The effects of hypothetical behavioral interventions on the 13-year incidence of overweight/obesity in children and adolescents

BACKGROUND

In view of the high burden of childhood overweight/obesity (OW/OB), it is important to identify targets for interventions that may have the greatest effects on preventing OW/OB in early life. Using methods of causal inference, we studied the effects of sustained behavioral interventions on the long-term risk of developing OW/OB based on a large European cohort.

METHODS

Our sample comprised 10 877 children aged 2 to < 10 years at baseline who participated in the well-phenotyped IDEFICS/I.Family cohort. Children were followed from 2007/08 to 2020/21. Applying the parametric g-formula, the 13-year risk of developing OW/OB was estimated under various sustained hypothetical interventions on physical activity, screen time, dietary intake and sleep duration. Interventions imposing adherence to recommendations (e.g. maximum 2 h/day screen time) as well as interventions 'shifting' the behavior by a specified amount (e.g. decreasing screen time by 30 min/day) were compared to 'no intervention' (i.e. maintaining the usual or so-called natural behavior). Separately, the effectiveness of these interventions in vulnerable groups was assessed.

RESULTS

The 13-year risk of developing OW/OB was 30.7% under no intervention and 25.4% when multiple interventions were imposed jointly. Meeting screen time and moderate-to-vigorous physical activity (MVPA) recommendations were found to be most effective, reducing the incidence of OW/OB by -2.2 [-4.4;-0.7] and -2.1 [-3.7;-0.8] percentage points (risk difference [95% confidence interval]), respectively. Meeting sleep recommendations (-0.6 [-1.1;-0.3]) had a similar effect as increasing sleep duration by 30 min/day (-0.6 [-0.9;-0.3]). The most effective intervention in children of parents with low/medium educational level was being member in a sports club; for children of mothers with OW/OB, meeting screen time recommendations and membership in a sports club had the largest effects.

CONCLUSIONS

While the effects of single behavioral interventions sustained over 13 years were rather small, a joint intervention on multiple behaviors resulted in a relative reduction of the 13-year OW/OB risk by between 10 to 26%. Individually, meeting MVPA and screen time recommendations were most effective. Nevertheless, even under the joint intervention the absolute OW/OB risk remained at a high level of 25.4% suggesting that further strategies to better prevent OW/OB are required.

Facilitating pharmacy staff's conversations about non-medical medication switches: Development and testing of a communication training

BACKGROUND

Non-medical medication switches, a change to another medicine or medication label not motivated by medical reasons, occur frequently. Switches often lead to negative patient emotions, such as confusion and anger. Pharmacy staff's communication, i.e. delivering the message and addressing patients' emotions is crucial, but experienced as difficult.

OBJECTIVE

To develop and test a communication training for the pharmacy team to facilitate medication switch conversations.

METHODS

A communication training was developed based on the 'breaking bad news model' and 'positive message framing' strategies, and incorporating needs and preferences from practice. The training consisted of an e-learning with theory and reflective exercises, a half-day live training session, and an online reflection session. The Kirkpatrick training evaluation model (levels one 'reaction' and two 'learning') was used to evaluate the training. Quantitative data were analyzed using descriptive statistics and interview data was transcribed verbatim and analyzed thematically.

RESULTS

Twelve pharmacists and 27 pharmacy technicians from 15 Dutch pharmacies participated in the training. According to Kirkpatrick's model level one, the major learning outcome was to give space to patients to express their emotions and/or concerns (e.g. more silences in the conversations). For level two, most participants valued practicing the conversations, role-playing, and receiving feedback. The majority of the participants indicated that they had sufficient tools and practice during the live training to apply the strategies in daily practice. A few participants still needed time and practice, or missed examples to apply the strategies.

CONCLUSION

The communication training based on the two strategies was well-received and participants felt well-equipped post-training. The take-away for participants was to give space to patients to express their emotions. Using these strategies and skills, pharmacy teams can tailor their medication counseling to patients' emotions and concerns during non-medical medication switches to better support patients in proper medication use.

Population prevalence of atrial fibrillation and QRS prolongation and mortality in people with suspected heart failure

Background

The 12-lead electrocardiogram (ECG) is an essential tool for the diagnosis and management of heart failure (HF). There are few population-based studies on the prevalence and prognostic implications of ECG abnormalities in patients with HF. There are also no robust diagnostic criteria for HF. We explored these issues in a large administrative database.

Methods

The National Health Service Greater Glasgow and Clyde Health Board serves a population of ∼1.1 million. We obtained de-identified administrative data, including investigations, diagnosis and prescriptions, linked to hospital admissions and deaths, for anyone with a diagnosis of vascular disease or HF or prescribed loop diuretics (LD) or neuro-endocrine antagonists between 1st January 2012 and 1st April 2018. People were classified into 5 exclusive groups: a) prevalent HF; b) incident (or latent) HF with onset during follow-up; c) people taking LDs but with no diagnosis of HF at any time; d) new prescription of LDs during follow-up but with no diagnosis of HF at any time and d) people to whom none of the above applied. ECGs were classified according to heart rhythm (sinus, AF or flutter or pacemaker/CRT/ICD) and QRS duration &lt;100ms, 100–130ms or &gt;130ms. Follow-up for each group started on 1st of January 2012 (prior to the onset of the classifying event for incident groups).

Results

During the observation period, of 316,350 people included, 158,421 had a recorded ECG (mean of 3.2 per person with an ECG), including 8,768 prevalent and 13,195 incident cases of HF. Of those who never got a diagnosis of heart failure, 11,508 were receiving and a further 14,633 were newly prescribed LD during follow-up. There were 110,317 people who did not fall into the above groups, of whom 51,089 were aged ≥60 years. A higher proportion of those who were prescribed loop diuretics without a diagnosis of heart failure were women. A similar proportion of those with heart failure and those prescribed diuretics alone had, lung disease and renal dysfunction but patients with heart failure had more ischaemic heart disease, more often had a heart rhythm other than sinus and had longer QRS duration. By three years, 8,816 people (11%) had died, of whom 2,919 (33%) had a diagnosis of heart failure and 2,694 (31%) had been prescribed LD without a diagnosis of HF, together accounting for 64% of all deaths. Patients with a rhythm other than sinus had a worse prognosis in all 5 groups of patients. QRS duration &gt;130ms was associated with a worse prognosis in patients with HF or taking LD.

Conclusions

Most people with cardiovascular disease who die will first develop HF or be prescribed a LD (indicating possible undiagnosed HF). Patient characteristics of those prescribed LD suggest that many might have HF with preserved left ventricular ejection fraction (HFpEF).

Baseline characteristics and HR

Funding Acknowledgement

Type of funding source: None

Dietary calcium intake and adiposity in children and adolescents: Cross-sectional and longitudinal results from IDEFICS/I.Family cohort

BACKGROUND AND AIMS

Studies in children and adolescents suggest that higher dairy consumption may exert a protective effect on adiposity. However, only few studies examined the association between dietary calcium intake and body mass measures with conflicting results. We evaluated the association between total dietary calcium, calcium from dairy and non-dairy sources and anthropometric indices in a large European cohort of children and adolescents.

METHODS AND RESULTS

As many as 6,696 children belonging to the IDEFICS study were eligible for the cross-sectional analysis (Boys = 51%; age 6.0 ± 1.8 years; mean ± SD). Of these, 2,744 were re-examined six years later (Boys = 49.6%; age = 11.7 ± 1.8 years) in the framework of the I.Family study. The exposures were the baseline energy-adjusted total, dairy and non-dairy calcium intakes measured by a validated 24-h dietary recall. Multivariable linear regression was used to determine the association between calcium intake and z-scores of anthropometric indices (body mass index, BMI; waist circumference, WC; sum of skinfolds, SS; fat mass index, FMI) at baseline, and their variation over the 6 years follow-up. The association of dietary calcium with the incidence of overweight/obesity was also assessed. At baseline, an inverse association between total calcium intake and all the adiposity indices was consistently observed in boys, while only SS and FMI were significant in girls. The prevalence of overweight/obesity decreased significantly (P < 0.0001) across tertiles of calcium intake, in both sexes. Over the follow-up, boys with higher baseline calcium intake value showed significantly lower increase in BMI, WC and FMI z-scores, while in girls only a lower increase in WC z-score was observed. Only in boys, the risk to become overweight/obese decreased significantly across tertiles of calcium intake. Similar results were observed by analyzing only dietary calcium from dairy, while no association was observed between non-dairy calcium and adiposity indices.

CONCLUSIONS

We showed in a large cohort of European children and adolescents that dietary calcium intake may play a role in the modulation of body fat in developmental age. The association between dietary calcium and adiposity indices was driven by dairy calcium, while no effect was observed for non-dairy calcium intake. The existence of a sex-related difference in the association deserves further investigations.

Exploring the concept of patient centred communication for the pharmacy practice

Background Patient centred communication can improve pharmaceutical care, but is not well described for pharmacists. Aim of the review To provide a comprehensive and accessible overview of the concept of patient centred communication for the pharmacy practice. Method A scoping review and thematic analysis was undertaken to synthesize the extracted data and present it in a model. Results Literature search and selection resulted in eighteen articles. Thematic analysis of the extracted data led to five categories regarding patient centred communication. Two categories refer to phases of a pharmaceutical consultation: (1) shared problem defining and (2) shared decision making; three refer to underlying concepts and assumptions about patient centredness regarding (3) the patient, (4) the pharmacist and (5) the therapeutic relation. The categories were modelled in the so called Utrecht’s Model for Patient centred communication in the Pharmacy. Conclusion Although there might be barriers to implement patient centred communication in the pharmacy, the concept of patient centred communication as described in the literature is relevant for the pharmacy practice.

Blood fatty acid composition in relation to allergy in children aged 2-9 years: results from the European IDEFICS study

BACKGROUND/OBJECTIVES

Blood polyunsaturated fatty acids (PUFA) are involved in allergy development, but the etiological role of n-6 and n-3 PUFA is still controversial. A European multicenter study of children (IDEFICS) provided the opportunity to explore the cross-sectional association between fatty acids (FA) and allergy.

SUBJECTS/METHODS

Blood FA levels were measured in 2600 children aged 2-9 years and were recorded as the percentage of weight of all FA detected. Logistic regression of allergy status on FA components was adjusted for age, sex, country, body mass index, family history of allergic disease, breast-feeding, and number of siblings. The results were given as odds ratios (OR) for current vs no allergy ever and an increase in FA by 1 s.d.

RESULTS

Overall, higher proportions of n-6 PUFA were associated with higher odds of allergy (OR=1.21 (1.05, 1.40)). Monounsaturated FA (MUFA) were associated with reduced risk for allergy (OR=0.75 (0.65, 0.87)), whereas saturated FA did not differ by allergy status. The strongest associations were observed in children <4 years old, with ORs of allergy given as 1.62 (1.15, 2.29) for n-3 PUFA and 0.63 (0.42, 0.95) for MUFA. With regard to individual FA, these associations were independently observed for docosapentaenoic acid (22:5 n-3) and oleic acid (18:1 n-9).

CONCLUSIONS

Both PUFA subtypes were positively associated with allergy in an age-dependent manner, whereas MUFA was associated with less allergy. The observation of high proportions of n-3 PUFA in allergic children younger than 4 years might help to understand the nature of early onset of atopic disease.

[Implications of TCGA Network Data on 2nd Generation Immunotherapy Concepts Based on PD-L1 and PD-1 Target Structures]

The era of cytokines, given to patients with metastatic renal cell carcinoma (mRCC) as part of an unspecific immunomodulatory treatment concept, seems to have ended with the introduction of targeted therapies. However, preliminary data from studies on treatment with checkpoint inhibitors (e. g. anti-PD-1 and anti-PD-L1) may point the way to second-generation immunotherapy. The rationale of such immunomodulatory treatment is to stop or interrupt the tumour from "escaping" the body's immune defence. Thompson et al. report that increased protein expression of PD-L1 (CD274/ B7-H1) in tumour cells and tumour-infiltrating immune cells (TILs; lymphocytes and histiocytes) is associated with unfavourable clinical pathological parameters as well as poor survival. In small pilot groups of mRCC patients it was found that increased PD-L1 protein expression in tumours and TILs may be correlated with the objective response to anti-PD-1 treatment. Sometimes, however, a very wide variety of response rates was observed, which raises the question if this can be explained by individual expression levels of PD-L1 (CD 274) or PD-1 (PDCD1).Recently published data from the Cancer Genome Atlas (TCGA) Kidney Renal Clear Cell Carcinoma (KIRC) Network now provide a genome-wide data base that allows us to review or validate the molecular results obtained in clear cell renal cell carcinomas (ccRCC) to date.In this study, we analysed the TCGA KIRC mRNA expression data for PD-L1 and PD-1 for a possible association with clinical pathological parameters and the survival of 417 ccRCC patients.The mRNA expression of PD-L1 in primary nephrectomy specimens revealed no significant association with unfavourable clinical parameters. Interestingly, though, a positive correlation with patient survival was found (HR=0,59, p=0,006).These results, which partly contradict the concept applied to date, point out the necessity to ascertain the characteristics of PD-L1 and PD-1 expression at mRNA and protein level in an appropriately sized patient population and evaluate the clinical significance.

[Partial Nephrectomy in cT1 Renal Tumours: Conventional Laparoscopic Partial Nephrectomy Compared with LESS Partial Nephrectomy in SITUS Technique]

BACKGROUND

Partial nephrectomy is the treatment of choice for clinical stage 1 renal tumours. Open partial nephrectomy is the standard operative technique. The use of minimally-invasive strategies such as laparoscopic, robot-assisted partial nephrectomy or laparoendoscopic single site (LESS) partial nephrectomy has increased in recent years.

PATIENTS/MATERIAL AND METHODS

In this retrospective study, patients undergoing laparoscopic partial nephrectomy between December 2008 and November 2013 were evaluated. All patients presented with renal lesions suspicious for malignancy. Operations were performed as conventional laparoscopic transperitoneal partial nephrectomies (cLPN) or LESS partial nephrectomies (LESS-PN) in SITUS technique (single incision transumbilical surgery). The aim of the study was to compare perioperative outcome parameters such as duration of surgery, time of ischaemia, complications, need for transfusion, conversion rates, changes in renal function and duration of hospital stay in both groups.

RESULTS

A total of 85 laparoscopic partial nephrectomies were performed in this study (72 cLPN and 13 LESS-PN). The average tumour size was 2.68±1.47 cm (cLPN) vs. 2.46±1.11 cm (LESS-PN). The mean duration of surgery was 175.17±50.026 min (cLPN) and 185.77±35.991 min (LESS-PN). 45 (62.5%) operations (cLPN) vs. 10 (76.9%) (LESS-PN) were performed in zero-ischaemia technique. There were no significant differences in perioperative outcome parameters between both groups. Postoperative complication rates (Clavien-Dindo≥3) were 11.1% (cLPN) vs. 7.7% (LESS-PN).

CONCLUSIONS

LESS partial nephrectomy in SITUS technique is an attractive alternative to conventional laparoscopic and open partial nephrectomy.

Reference values of whole-blood fatty acids by age and sex from European children aged 3-8 years

OBJECTIVES

To establish reference values for fatty acids (FA) especially for n-3 and n-6 long-chain polyunsaturated FAs (LC PUFA) in whole-blood samples from apparently healthy 3-8-year-old European children. The whole-blood FA composition was analysed and the age- and sex-specific distribution of FA was determined.

DESIGN AND SUBJECTS

Blood samples for FA analysis were taken from 2661 children of the IDEFICS (identification and prevention of dietary- and lifestyle-induced health effects in children and infants) study cohort. Children with obesity (n=454) and other diseases that are known to alter the FA composition (n=450) were excluded leaving 1653 participants in the reference population.

MEASUREMENTS

The FA composition of whole blood was analysed from blood drops by a rapid, validated gas chromatographic method.

RESULTS

Pearson correlation coefficients showed an age-dependent increase of C18:2n-6 and a decrease of C18:1n-9 in a subsample of normal weight boys and girls. Other significant correlations with age were weak and only seen either in boys or in girls, whereas most of the FA did not show any age dependence. For age-dependent n-3 and n-6 PUFA as well as for other FA that are correlated with age (16:0, C18:0 and C18:1n-9) percentiles analysed with the general additive model for location scale and shape are presented. A higher median in boys than in girls was observed for C20:3n-6, C20:4n-6 and C22:4n-6.

CONCLUSIONS

Given the reported associations between FA status and health-related outcome, the provision of FA reference ranges may be useful for the interpretation of the FA status of children in epidemiological and clinical studies.

[Transurethral en bloc resection of non-muscle invasive bladder cancer. What is the state of the art?]

Bladder cancer of the urothelium is the second most common malignancy among urological tumors. In view of a worldwide aging population and the fact that increased incidence rates are associated with higher age, new socioeconomic challenges will appear. Even nowadays the treatment of bladder cancer bears the highest lifetime treatment costs per patient among all forms of cancer. In conjunction with higher comorbidity rates among older patients urologists are facing new challenges in the treatment and care of patients with bladder cancer. The standard treatment for non-muscle invasive bladder cancer (NMIBC) is monopolar transurethral resection using resection loops (TURB). Based on experience in the surgical treatment of benign prostatic hyperplasia, different concepts of en bloc resection of bladder tumors using alternative energy resources (e.g. holmium laser, thulium laser and the water-jet HybridKnife) have been developed. Goals of new treatment modalities are reduction of perioperative and postoperative comorbidities, better pathological work-up of the specimens and increased recurrence-free survival. Postulated advantages using laser devices are a more precise cutting line as well as better hemostasis. The evidential value of this review is limited due to the lack of randomized, prospective studies. However, there is a tendency towards a limitation of perioperative and postoperative morbidities as well as higher chance of well-preserved tissues for better pathohistological evaluation using en bloc resection methods. More studies with long-term follow-up periods and better randomization are needed to clarify whether en bloc strategies provide better long-term oncological survival.

Pharmaceutical education in patient counseling: 20h spread over 6 years?

OBJECTIVE

To share our experiences with an educational program to increase pharmacy students' patient counseling competency.

METHODS

A description is given of the various steps taken to develop an educational program about patient counseling:

RESULTS

The Health Belief Model has been chosen as the theoretical model to make students understand patients' drug use behavior. A stepwise development of students' communication skills is combined with assessments in which relatively high norms are applied. Actors act as patients in standardized role plays. In total the basic education consists of 20h of training.

CONCLUSION

With a rather small educational investment, 50% of our students achieve the required level of patient counseling. The remaining students succeed to pass the assessments, after having received additional education.

PRACTICE IMPLICATIONS

Pharmacy students differ in their needs for educational support in developing their patient counseling competency. These differences are to be taken into account in educational programs addressed to student's patient counseling competency.

Communication with patients who are dispensed a first prescription of chronic medication in the community pharmacy

OBJECTIVE

To analyze information and communication in the community pharmacy when patients collect a first dispensing for chronic medication.

METHODS

In 3 pharmacies in the South-West of the Netherlands, counter-based communication with patients receiving a first dispensing for chronic medication was observed and audiotaped. Each contact was analyzed by two observers using an observation checklist. An 11-item questionnaire was given to the patients.

RESULTS

72 Patients were included. Only pharmacy technicians provided information. Average contact lasted approximately 2min. A computer checklist to support information giving was closely followed. Interactions were structured with introduction and closure. Mostly, information was given without exploring needs of the patient. Questioning showed open-ended questions (26%); check-questions and questions asking feedback (57%). A mean general score given was 5.8 (range 1-9). Of 46 responders who filled in a questionnaire, the majority felt that information was useful, clear and understandable.

CONCLUSION

Our results show a concise and efficient way of information giving, closely related to a computer checklist. Technicians dominate the interaction. They ask few questions. Patients are satisfied about provided information and the contact.

PRACTICE IMPLICATIONS

We suggest a more patient-centered way of communication to increase patients' participation and to meet patients' needs for information.

[Infection with Helicobacter pylori--outcome of a cross-sectional investigation]

BACKGROUND AND OBJECTIVE

Different information exists about the prevalence of Helicobacter pylori (Hp) in Germany, ranging from 35 to 40%. Several investigations have identified factors influencing the colonization of Hp in the stomach, but their significance is still being discussed. This study aimed at determining the prevalence of Hp in the metropolitan area of Hannover and defining the impact of education and lifestyle on Hp colonization.

SUBJECTS AND METHODS

The study was designed as a cross-sectional survey. Advertisements were placed in newspapers and on the radio. Of 829 who responded and were informed of the study 35 were excluded according to predefined criteria, the remainder sent questionnaires and containers for stool samples. 579 persons returned questionnaires and stool samples, but 16 were excluded because of borderline test results. The detection of Hp was done with a test for Hp-antigens in stool (Femto Lab H. pylori-Cnx-Test, R-Biopharm).

RESULTS

Among the final 563 tested persons (322 women, 241 men; mean age 46.6 12.2 years) 21% were Hp-positive and 79% negative. Participants with Hp were older than those without. Neither gender nor the consumption of caffeine, alcohol, nicotine and particular eating behaviour were related to Hp-status. However, persons who had incomplete or lower-level schooling were infected more often than those who had graduated from with high school.

CONCLUSION

These results indicate that Hp-prevalence among German adults may be lower than previously published. Known associations between Hp infection and age and education were confirmed.

Effects of combined supplementation with B vitamins and antioxidants on plasma levels of asymmetric dimethylarginine (ADMA) in subjects with elevated risk for cardiovascular disease

Elevated plasma asymmetric dimethylarginine (ADMA) concentrations have been suggested as a potential risk factor for cardiovascular disease (CVD). Studies indicate a linkage between hyperhomocysteinemia, oxidative stress and ADMA metabolism. We tested the hypothesis that combined supplementation of B vitamins and antioxidants reduces ADMA concentrations in subjects with at least two CVD risk factors. A total of 123 men and women (58+/-8.1 years) were randomly assigned to take either a preparation including B vitamins and antioxidants (verum) or placebo for 6 months in a double-blind design. Blood concentrations of ADMA, symmetric dimethylarginine (SDMA), L-arginine, B vitamins, total homocysteine (tHcy), alpha-tocopherol, antioxidant capacity (TEAC), and oxLDL were measured pre- and post-intervention. Treatment with verum significantly decreased tHcy (-2.14 micromol/L; P<0.001) and significantly increased TEAC values (+39.3 microM; P<0.022), but no effect on ADMA was observed. OxLDL was significantly reduced in verum (-7.3 U/L; P=0.001) and placebo (-9.2U/L; P<0.001). At baseline, significant correlations were found only between ADMA and SDMA (r=0.281; P=0.002), L-arginine/ADMA and SDMA (r=-0.294; P<0.001), L-arginine/ADMA and oxLDL (r=-0.281; P=0.016), and L-arginine/ADMA and age (r=-0.231; P=0.010). Our results indicate that combined supplementation of B vitamins and antioxidants is not an adequate strategy to reduce ADMA plasma levels in subjects with elevated CVD risk.

[The significance of diet and associated factors in psoriasis]

Psoriasis is a T cell mediated inflammatory skin disease characterized by hyperproliferation and reduced differentiation of epidermal keratinocytes. In severe cases, the disease can result in an insufficient nutritional status which may even be promoted by nutrient-drug interactions. Both the general diet and single food components have been suggested to play a role in etiology and pathogenesis of psoriasis. Fasting periods, vegetarian diets, and diets rich in omega-3 polyunsaturated fatty acids from fish oil have all been associated with improvement in some studies. The most likely explanation is the reduced amounts of arachidonic acid and the increased eicosapentaenoic acid intake resulting in a modulated eicosanoid profile. However, only one of four controlled studies showed a benefit of omega-3 fatty acids compared to placebo. Some psoriasis patients are gluten-sensitive and may benefit from a gluten free diet. The active form of vitamin D exhibits anti-proliferative and immunoregulatory effects and has been shown to be useful in the treatment of psoriasis.

Komplikationen nach Faltenunterspritzung und ihre Behandlung

All dermal fillers are associated with the risk of both early and late complications. Early side effects such as swelling, redness, and bruising occur after intradermal or subdermal injections. The patient has to be aware of these risks and be prepared to accept them. Adverse events that last longer than 2 weeks can be attributable to technical shortcomings (e.g., the implantation of a long-lasting filler substance was too superficial). Such adverse events can be treated with intradermal 5-fluorouracil and steroid injections, vascular lasers, or intense pulsed light, and later with dermabrasion or shaving. Late adverse events also include immunological phenomena such as late-onset allergy and non-allergic foreign body granulomas. Both react well to intralesional steroid injections, which often have to be repeated to establish the right dose. Surgical excisions should remain the last option and are indicated for hard lumps in the lips and visible hard nodules or hard granulomas in the subcutaneous fat.

Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids in diabetes mellitus type 2

BACKGROUND

According to previous studies, cinnamon may have a positive effect on the glycaemic control and the lipid profile in patients with diabetes mellitus type 2. The aim of this trial was to determine whether an aqueous cinnamon purified extract improves glycated haemoglobin A1c (HbA1c), fasting plasma glucose, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL) and triacylglycerol concentrations in patients with type 2 diabetes.

METHODS

A total of 79 patients with diagnosed diabetes mellitus type 2 not on insulin therapy but treated with oral antidiabetics or diet were randomly assigned to take either a cinnamon extract or a placebo capsule three times a day for 4 months in a double-blind study. The amount of aqueous cinnamon extract corresponded to 3 g of cinnamon powder per day.

RESULTS

The mean absolute and percentage differences between the pre- and post-intervention fasting plasma glucose level of the cinnamon and placebo groups were significantly different. There was a significantly higher reduction in the cinnamon group (10.3%) than in the placebo group (3.4%). No significant intragroup or intergroup differences were observed regarding HbA1c, lipid profiles or differences between the pre- and postintervention levels of these variables. The decrease in plasma glucose correlated significantly with the baseline concentrations, indicating that subjects with a higher initial plasma glucose level may benefit more from cinnamon intake. No adverse effects were observed.

CONCLUSIONS

The cinnamon extract seems to have a moderate effect in reducing fasting plasma glucose concentrations in diabetic patients with poor glycaemic control.

Selenium and antioxidant vitamin status of elderly German women

OBJECTIVE

Low antioxidant intake and status have been shown to be associated with an elevated risk for various diseases. Data on the status of antioxidant vitamins, selenium and coenzyme Q10 of younger female seniors are scarce. The aim of this study was to assess the status of these antioxidants, as well as influencing factors such as dietary intake, anthropometric data and educational level in female seniors (60-70 years) in Germany.

DESIGN

Dietary intake of alpha-tocopherol, beta-carotene and ascorbic acid was determined by a 3-day diet record. Serum concentrations of alpha-tocopherol, beta-carotene, ascorbic acid, selenium and coenzyme Q10 were measured. Anthropometric measures, socioeconomic and educational status were assessed.

SETTING

In total, 178 elderly women without severe diseases in the region of Hannover, Germany, were included in the study. The mean (+/- s.d.) age and BMI of the women was 63.2 (2.73) years and 25.6 (3.77) kg/m2, respectively. The study participants were generally better educated than the overall German female population.

RESULTS

Dietary intake of the ascorbic acid and alpha-tocopherol was below RDA in six and 75% of the women, respectively. In comparison to estimated desirable serum concentrations of alpha-tocopherol, ascorbic acid, beta-carotene and selenium, lower concentrations were found in 23, 1, 6, and 39% of the women, respectively. Ascorbic acid (r = 0.205, P = 0.009) and beta-carotene (r = 0.173, P = 0.025) intake were significantly associated with serum concentrations. Beta-carotene concentrations were influenced by the type of diet, BMI, and school education (R2 = 0.128, P < 0.001). Serum selenium was positively associated with alcohol intake (r = 0.229, P = 0.003). Neither employment nor vocational training was predictive for the serum concentrations of antioxidant vitamins, selenium or coenzyme Q10.

CONCLUSIONS

Poor status of selenium and alpha-tocopherol is highly prevalent even among younger, well-educated female seniors, whereas ascorbic acid and beta-carotene status seems sufficient in most women.

Diet and psoriasis: experimental data and clinical evidence

Psoriasis is considered as a T-cell-mediated inflammatory skin disease which is characterized by hyperproliferation and poor differentiation of epidermal keratinocytes. While susceptibility to psoriasis is inherited, the disease is influenced by environmental factors such as infections and stress. Diet has been suggested to play a role in the aetiology and pathogenesis of psoriasis. Fasting periods, low-energy diets and vegetarian diets improved psoriasis symptoms in some studies, and diets rich in n-3 polyunsaturated fatty acids from fish oil also showed beneficial effects. All these diets modify the polyunsaturated fatty acid metabolism and influence the eicosanoid profile, so that inflammatory processes are suppressed. Some patients with psoriasis show an elevated sensitivity to gluten. In patients with IgA and/or IgG antigliadin antibodies the symptoms have been shown to improve on a gluten-free diet. The active form of vitamin D, 1,25-dihydroxyvitamin D(3), exhibits antiproliferative and immunoregulatory effects via the vitamin D receptor, and thus is successfully used in the topical treatment of psoriasis. In this review, dietary factors which play a role in psoriasis are assessed and their potential benefit is evaluated. Furthermore, the risk of drug-nutrient interactions in psoriasis therapy is discussed.

Monitoring the development of intertidal habitats on former agricultural land after the managed realignment of coastal defences at Tollesbury, Essex, UK

The managed realignment of coastal defences and subsequent creation of intertidal habitats is one of several 'soft' engineering options that could reduce the costs of maintaining embankments and at the same time deliver environmental benefits. The managed realignment at Tollesbury was one of the first in the UK, undertaken as an experimental test case to improve understanding of the practical techniques and processes involved. Independent studies were undertaken on the development of soils, benthic invertebrates and vegetation within the site in addition to methods of enhancing the process of natural colonisation of saltmarsh plants. Bathymetric and vegetation monitoring were undertaken on the adjacent estuary to determine any breach effect that may be attributed to the realignment. This paper summarises the results from the vegetation, sedimentation and invertebrate monitoring and discusses the implications for other managed realignment schemes in the UK.

Altersassoziierte Ver�nderungen im Vitamin-B 12 - und Fols�urestoffwechsel: Pr�valenz, �tiopathogenese und pathophysiologische Konsequenzen

The increasing number of older people is characteristic for most industrialised nations and implicates the known psychosocial and economic consequences. Therefore, an optimal nutrient supply that promotes continuing mental and physical well-being is particularly important. In this respect, vitamin B(12) and folic acid play a major role, since deficiency of both vitamins is associated with the pathogenesis of different diseases such as declining neurocognitive function and atherosclerotic lesions. Vitamin B(12) and folic acid act as coenzymes and show a close molecular interaction on the basis of the homocysteine metabolism. In addition to the serum concentrations of the vitamins, the metabolites homocysteine and methylmalonic acid are sensitive markers of cobalamin and folate status. Depending on the used marker, 3-60% of the elderly are classified as vitamin B(12) deficient and about 29% as folate deficient. Predominantly, this high prevalence of poor cobalamin status is caused by the increasing prevalence of atrophic gastritis type B, which occurs with a frequency of approximately 20-50% in elderly subjects. Atrophic gastritis results in declining gastric acid and pepsinogen secretion, and hence decreasing intestinal digestion and absorption of both B vitamins. This is the reason why an insufficient vitamin B(12) status in the elderly is rarely due to low dietary intake. In contrast, folic acid intake among elderly subjects is generally well below the recommended dietary reference values. Even moderately increased homocysteine levels or poor folate and vitamin B(12) status are associated with vascular disease and neurocognitive disorders. Results of a meta-analysis of prospective studies revealed that a 25% lower homocysteine level (about 3 micromol/L) was associated with an 11% lower ischemic heart disease risk and 19% lower stroke risk. It is still discussed, whether hyperhomocysteinemia is causally related to vascular disease or whether it is a consequence of atherosclerosis. Estimated risk reduction is based on cohort studies, not on clinical trials. Homocysteine initiates different proatherogenetic mechanisms such as the formation of reactive oxygen species and an enhanced fibrin synthesis. Supplementation of folic acid (0.5-5 mg/d) reduces the homocysteine concentration by 25%. Additional vitamin B(12) (0.5 mg/d) induces further reduction by 7%. In secondary prevention, supplementation already led to clinical improvements (reduction of restenosis rate and plaques). Depression, dementia, and mental impairment are often associated with folate and vitamin B(12) deficiency. The biochemical reason of this finding may be the importance of folic acid and vitamin B(12) for the transmethylation of neuroactive substances (myelin, neurotransmitters) which is impaired in vitamin deficiency ("hypomethylation hypothesis"). In recent years, there is increasing evidence for a role of folic acid in cancer prevention. As a molecular mechanism of a preventive effect of folic acid the hypomethylation of certain DNA sections in folate deficiency has been suggested. Since folate and vitamin B(12) intake and status are mostly insufficient in elderly subjects, a supplementation can generally be recommended.

[Infant crying diary: a useful aid in distinguishing between normal and excessive crying behavior]

Three infant girls aged 9, 10 and 8 weeks, who cried excessively according to their parents, were referred by the general practitioner to the paediatrician. Using a crying diary it was possible to ascertain that one infant fulfilled the criteria of infantile colic. The diary showed that a second infant was not crying excessively and her mother could be reassured that her baby's behaviour was normal. The third infant proved to be suffering from an organic disease (Alpha-I antitrypsin deficiency), which had not been obvious at clinical assessment. The crying diary provided clues that warranted further investigation. The parents of all 3 infants were reassured and the crying lessened over a period of several weeks. When parents complain that their child cries excessively, it is useful to chart the amount of crying time in a diary. Registration for one week is sufficient. If the child does not suffer from an organic disease, the mainstay of treatment is to explain normal crying behaviour and that it often helps if the infant is not offered too many stimuli. Parents can be reassured that spontaneous resolution will generally occur at the age of three months.

[Dietary supplements and functional food for weight reduction -- expectations and reality]

Looked at with scientific dispassion, much of the frequently aggressive advertising for slimming products must be considered to be dishonest and misleading. This applies, for example, to the "fat burner" carnitine or for chromium-containing preparations such as chromium picolinate, which in large doses have been shown to have detrimental effects on health. Products for which there actually is a scientific rationale all have minor weight-reducing effects, so that they must be considered to have at most an adjuvant role within the framework of evidence-based concepts for losing weight. Examples of alleged slimming substances that in reality can do no more than support weight reduction are the so-called medium-chain triglycerides (MCT) or caffeine, with the latter showing an effect vis-à-vis placebo only in combination studies with ephedrine.

[Possibilities and limits of ambulatory surgery: demands and reality in plastic surgery]

With the development of office-based operating rooms and improved office anesthesia, the ability to perform more extensive surgery outside the hospital is now given. Experience with the tumescent technique for liposuction and abdominoplasty has demonstrated that extensive plastic surgery can performed with minimal postoperative discomfort. An emergency phone after surgery is necessary, and a call on the operating day evening and the initial postoperative day is a safe strategy with high patient acceptance for most types of plastic surgery. Additionally, the cost savings of office-based plastic surgery makes this surgery much cheaper for the patients and the health insurance organizations.

Sentinel node procedure in Ib cervical cancer: a preliminary series

The aim of this study was to determine the diagnostic accuracy and feasibility of sentinel lymph node (SLN) detection using a gamma probe in patients with Figo IB cervical cancer. Between January 1999 and September 2000, 14 patients with cervical cancer, planned for radical hysterectomy were eligible for the study. The day before radical hysterectomy we injected technetium(99)m-labelled nanocolloid in each quadrant of the cervix. Dynamic and static images were recorded using a gamma camera. SLNs were identified intraoperatively using a handheld gamma-detection probe. After resection of SLNs a standard radical hysterectomy with pelvic lymph node dissection was performed. Patients and tumour characteristics were compared with sentinel node detection and with final histopathological and immunohistochemical results. Scintigraphy showed focal uptake in 13 of the 14 patients. Intraoperatively we detected 26 sentinel nodes by gamma probe. In 8 of 13 patients, one or more sentinel nodes were identified unilaterally, in 5 women bilaterally. Histologically positive SLNs were found in only 1 patient. We did not find any false-negative SLN in our series. In conclusion identification of sentinel nodes in cervical cancer is feasible with preoperatively administered technetium(99)m-labelled nanocolloid. A larger series will be required to establish sentinel node detection in cervical cancer for further therapy concepts and planning.

Sacrospinous ligament fixation for vaginal vault prolapse

INTRODUCTION

To assess intra- and postoperative complications and to look for long term follow-up results in women with sacrospinous ligament fixation.

METHODS

Between 1988 and 1999, 200 women (mean age 59.8 years, range 33 to 83 years) underwent vaginal unilateral sacrospinous ligament fixation. 172 patients had had prior hysterectomy. In 28 patients concomitant hysterectomy and sacrospinous ligament fixation was performed. Sacrospinous ligament fixation was combined with the following procedures: 109 enterocele repairs (54.5%), 88 anterior colporrhaphies (44%), 57 reconstructions of urogenital diaphragma (28.5%) and 23 posterior colporrhaphies (11.5%). Additional Burch colposuspension and a Stamey procedure were carried out in 7 (3.5%) and 15 (7.5%) patients, respectively.

RESULTS

All 200 patients were analysed for intra- and postoperative complications. Urinary tract infection (n = 16, 8.0%), temporary irritation of the sciatic nerve (n = 15, 7.5%), temporary partial ureteral obstruction (n = 11, 5.5%) and blood loss less than 400 ml (n = 7, 3.5%), occurred in the postoperative phase. Long-term data (range from 6 months to 9 years, mean 4.8 years) exist for 123 patients. 119 were completely cured without any signs of urinary incontinence and prolapse. At follow-up 4 patients (3.25%) showed recurrent vaginal vault prolapse. Recurrent cystoceles, rectoceles, enteroceles, were found in 10 cases (8.1%), one (0.8%) and one (0.8%), respectively. Two patients with complete recurrence of vaginal vault prolapse successfully underwent colpectomy and repeated sacrospinous ligament fixation, respectively. CONCLUSIONS. Sacrospinous ligament fixation is an effective and safe procedure with a low recurrence and complication rate.

Deep brain stimulation of the globus pallidus pars interna in advanced Parkinson's disease

Pallidotomy is now widely performed for the treatment of advanced Parkinson's disease (PD). Preliminary reports of the effect of globus pallidus pars interna deep brain stimulation (GPi DBS) have also been promising. We have analyzed a cohort of 22 consecutive patients enrolled in a multicenter study. Surgery was bilateral in 17 and unilateral in five patients. At 6-month follow-up, the bilaterally GPi-implanted patients demonstrated a marked improvement when examined after drug withdrawal ("off") and under optimal medication ("on") using the Unified Parkinson's Disease Rating Scale (UPDRS). The benefit induced by the stimulation in the "off" medication condition in the total motor score was 31% and in the activities of daily living (ADL) scores was 39%. During the "on" medication period, the reduction in the total "on" dyskinesias score was 66% and in the ADL score was 32%. A similar pattern of improvement was seen in the group of patients with unilateral GPi stimulation, although a second cohort of 12 patients not included in the multicenter study showed greater improvements in "on" motor functioning. Although the effect of DBS is predominantly reversible, electrode insertion alone resulted in measurable clinical effects in the absence of stimulation. Thus, at 6-month follow-up, the benefit observed without stimulation was up to 44% in the "on" dyskinesias score and 29% in timed tapping scores undertaken in the "off" medication state. Complications among 34 patients from all centers included perioperative infection (n=3), hardware fracture (n=2), and premature battery failure (n=3). These results show a positive antiparkinsonian effect of pallidal DBS. No specific complications were observed with bilateral procedures.

Significance of endovaginal ultrasonography in assessing tamoxifen-associated changes of the endometrium. A prospective study

BACKGROUND

A prospective study was conducted investigating the value of endovaginal ultrasound in the assessment of tamoxifen-associated changes of the endometrium in patients with breast cancer.

METHODS

Seventy postmenopausal patients with breast cancer treated with anti-estrogens for at least 6 months were entered. Those with bleeding disorders and/or an endometrial thickness of > or =10 mm found on ultrasonography underwent hysteroscopy and dilatation and curettage (D&C) for further histological evaluation. In 22 patients, positive ultrasound findings could be compared with histopathology.

RESULTS

82% of the 22 patients with positive sonographic findings had a glandular-cystic hyperplasia or a glandular-cystic polyp. No adenomatous hyperplasia or endometrial cancer was observed in our series.

CONCLUSION

Vaginal ultrasound represents a useful diagnostic tool to detect tamoxifen-associated changes of the endometrium. A threshold of 10 mm endometrial thickness appears suitable to identify endometrial abnormalities while reducing the rate of false-positive findings to an acceptable level. However, the role of vaginal ultrasound in screening for endometrial cancer or premalignant lesions remains uncertain.

Bacillus stearothermophilus lctB gene gives rise to functional K+ channels in Escherichia coli and in Xenopus oocytes

We have cloned a small K+ channel subunit (LctB) of the gram-positive bacterium Bacillus stearothermophilus (B. stearo.). The B. stearo. LctB protein is only 134 amino acids long. The sequence contains a typical K+ channel P-domain with a K+ channel GYGD signature sequence and two hydrophobic, possibly membrane-spanning segments M1 and M2. Unexpectedly, LctB K+ channels exhibited properties which differed markedly from the ones reported for KcsA channels of the gram-positive bacterium Streptomyces lividans. LctB channels, when expressed in E. coli, were targeted to the outer membrane and not like KcsA channels to the inner membrane. After reconstitution in black lipid membrane, LctB channels mediated K+ currents at neutral pH. They were apparently not gated by pH like KcsA channels. Also, LctB cRNA produced functional LctB channels in the Xenopus oocyte expression system in marked contrast to KcsA. The results demonstrated that heterologous expression produced functional LctB channels both in E. coli and in Xenopus oocytes. It is proposed that bacterial LctB subunits can be properly handled by the Xenopus oocyte leading to the occurrence of functional LctB K+ channels in the oocyte plasma membrane.