: This pilot project provides preliminary data supporting the premise that a tailored behaviorally based MQOL intervention for men with biochemical recurrence of prostate cancer is acceptable to men and might reduce prostate cancer specific anxiety and enhance QOL. Further research examining the efficacy of this intervention in a larger randomized trial is warranted.

Collaborative care plans reduce subspecialty consults: the experience from a safety net hospital.

Several strategies have been proposed to improve referrals and communication between primary care providers (PCPs) and specialists. In this article, we describe the effectiveness of collaborative care plans (CCPs) in reducing utilization of specialist resources in a capitated health plan based in a safety net hospital. To operationalize individual care plans, a single clinic called the Total Care Clinic (TCC) was launched. Midlevel providers were assigned to subspecialties and trained in specific algorithms of care that they were responsible for. Midlevel providers in the TCC were invited to attend in-house education opportunities. These interventions resulted in an overall 33.6-percentage-point reduction in the referral rate over 7 years of observation. The largest decrease in referrals was observed in gastroenterology, which resulted mostly from colon cancer screening with fecal immunochemical tests in place of colonoscopies. No increase in emergency department (ED) visits or hospital admissions accompanied the decreased referrals to specialists. Combining CCPs with provider education and placing select specialists in proximity of the PCPs resulted in significant referral reductions to specialists without increases in ED visits or hospital admissions.

Hypometabolizers: characteristics of obese patients with abnormally low resting energy expenditure.

Weight gain or loss is determined by the difference between calorie intake and energy expenditure. The Mifflin metabolic equation most accurately predicts resting energy expenditure (REE) in morbidly obese patients. Hypometabolizers have a measured REE that is much less than predicted and pose the greatest challenge for weight loss induced by restriction of calorie intake. We studied 628 morbidly obese patients (467 female and 161 men, aged 52.5 ± 15.7 years, body mass index [BMI] of 42.6 ± 7.6 m/kg(2) [mean ± SD]). REE was measured using the MedGem® device (REEm) and the percentage variance (ΔREE%) from the Mifflin-predicted expenditure (REEp) was calculated. Patients with ΔREE% more than 1 standard deviation from the mean were defined as hypometabolizers (REEm greater than 27% below REEp) and hypermetabolizers (REEm less than 13% above REEp), respectively. Hypometabolizers had greater REEp (1900 ± 301 vs 1719 ± 346 calories, P = 0.005) and lower REEm (1244 ± 278 vs 2161 ± 438 calories, P < 0.0001) than hypermetabolizers. Hypometabolizers, when compared with hypermetabolizers, were taller (167.2 ± 8.4 vs 164.0 ± 10.9 cm, P = 0.04), heavier (123.6 ± 22.2 vs 110.2 ± 23.1 kg, P = 0.006), and had increased BMI (44.1 ± 6.5 vs 40.8 ± 6.5 kg/m(2), P = 0.04). Other measured anthropometrics were not different between hypo- and hypermetabolizers. Hypometabolizers were less likely to be diabetic (23 vs 43%, P = 0.03) and more likely to be black (25 vs 5%, P = 0.002) than hypermetabolizers. This study defines hypometabolizers as having variance in REEm more than 27 per cent below that predicted by the Mifflin equation. We could not identify any distinguishing phenotypic characteristics of hypometabolizers, suggesting an influence unrelated to body composition.

Quality of life of men with biochemical recurrence of prostate cancer.

This investigation evaluated the psychological needs of men (n = 28) with biochemical recurrence of prostate cancer. A mixed qualitative-quantitative approach was employed. The qualitative component consisted of focus groups and the quantitative component included administration of standardized measures assessing quality of life (QOL), anxiety, and mood. Participants reported substantial anxiety and other negative moods secondary to prostate cancer. Responses form the quantitative instruments suggest participants experience significant health problems specific to prostate cancer, while their general QOL is superior to other chronically ill medical populations. In contrast to the qualitative data, participants rated their mood as favorable on the quantitative measures. Data were used to guide development of a novel QOL intervention.

Medical and gastroenterologic management of the post-bariatric surgery patient.

Morbid obesity is a serious disease resulting in considerable morbidity. Bariatric surgery is an important treatment modality of morbid obesity. It appears to be safe and effective in reduction of excess weight in carefully selected patients. However, it carries a risk of many short- and long-term complications, some of them unique to bariatric surgery. Knowledge of possible postoperative complications and their management will allow the achievement of the best results. Despite many types of bariatric procedures developed, only a few are currently performed. Since the number of bariatric procedures performed annually increases, primary care physicians and gastroenterologists will be increasingly challenged by post-bariatric surgery patients. Hence, better understanding of the anatomy and adaptive changes in bariatric patients allows for a more efficient evaluation and management of post-bariatric surgery problems. This article reviews common complications in post-bariatric surgery patients and provides guidelines for their evaluation and management.

Validation of the fieldwork evaluation for the occupational therapist.

The psychometric properties of the Fieldwork Evaluation for the Occupational Therapist were examined, in particular the evidence supporting the independent use of the performance, attitude, and judgment scales to determine suitability for entry-level work. High levels of internal consistency were found on all of the scales and on the Evaluation as a whole, a reflection of the high correlations among items. A factor analysis was performed that suggested that the Evaluation primarily measures a single factor.