Recognition and management of overweight and obesity in primary care in Germany

BACKGROUND: In contrast to the well-documented high prevalence of overweight and obesity in the general population, the prevalence, recognition rates and management by primary care physicians--as the core gatekeeper in the health care system--remains poorly studied. PURPOSE OF THE STUDY: To examine (1) the point prevalence of overweight (BMI 25.0-29.9 kg/m(2)) and obesity (BMI> or =30 kg/m(2)) in primary care patients, (2) prevalence patterns in patients with high-risk constellations (diabetes, hypertension, cardiovascular disease, etc.), (3) doctors' recognition and interventions, as well as patients' use and perceived effectiveness of weight-loss interventions and (4) factors associated with non-treatment. METHODS: Cross-sectional point prevalence study of 45 125 unselected consecutive primary care attendees recruited from a representative nationwide sample of 1912 primary care practices. Measures: (1) standardized clinical appraisal of each patient by the physician (diagnostic status and recognition, severity, comorbidity, current and past interventions). (2) Patient self-report questionnaire: height and weight, illness history, past and current treatments and their perceived effectiveness, health attitudes and behaviors. RESULTS: (1) In all, 37.9% of all primary care attendees were overweight, 19.4% obese. (2) Rates for overweight and obesity were highest in patients with diabetes (43.6 and 36.7%) and hypertension (46.1 and 31.3%), followed by patients with cardiovascular disorders. Rates of overweight/obesity increased steadily by the number of comorbid conditions. (3) Doctors' recognition of overweight (20-30%) and obesity (50-65%) was low, patients' actual use of weight control interventions even lower (past 12 months: 8-11%, lifetime: 32-39%). Patient success rates were quite limited. (4) Co- and multimorbidity in particular as well as other patient and illness variables were identified as predictors for recognition, but prediction of patients' actual use of weight loss interventions was limited. CONCLUSIONS: Primary care management of overweight and obesity is largely deficient, predominantly due to four interrelated factors: doctors' poor recognition of patients' weight status, doctors' inefficient efforts at intervention, patients' poor acceptance of such interventions and dissatisfaction with existing life-style modification strategies.     

Influence of cholesterol and fat in food on indirect parameters of exocrine pancreatic function.

Fecal elastase 1, chymotrypsin activity, and fat content in stool are clinical parameters of exocrine pancreatic function. The aim of this study was to clarify the possible impact of extreme changes in diet on fecal enzyme concentration/activity, since extreme diets may lead to wrong conclusions in the diagnosis of pancreatic insufficiency. Twelve healthy test persons followed 4 diet phases, each with a duration of 6 days. The 4 diet phases were (1) nearly fat-free with a low-cholesterol content; (2) high in fat and low in cholesterol; (3) high in cholesterol deriving from meat, and (4) high in cholesterol deriving from eggs. At the end of each diet phase, a 72-hour stool collection was carried out to measure fecal elastase 1, chymotrypsin and fecal fat content. The results showed no significant changes after each of the 4 diet phases. The clinical parameters of fecal elastase 1 and chymotrypsin activity in stool do not seem to be significantly influenced by fat and cholesterol deriving from food.     

The Overlapping Risk Profile Between Dialysis Patients Listed and Not Listed for Renal Transplantation

The survival advantage of kidney transplantation extends to many high-risk ESRD patients; however, numerous factors ultimately determine which patients are evaluated and listed for the procedure. Broad goals of patient evaluation comprise identifying patients who will benefit from transplantation and excluding patients who might be placed at risk. There is limited data detailing whether current access limitations and screening strategies have achieved the goal of listing the most appropriate patients. The study estimated the life expectancy of adult patients in the United States prior to transplantation with ESRD onset from 1995 to 2003. Factors associated with transplant listing were examined based on patient prognosis after ESRD. Approximately one-third of patients listed for transplantation within 1 year of ESRD had ≤5-year life expectancy on dialysis. In contrast, one-third of patients not listed had >5-year life expectancy. The number of patients not listed with 'good' prognosis was significantly higher than those listed with 'poor' prognosis (134 382 vs. 16 807, respectively). Age, race, gender, insurance coverage and body mass index (BMI) were associated with likelihood for listing with 'poor' prognosis and not listing with 'good' prognosis. Over the past decade, many ESRD patients viable for transplantation have not listed for transplantation while higher-risk patients have listed rapidly.     

Successful and safe use of 2 min cold atmospheric argon plasma in chronic wounds: results of a randomized controlled trial

Background The development of antibiotic resistance by microorganisms is an increasing problem in medicine. In chronic wounds, bacterial colonization is associated with impaired healing. Cold atmospheric plasma is an innovative promising tool to deal with these problems. Objectives The 5‐min argon plasma treatment has already demonstrated efficacy in reducing bacterial numbers in chronic infected wounds in vivo. In this study we investigated a 2‐min plasma treatment with the same device and the next‐generation device, to assess safety and reduction in bacterial load, regardless of the kind of bacteria and their resistance level in chronic wounds. Methods Twenty‐four patients with chronic infected wounds were treated in a prospective randomized controlled phase II study with 2 min of cold atmospheric argon plasma every day: 14 with MicroPlaSter alpha device, 10 with MicroPlaSter beta device (next‐generation device) in addition to standard wound care. The patient acted as his/her own control. Bacterial species were detected by standard bacterial swabs and bacterial load by semiquantitative count on nitrocellulose filters. The plasma settings were the same as in the previous phase II study in which wounds were exposed for 5 min to argon plasma. Results Analysis of 70 treatments in 14 patients with the MicroPlaSter alpha device revealed a significant (40%, P < 0·016) reduction in bacterial load in plasma‐treated wounds, regardless of the species of bacteria. Analysis of 137 treatments in 10 patients with the MicroPlaSter beta device showed a highly significant reduction (23·5%, P < 0·008) in bacterial load. No side‐effects occurred and the treatment was well tolerated. Conclusions A 2‐min treatment with either of two cold atmospheric argon plasma devices is a safe, painless and effective technique to decrease the bacterial load in chronic wounds.     

Immunosuppressive strategies to improve outcomes of kidney transplantation

The introduction of several immunosuppressive agents over the past decade has reduced the rate of acute rejection significantly and has improved short-term renal allograft survival. However, their impact on long-term outcomes remains unclear. Current immunosuppressive strategies are focused on improving long-term graft and patient survival along with maintaining allograft function. The approval of the new immunosuppressive agents: rabbit antithymocyte globulin, basiliximab, daclizumab, tacrolimus, mycophenolate, and sirolimus, also has facilitated the development of steroid- and calcineurin inhibitor-sparing regimens in kidney transplantation. We discuss the impact of various immunosuppressive regimens on the outcome measures of kidney transplantation: acute rejection episodes, allograft survival, and renal function.     

Half of Kidney Transplant Candidates Who Are Older than 60 Years Now Placed on the Waiting List Will Die before Receiving a Deceased-Donor Transplant

Background and objectives: Waiting times to deceased-donor transplantation (DDTx) have significantly increased in the past decade. This trend particularly affects older candidates given a high mortality rate on dialysis.Design, setting, participants, & measurements: We conducted a retrospective analysis from the national Scientific Registry of Transplant Recipients database that included 54,669 candidates who were older than 60 yr and listed in the United States for a solitary kidney transplant from 1995 through 2007. Using survival models, we estimated time to DDTx and mortality after candidate listing with and without patients initially listed as temporarily inactive (status 7).Results: Almost half (46%) of candidates who were older than 60 yr and listed in 2006 through 2007 are projected to die before receiving a DDTx. This proportion varied by individual characteristics: Diabetes (61%), age ≥70 yr (52%), black (62%), blood types O (60%) and B (71%), highly sensitized (68%), and on dialysis at listing (53%). Marked variation also existed by United Network for Organ Sharing region (6 to 81%). The overall projected proportion was reduced to 35% excluding patients who initially were listed as status 7.Conclusions: These data highlight the prominent and growing challenge facing the field of kidney transplantation. Older candidates are now at significant risk for not surviving the interval in which a deceased-donor transplant would become available. Importantly, this risk is variable within this population, and specific information should be disseminated to patients and caregivers to facilitate informed decision-making and potential incentives to seek living donors.Currently, more than half of a million patients have ESRD in the United States. Among these individuals, approximately one half (48%) are older than 60 yr (1). Rates of ESRD have increased in the past decade in virtually all patient groups, most rapidly in older patients (2). Among patients who have ESRD and are medically cleared for the procedure, kidney transplantation has repeatedly been shown to convey a significant survival advantage as compared with the alternative treatment modality of maintenance dialysis (3). This survival advantage is applicable across age groups including a nearly doubling of life expectancy among patients who are older than 60 yr (3,4); however, one of the greatest challenges facing this population is that the number of available organs from deceased donors has not kept pace with the growing number of transplant candidates. There was a 50% rise in the number of new kidney candidate listings from 1997 through 2006—an increase evident across age groups, race, blood type, and gender (5). Consequences of this unmet demand are longer waiting periods for transplantation and increased mortality on the waiting list before receiving an organ. Even among patients who meet initial screening criteria, there is a significantly elevated risk among older candidates of health deterioration while awaiting transplantation, rendering many patients ineligible for the procedure (6,7).Factors that influence patient decisions to list for a deceased-donor transplant are complex, including individual patient preferences, perceived benefit, and the availability and desire to obtain a living donor (8,9). Rates of listing for a deceased-donor transplant and progression on the waiting list vary significantly by race/ethnicity, body mass index, socioeconomic factors, and geographic location (10,11). Numerous reports demonstrated that patients who are proactive and are able to navigate the processes involved to receive a transplant have significantly improved prognoses (12–14). In general, patient prognoses are not the sole determinant of expeditious listing for the procedure. In fact, a sizeable proportion of candidates are listed for renal transplantation and have a relatively poor prognosis, and many patients with substantial life expectancy are never listed (15).We undertook this study to examine specific considerations for prospective older transplant candidates with the primary aim of projecting the likelihood of newly listed older candidates to receive a deceased-donor transplant on the basis of the combination of patient and regional factors. The aim of the study was to provide consolidated information for older candidates concerning individual prognoses, the likelihood to receive a deceased-donor transplant, or alternatively the incentive to consider seeking living donors. In addition, this information may inform policy makers as to the general prognoses for prospective older transplant candidates in the modern era and the potential role and need for organ allocation algorithms based on factors specific to this rapidly growing population.