Treatment of obesity in older persons—A systematic review

The study aims to systematically review the available evidence regarding weight loss interventions (lifestyle, surgical, and pharmacological) for obesity in adults aged over 60 years. A search of prospective, randomized studies took place in January 2018, on Medline (Web of Science) and PubMed databases. Search terms included the following: elderly, obese, hypocaloric, pharmacotherapy, and bariatric surgery. Abstracts were screened for eligibility. A total of 256 publications regarding lifestyle interventions were identified; of these, 69 studies were eligible. As no eligible studies were identified for pharmacotherapy or bariatric surgery, the search was broadened to include non‐ randomized studies. Four pharmacotherapy and 66 surgery studies were included. Lifestyle intervention had similar weight loss efficacy in older compared with younger people, with positive effects on a number of relevant outcomes, including physical function and cardiovascular parameters. There was little data regarding obesity pharmacotherapy in older persons. The available data for bariatric surgery indicate comparable weight loss and resolution of type 2 diabetes, with similar or slightly higher complication rates in older compared with younger people. Older age alone should not be considered a contraindication to intensive lifestyle or surgical intervention for obesity. There are insufficient data to guide clinical decisions regarding obesity pharmacotherapy in older people.     

Implantation des Watchman™-Vorhofohr-Okkluders

The implantation of an occluder system for the left atrial appendage (LAA) represents an interesting alternative for patients with atrial fibrillation and a CHA₂DS₂-VASc-Score ≥?2 who cannot take permanent anticoagulation for various reasons. As in other left cardiac interventions, there are potentially dangerous possibilities for complications that can limit the advantages of this therapy. This overview summarizes practical tips and tricks at the implantation of a Watchman? occluder which may help to minimize the complication rate. These hints refer to peri-interventional anticoagulation as well as transseptal puncture (technique, imaging), exchange of catheters, left atrial pressure, intubation and fluoroscopy of the LAA, preparation of the device and sheath, delivery of the Watchman? device, confirmation of optimal position, and partial or complete recapture. If these precautions are considered, the complication rate at implantation of a Watchman? occluder should be <?5?%, the rate of complications with long-term consequences <?1?%, and the implant success should lie >?95?%.     

Treatment of alcohol problems

This paper gives an overview of the variety of approaches that have been used in the treatment of alcohol problems. There is good evidence that approaches directed at improving social and marital relationships, self-control and stress management are effective. There is at present little to suggest that aversion therapies, confrontational interventions, educational lectures or films and group psychodynamic therapy are effective, nor is there good evidence yet that use of psychotropic medications is effective. However, it may be that therapies that have not proved effective with the broad range of individuals with alcohol problems might prove effective with selected cases. Future research should place more emphasis on determining the kinds of alcohol problems that are likely to respond to different kinds of treatments directed at different kinds of goals and by different kinds of practitioners. The base of treatment should be broadened to include the large numbers of individuals with alcohol problems but who could not be considered as alcohol-dependent. This would have to involve a wide range of primary care and generic workers and include use of brief interventions.     

Physical, functional and other non-pharmacological interventions for osteoarthritis

Non-pharmacological interventions are frequently and widely used in the management of patients with osteoarthritis (OA). However, there is little evidence that most of these interventions are efficacious (i.e. that they work under ideal circumstances) owing to the paucity of research studies on these interventions and the fundamental methodological flaws in published studies. Moreover, the clinical effectiveness of non-pharmacological interventions (i.e. their efficacy under the conditions prevailing in clinical practice) is unknown, and cost-analysis of these interventions has not been carried out. If evidence-based management guidelines were to be constructed solely from firm research studies few could be recommended. Established and developing research methodologies and techniques should be employed to construct and conduct research programmes that appropriately evaluate the clinical and cost effectiveness of these complex non-pharmacological healthcare interventions. Establishing clinical effectiveness will ensure that we have practice-based evidence and are administering relevant, effective and optimal healthcare for patients with OA, maximizing the efficient use of healthcare resources.     

Gastrointestinal endoscopy in pregnancy

Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.     

Therapy insight: drugs for gastrointestinal disorders in pregnant women

The management and treatment of gastrointestinal ailments in pregnant women requires special attention and expertise, since the safety of the mother, fetus and neonate remains the primary focus. Nausea and vomiting during pregnancy is common, as is symptomatic gastroesophageal reflux disease. Peptic ulcer disease occurs less frequently and with fewer complications. Gastroenterologists and obstetricians should be familiar with safe treatment options for these conditions, because they can profoundly impair the quality of life of pregnant women. During pregnancy, constipation can develop de novo, or chronic constipation can increase in severity. Given the array of therapies for constipation, physicians must apprise themselves of drugs that are safe for both mother and fetus. Management of acute, self-limited diarrhea should focus on supportive therapy, dietary changes and maintenance of hydration. Treatment of chronic diarrhea should be considered in the context of therapy for the underlying disorder. Inflammatory bowel disease and irritable bowel syndrome present a unique therapeutic challenge--to control the disease while minimizing toxicity to the fetus and mother. Initiation and alteration of medical therapy for gastrointestinal disorders during pregnancy must be undertaken after discussion with the patient's obstetrician.     

Is the Poly A (T>C) Mutation a Causative Factor For Misdiagnosis in Second Trimester Prenatal Diagnosis of β-Thalassemia by Fetal Blood Analysis on High Performance Liquid Chromatography?

We report the problems in diagnosis faced by two families referred for prenatal diagnosis of thalassemia where cordocentesis and fetal blood analysis by high performance liquid chromatography (HPLC) had to be done. The Hb A levels of the fetal blood measured by HPLC on the VARIANT? Hemoglobin Testing System were 1.2 and 6.7%, respectively, suggestive of a heterozygous β-thalassemia (β-thal) fetus in the first case and a normal fetus in the second case. In one family, one of the parents had a borderline Hb A₂ level and in the other, one parent had normal RBC indices. However, DNA sequencing, done later, showed that in the first case the fetus was a compound heterozygote for the IVS-I-5 (G>C) and the polyadenylation signal site [poly A (T>C)] mutation, while in the second case, the fetus was homozygous for the poly A mutation. This emphasizes that characterization of β-thal mutations must be done whenever one of the parents has a borderline Hb A₂ level or normal RBC indices, and one should not rely on fetal blood analysis by HPLC for prenatal diagnosis of β-thal so as to avoid misdiagnosis.     

Insulintherapie in der Schwangerschaft

The paper focuses on the special requirements of insulin therapy in pregnant women with diabetes because glucose goals, frequency and timing of glucose monitoring, and the dynamics of insulin adjustment differ substantially from when a woman is not pregnant. Planning of pregnancy with preconceptional optimizing of glucose control is essential; there is good evidence that the level of HbA_1c seems to determine the whole course of pregnancy. Studies have shown that there is no significant difference in achievement of good perinatal outcome comparing insulin application by insulin pump or by intensified conventional insulin therapy (ICT); the same is valid for human insulin versus analogs. Meanwhile, long-term analogs are also considered safe in pregnancy. Glucose goals are substantially lower than outside pregnancy but individual maternal risk of hypoglycemia must be taken into account. Personal consultation with a diabetologist at least every 2 weeks is highly recommended to adjust the rapidly changing insulin demand during the course of pregnancy. Fetal growth as a parameter of potential over- or undernutrition must also be considered. Standards at the delivery hospital for glucose and insulin management of the fetus during and after delivery are required. The same principles of insulin therapy are valid for women with type 2 diabetes. Insulin demand can be very high in the third trimester, and sometimes glucose goals can be reached only by additional off-label use of metformin. In women taking oral agents before pregnancy it is recommended to switch to insulin before conception. During breast feeding, women should stay on insulin for better glucose control.     

Diabetes in Pregnancy: Timing and Mode of Delivery

Diabetes in pregnancy represents a risk condition for adverse maternal and feto-neonatal outcomes and many of these complications might occur during labor and delivery. In this context, the obstetrician managing women with pre-existing and gestational diabetes should consider (1) how these conditions might affect labor and delivery outcomes; (2) what are the current recommendations on management; and (3) which other factors should be considered to decide about the timing and mode of delivery. The analysis of the studies considered in this review leads to the conclusion that the decision to deliver should be primarily intended to reduce the risk of stillbirth, macrosomia, and shoulder dystocia. In this context, this review provides useful information for managing specific subgroups of diabetic women that may present overlapping risk factors, such as women with insulin-requiring diabetes and/or obesity and/or prenatal suspicion of macrosomic fetus. To date, the lack of definitive evidences and the complexity of the problem suggest that the “appropriate” clinical management should be customized according with the clinical condition, the type and mode of intervention, its consequences on outcomes, and considering the woman’s consent and informed decisions.     

Ebstein disease and pregnancy

Three patients with Ebstein's disease became pregnant 11 times, 6 of which ended as spontaneous abortion, 2 newborn deaths and 3 successful term pregnancies. Ventricular overloading, arterial hypoxemia and arrhythmias are the major physiopathologic determinants. The ventricular overloading is the most important risk factor for the mother, so as the hypoxemia and the arrhythmias for the fetus. Pregnancy in these patients must be considered at high risk, and a close cardiologic assess with continuous hormonal controls of fetus maturity during the last trimester should be done. A team including obstetricians, cardiologists and anesthesiologists is suggested for the care of these patients in the view of a successful outcome.     

High-value, cost-conscious health care: concepts for clinicians to evaluate the benefits, harms, and costs of medical interventions

Health care costs in the United States are increasing unsustainably, and further efforts to control costs are inevitable and essential. Efforts to control expenditures should focus on the value, in addition to the costs, of health care interventions. Whether an intervention provides high value depends on assessing whether its health benefits justify its costs. High-cost interventions may provide good value because they are highly beneficial; conversely, low-cost interventions may have little or no value if they provide little benefit. Thus, the challenge becomes determining how to slow the rate of increase in costs while preserving high-value, high-quality care. A first step is to decrease or eliminate care that provides no benefit and may even be harmful. A second step is to provide medical interventions that provide good value: medical benefits that are commensurate with their costs. This article discusses 3 key concepts for understanding how to assess the value of health care interventions. First, assessing the benefits, harms, and costs of an intervention is essential to understand whether it provides good value. Second, assessing the cost of an intervention should include not only the cost of the intervention itself but also any downstream costs that occur because the intervention was performed. Third, the incremental cost-effectiveness ratio estimates the additional cost required to obtain additional health benefits and provides a key measure of the value of a health care intervention.     

COVID-19 vaccination in pregnant and lactating diabetic women

AimTo discuss available information on the opportunity for pregnant women affected by diabetes/obesity to receive COVID-19 vaccine.Data synthesisPregnant women with SARS-CoV-2 (COVID-19) infection are at high risk for severe acute respiratory syndrome and adverse outcomes. Pregnant women with severe COVID-19 present increased rates of preterm delivery (<37 gestational weeks), cesarean delivery and neonatal admissions to the intensive care unit. Comorbidity such as diabetes (pregestational or gestational) or obesity further increased maternal and fetal complications. It is known that diabetic or obese patients with COVID-19 present an unfavorable course and a worse prognosis, with a direct association between worse outcome and suboptimal glycol-metabolic control or body mass index (BMI) levels. Critical COVID-19 infection prevention is important for both mother and fetus. Vaccination during pregnancy is a common practice. Vaccines against COVID-19 are distributed across the world with some population considered to have a priority. Since pregnant women are excluded from clinical trials very little information are available on safety and efficacy of COVD-19 vaccines during pregnancy. However, it is well known the concept of passive immunization of the newborn obtained with transplacental passage of protective antibodies into the fetal/neonatal circulation after maternal infection or vaccination. Moreover, it has been reported that COVID-19 vaccine-induced IgG pass to the neonates through breastmilk. Therefore, maternal vaccination can protect mother, fetus and baby.ConclusionsAfter an individual risk/benefit evaluation pregnant and lactating women should be counselled to receive COVID-19 vaccines.     

Lung donor selection criteria

The criteria that define acceptable physiologic and social parameters for lung donation have remained constant since their empiric determination in the 1980s. These criteria include a donor age between 25-40, a arterial partial pressure of oxygen (PaO₂)/FiO₂ ratio greater than 350, no smoking history, a clear chest X-ray, clean bronchoscopy, and a minimal ischemic time. Due to the paucity of organ donors, and the increasing number of patients requiring lung transplant, finding a donor that meets all of these criteria is quite rare. As such, many transplants have been performed where the donor does not meet these stringent criteria. Over the last decade, numerous reports have been published examining the effects of individual acceptance criteria on lung transplant survival and graft function. These studies suggest that there is little impact of the historical criteria on either short or long term outcomes. For age, donors should be within 18 to 64 years old. Gender may relay benefit to all female recipients especially in male to female transplants, although results are mixed in these studies. Race matched donor/recipients have improved outcomes and African American donors convey worse prognosis. Smoking donors may decrease recipient survival post transplant, but provide a life saving opportunity for recipients that may otherwise remain on the transplant waiting list. No specific gram stain or bronchoscopic findings are reflected in recipient outcomes. Chest radiographs are a poor indicator of lung donor function and should not adversely affect organ usage aside for concerns over malignancy. Ischemic time greater than six hours has no documented adverse effects on recipient mortality and should not limit donor retrieval distances. Brain dead donors and deceased donors have equivalent prognosis. Initial PaO₂/FiO₂ ratios less than 300 should not dissuade donor organ usage, although recruitment techniques should be implemented with intent to transplant.     

Empirical use of antibiotics and adjustment of empirical antibiotic therapies in a university hospital: a prospective observational study

Background  

Several strategies to optimise the use of antibiotics have been developed. Most of these interventions can be classified as educational or restrictive. Restrictive measures are considered to be more effective, but the enforcement of these measures may be difficult and lead to conflicts with prescribers. Any intervention should be aimed at targets with the highest impact on antibiotic prescribing. The aim of the present study was to assess the adequacy of empirical and adjusted antibiotic therapies in a Swiss university hospital where no antibiotic use restrictions are enforced, and to identify risk factors for inadequate treatment and targets for intervention.     

Diets and enteral supplements for improving outcomes in chronic kidney disease

Protein-energy wasting (PEW), which is manifested by low serum levels of albumin or prealbumin, sarcopenia and weight loss, is one of the strongest predictors of mortality in patients with chronic kidney disease (CKD). Although PEW might be engendered by non-nutritional conditions, such as inflammation or other comorbidities, the question of causality does not refute the effectiveness of dietary interventions and nutritional support in improving outcomes in patients with CKD. The literature indicates that PEW can be mitigated or corrected with an appropriate diet and enteral nutritional support that targets dietary protein intake. In-center meals or oral supplements provided during dialysis therapy are feasible and inexpensive interventions that might improve survival and quality of life in patients with CKD. Dietary requirements and enteral nutritional support must also be considered in patients with CKD and diabetes mellitus, in patients undergoing peritoneal dialysis, renal transplant recipients, and in children with CKD. Adjunctive pharmacological therapies, such as appetite stimulants, anabolic hormones, and antioxidative or anti-inflammatory agents, might augment dietary interventions. Intraperitoneal or intradialytic parenteral nutrition should be considered for patients with PEW whenever enteral interventions are not possible or are ineffective. Controlled trials are needed to better assess the effectiveness of in-center meals and oral supplements.     

Platelet glycoprotein IIb/IIIa inhibitors

Glycoprotein (GP) IIb/IIIa inhibitors including abciximab, eptifibatide and tirofiban have been studied extensively as short-term adjuncts to short-term heparin and indefinite aspirin in patients with acute coronary syndrome or undergoing percutaneous coronary interventions on native vessels. The drugs provide a small advantage in the composite endpoint of death, myocardial infarction, and need for revascularization at 30 days (1-2% of treated patients) at the expense of an increase in major and potentially fatal bleeding complications (1% of treated patients over heparin plus aspirin alone). Highest-risk patients appear to benefit the most; clopidogrel should also be considered in these patients. Patients undergoing percutaneous interventions on bypass grafts do not benefit. Whether one GP IIb/IIIa inhibitor is superior to another is incompletely clarified. Abciximab causes severe immune-mediated thrombocytopenia (<20,000/microl) in 0.7% of cases; this is more often than eptifibatide or tirofiban (0.2%). Pseudothrombocytopenia should be differentiated. Effective use of GP IIb/IIIa inhibitors for acute coronary syndrome and percutaneous coronary interventions requires discerning clinical judgment. The value of GP IIb/IIIa inhibitors is not established in other forms of vascular disease.     

Experience with school-based interventions against soil-transmitted helminths and extension of coverage to non-enrolled children

This paper reviews the experience with school-based interventions against soil-transmitted helminths with regard to reduction in prevalence, intensity of infection and morbidity. It also examines the existing experience with coverage of school-based programmes to non-enrolled children. However, as this experience is limited, the paper also seeks to give an overview of the need for school control programmes to include other segments of the community. The experiences from the programmes indicate that treatment should be performed twice or thrice yearly without prior diagnosis, should be school-based and involving schoolteachers assisted by health staff, if possible. The drugs of choice are a single dose of 400 mg albendazole or 500 mg mebendazole. If intensities of Trichuris trichiura or hookworm infections are high, a double or triple dose of one of these drugs could be considered to maximise reduction in intensities. For the benefit of growth and iron status, it should be considered to supplement with iron and other micronutrients. School-based programmes should include non-enrolled school age children and pre-school children, and the system of having 'treatment days' at school, where these groups are invited for treatment, seems to be a promising strategy. While antenatal clinics have been involved in the anthelminthic treatment of pregnant women, they have not covered non-pregnant adolescent girls and women. These could be offered treatment through the 'treatment days' at school mentioned earlier.     

European AIDS Clinical Society (EACS) guidelines on the prevention and management of metabolic diseases in HIV

BACKGROUND: Metabolic diseases are frequently observed in HIV-infected persons and, as the risk of contracting these diseases is age-related, their prevalence will increase in the future as a consequence of the benefits of antiretroviral therapy (ART). SUMMARY OF GUIDELINES: All HIV-infected persons should be screened at regular intervals for a history of metabolic disease, dyslipidaemia, diabetes mellitus, hypertension and alteration of body composition; cardiovascular risk and renal function should also be assessed. Efforts to prevent cardiovascular disease will vary in intensity depending on an individual's absolute risk of ischaemic heart disease and should be comprehensive in nature. Lifestyle interventions should focus on counselling to stop smoking, modify diet and take regular exercise. A healthy diet, exercise and maintaining normal body weight tend to reduce dyslipidaemia; if not effective, a change of ART should be considered, followed by use of lipid-lowering medication in high-risk patients. A pre-emptive switch from thymidine analogues is recommended to reduce the risk of development or progression of lipoatrophy. Intra-abdominal fat accumulation is best managed by exercise and diet. Prevention and management of type 2 diabetes mellitus and hypertension follow guidelines used in the general population. When using medical interventions to prevent and/or treat metabolic disease(s), impairment of the efficacy of ART should be avoided by considering the possibility of pharmacokinetic interactions and compromised adherence. Specialists in HIV and specialists in metabolic diseases should consult each other, in particular in difficult-to-treat cases. CONCLUSION: Multiple and relatively simple approaches exist to prevent metabolic diseases in HIV-infected persons; priority should be given to patients at high risk of contracting these diseases.