An overview of methodologies,proficiencies, and training resources for controlled feeding studies

Dietary intervention studies of human beings produce valuable information regarding dietary effects on biological processes and risk factors for chronic diseases. Using the well-controlled feeding approach, participants consume only foods that have been precisely prepared in a research kitchen, whereas in behavioral counseling studies, participants self-select their foods within guidelines. Because controlled feeding studies meticulously control experimental diets, they are intellectually and logistically challenging to conduct. They afford exciting opportunities for dietetic professionals in designing protocols, developing budgets, and collaborating in multidisciplinary research teams. Research dietitians use food composition data and chemical analysis of menus to prepare research diets with precision. They determine the energy requirements of subjects and adjust diets as required, most often for weight maintenance, throughout the study. All people involved in research must be attentive to the ethical treatment of the study participants while motivating them to adhere to the protocol requirements. Dietitians possess many of these skills, but may require training specific to well-controlled feeding studies. Information related to the conduct of controlled feeding studies has recently become more accessible. We provide an overview of well-controlled feeding study methodologies, proficiencies for planning and implementing these studies, and training resources.     

Managing children with acute non‐traumatic limp: the utility of clinical findings,laboratory inflammatory markers and X‐rays

Objectives: To examine the utility of clinical findings, laboratory markers and X‐ray radiographs (X‐ray) in the assessment of children presenting with an acute non‐traumatic limp. Methods: A retrospective review of all children who received hip X‐rays over a 2 year period in the Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand. Children were identified from the radiology database and clinical notes reviewed. Children aged 0–12 years old were included if the limp was acute (less than 2 weeks of duration) with no history of trauma. X‐rays were reported by a consultant paediatric radiologist. Univariate and multivariate analysis was performed to determine predictors of osteomyelitis and septic arthritis. Receiver operator curves were used to assess the optimum cut‐off points for C reactive protein (CRP), erythrocyte sedimentation rate (ESR) and white cell count (WCC). Results: A total of 350 patients were enrolled. There were 21 (6%) abnormal X‐rays . Fever, non‐weight bearing, raised white cell count, raised erythrocyte sedimentation rate and raised CRP were all associated with increased risk of septic hip or osteomyelitis. The optimum inflammatory marker cut‐off was a CRP of 12 with a sensitivity of 87% and specificity of 91%. Conclusion: In acute non‐traumatic limp, X‐rays of the hips diagnose slipped upper femoral epiphysis, as such they should be routinely used from the age of 9 years upwards. Below this age they are of little value. Inflammatory markers have utility in risk‐stratifying children and selecting a group in whom to proceed with definitive tests to exclude osteomyelitis or septic hip. Children with a short history and minimal symptoms can be managed with appropriate follow up and no investigations.     

Electronic Medical Record Adoption in Hospitals That Care for Children

ObjectiveHospitals that care for children face unique barriers in electronic medical records (EMR) use that may affect their ability to meaningfully use EMR. The purpose of this study was to investigate hospitals that care for children, both freestanding and adult hospitals with children's services, to determine progress toward advanced stages of EMR use.MethodsThe American Hospital Association survey described hospitals across the United States. Healthcare Information and Management Systems Society 2006 and 2010 databases identified hospitals' EMR use. EMR stage was classified according to previous studies. Multivariable analysis was used to determine independent predictors of EMR use.ResultsThe analysis included 2794 hospitals. During the study time frame, a significant increase occurred for hospitals moving into any stage of EMR in adult hospitals with children's services (47% to 75%; P < .001), while improvements for freestanding children's hospitals were modest at best (46% to 59%; P = .3). Conversely, freestanding children's hospitals had the largest gain in advance stage 3 adoption (6% to 39%; P < .001) compared to adult hospitals with children's services (6% to 23%; P < .001). Freestanding children's hospitals were less likely to use pharmacy information systems but more likely to use computerized provider order entry.ConclusionsIn 2010, freestanding children's hospitals had the highest percentage use of advanced stage EMR (39%), but the lowest improvements in percentage of hospitals entering into any stage of adoption over the study period. This trend created a digital divide among freestanding children's hospitals that may improve with pediatric-specific electronic medication management products.     

Personalized Medicine for Diabetes: Environmental Influences on Development of Type 2 Diabetes and Obesity: Challenges in Personalizing Prevention and Management

Recent epidemic increases in the U.S. prevalence of obesity and diabetes are a consequence of widespread environmental changes affecting energy balance and its regulation. These environmental changes range from exposure to endocrine disrupting pollutants to shortened sleep duration to physical inactivity to excess caloric intake. Overall, we need a better understanding of the factors affecting individual susceptibility and resistance to adverse exposures and behaviors and of determinants of individual response to treatment. Obesity and diabetes prevention will require responding to two primary behavioral risk factors: excess energy intake and insufficient energy expenditure. Adverse food environments (external, nonphysiological influences on eating behaviors) contribute to excess caloric intake but can be countered through behavioral and economic approaches. Adverse built environments, which can be modified to foster more physical activity, are promising venues for community-level intervention. Techniques to help people to modulate energy intake and increase energy expenditure must address their personal situations: health literacy, psychological factors, and social relationships. Behaviorally oriented translational research can help in developing useful interventions and environmental modifications that are tailored to individual needs.     

Airway interventions in children with Pierre Robin Sequence

OBJECTIVE: To describe the interventions required for successful airway management in children with Pierre Robin Sequence (PRS). STUDY DESIGN: Case series. SUBJECTS AND METHODS: The records of both a cleft and craniofacial clinic and a pediatric otolaryngology clinic were searched, and all children with PRS were identified. Data concerning feeding interventions, airway interventions, and comorbid conditions were extracted. RESULTS: Seventy-four cases of PRS were identified. Thirty-eight of the 74 children required airway intervention other than prone positioning. Fourteen of these 38 were managed nonsurgically with nasopharyngeal airway and/or short-term endotracheal intubation, whereas the remaining 24 required surgical intervention. Eighteen of the 24 underwent distraction osteogenesis of the mandible, one underwent tracheostomy, and five underwent tracheostomy followed by eventual distraction. CONCLUSION: In our series, over 50 percent of children with PRS required an airway intervention. These were both nonsurgical and surgical. As otolaryngologists, we must be prepared for the challenges children with PRS may present and the interventions that may be necessary to successfully manage these difficult airways.     

Student USMLE Step 1 Preparation and Performance

Objectives: Many medical students take commercial preparation courses to prepare for the USMLE Step 1. This investigation examined the relationships among Step 1 performance, preparation method, and academic achievement in medical school. Method: A survey was conducted on 148 junior students at a medical school in July 2000 regarding their preparation methods for Step 1. Additional data was collected on student Step 1 scores, attendance record on preparation courses, and course grades in medical school. Results: One hundred students (68%) responded to the survey including 32 preparation course participants. Course participants had significantly lower Step 1 scores and second-year GPAs than those of the non-participants (p < 0.05). However, the effect of preparation method was not significant by using ANCOVA when the second-year GPA was used as a covariate (p = 0.71). Conclusion: Performance on Step 1 is related to academic performance in medical school and not the type of preparation methods.     

Why and how to improve physical activity promotion: Lessons from behavioral science and related fields

This commentary highlights the importance of regular physical activity to the nation’s health and discusses some of the major challenges and opportunities currently facing the field.     

The development of an observational screening tool to assess safe,effective and appropriate walking aid use in people with multiple sclerosis

Purpose: The purpose of this study was to identify potential items for an observational screening tool to assess safe, effective and appropriate walking aid use among people with multiple sclerosis (MS). Such a tool is needed because of the association between fall risk and mobility aid use in this population.

Methods: Four individuals with MS were videotaped using a one or two straight canes, crutches or a rollator in different settings. Seventeen health care professionals from Canada, Ireland and the United States were recruited, and viewed the videos, and were then interviewed about the use of the devices by the individuals in the videos. Interview questions addressed safety, effectiveness and appropriateness of the device in the setting. Data were analyzed qualitatively. Coding consistency across raters was evaluated and confirmed.

Results: Nineteen codes were identified as possible items for the screening tool. The most frequent issues raised regardless of setting and device were “device used for duration/abandoned”, “appropriate device”, “balance and stability”, “device technique”, “environmental modification” and “hands free.”

Conclusion: With the identification of a number of potential tool items, researchers can now move forward with the development of the tool. This will involve consultation with both healthcare professionals and people with MS.

• Implications for rehabilitation

• Falls among people with multiple sclerosis are associated with mobility device use and use of multiple devices is associated with greater falls risk.

• The ability to assess for safe, effective and efficient use of walking aids is therefore important, no tools currently exist for this purpose.

• The codes arising from this study will be used to develop a screening tool for safe, effective and efficient walking aid use with the aim of reducing falls risk.

     

Role of Plasma Vasopressin in Impaired Water Excretion of Glucocorticoid Deficiency

In the present study, the effect of selective glucocorticoid deficiency on renal water excretion was investigated in conscious, trained, adrenalectomized dogs. The animals were studied before and after a water load while on replacement therapy of desoxycorticosterone acetate, 5 mg/day, and dexamethasone, 0.8 mg/day (group I), and while off dexamethasone for 5-9 days (group II). Before the water load the weight, inulin space, cardiac output, blood pressure, glomerular filtration rate, renal blood flow, plasma osmolality, and plasma antidiuretic hormone measured by radioimmunoassay were similar in both groups I and II. However, after a 40 ml/kg water load a marked impairment in renal water excretion in the glucocorticoid deficient dogs became apparent. Maximal free water clearance was −0.046±0.16 vs. 6.51±0.72 ml/min (P < 0.001) and minimal urinary osmolality was 425±56 vs. 82±3.5 mosmol/kg H₂O (P < 0.001) in group II as compared to group I. Plasma antidiuretic hormone was maximally suppressed during the water load in group I to 0.34±0.08 pg/ml but remained elevated at 9.18±1.79 pg/ml (P < 0.005) in group II. This nonsuppressibility of plasma antidiuretic hormone during water loading in group II was associated with a significant tachycardia of 145±6 vs. 87±6 beats/min (P < 0.001) in group I and a significantly lower stroke volume of 27±0 vs. 59±0.5 ml/beat (P < 0.001). In conclusion, our results implicate a persistent secretion of antidiuretic hormone as an important factor in the impaired water excretion of glucocorticoid deficiency. A deleterious effect of glucocorticoid deficiency on cardiac function was observed and this hemodynamic alteration could be involved in initiating a nonosmolar, baroreceptor-mediated release of vasopressin.