Documented Weight Loss Research Articles

Primary anastomosis closure after endoscopic ultrasound-directed transgastric intervention.

Background and study aims Endoscopic ultrasound-directed transgastric intervention (EDGI) is a technique that creates an anastomosis between the gastric pouch or jejunum to the excluded stomach in Roux-en-Y gastric bypass (RYGB) anatomy to allow access to the pancreaticobiliary system. Thus far, management of anastomosis closure at the time of lumen-apposing metal stent (LAMS) removal has varied widely. This study aimed to assess the efficacy of primary closure at the time of LAMS removal using athrough-the-scope (TTS) tack-based suture system. Patients and methods This was a two-center retrospective study of RYGB patients who underwent single-stage EDGI using a 20-mm LAMS and subsequent primary anastomosis closure with the X-tack system at the time of stent removal. Patient demographics, procedure details, clinical outcomes, and imaging findings are reported. Results Nineteen patients (median age 63 years, 84% female) underwent single-stage EDGI with a median follow-up of 31.5 months. Adverse events occurred in two patients (11%) who had abdominal pain requiring hospitalization. The median LAMS dwell time was 32 days (range 16-86). All patients (100%) who underwent follow-up studies after LAMS removal had confirmed anastomosis closure (n = 18). Most patients had documented weight loss at the time of LAMS removal and at last follow-up (68%, n = 13). Conclusions Single-stage EDGI is an effective approach to managing RYGB patients with pancreaticobiliary pathology. Thus far, endoscopic TTS tack-based suturing appears to have a high success rate in anastomosis closure after LAMS removal and should be considered as a primary method for preventing chronic fistulae.

Associations between adverse childhood experiences and history of weight cycling.

Adverse childhood experiences (ACEs) predict obesity onset; however, the relationship between ACEs and history of weight cycling has not been adequately explored. This gap is problematic given the difficulty in weight loss maintenance and the impact of ACEs on obesity development, chronicity, and associated weight stigma. The objective of this study was to examine associations between self-reported history of ACEs and weight cycling in a sample of weight loss treatment-seeking adults with overweight/obesity. The number of participants in the analyzed sample was 78, mostly white educated adult women (80% female, 81% Caucasian, 75%≥bachelor's degree) with excess adiposity enrolled in the Cognitive and Self-regulatory Mechanisms of Obesity Study. ACEs were measured at baseline using the ACEs Scale. History of weight cycling was measured using the Weight and Lifestyle Inventory that documented weight loss(es) of 10 or more pounds. Higher ACE scores were associated with a greater likelihood of reporting a history of weight cycling. Participants with four or more ACEs had 8 times higher odds (OR=8.301, 95% CI=2.271-54.209, p=0.027) of reporting weight cycling compared with participants with no ACEs. The association of weight cycling for those who endorsed one to three ACEs was not significant (OR=2.3, 95% CI=0.771-6.857, p=0.135) in this sample. The role of ACEs in health may be related to associations with weight cycling. Results indicated that those who reported four or more ACEs had significantly higher odds of reporting weight cycling compared with those with no ACEs. Further research is needed to further explore how ACEs predict the likelihood of weight cycling, which may be prognostic for sustained weight loss treatment response and weight stigma impacts.

Frequency of malnutrition and anorexia-cachexia syndrome in patients with advanced cancer evaluated in an outpatient supportive care clinic.

257 Background: Patients with cancer are at risk for malnutrition and the development of anorexia-cachexia syndrome, which is often under-treated. The objective of our study was to determine the frequency of these conditions in advanced cancer patients who were evaluated in an outpatient Supportive Care Clinic (SCC). Methods: Advanced cancer patients seen in SCC were prospectively enrolled to complete a cross-sectional one-time survey. We collected patient demographics, weight history and height, cancer history, the Functional Assessment of Anorexia Therapy – Anorexia/Cachexia Subscale (FAACT-A/CS) questionnaire, Edmonton Symptom Assessment Scale (ESAS), the Patient Generated Subjective Global Assessment – short form (PG-SGA SF), and a Body Image Scale (BIS) questionnaire. Malnutrition was indicated by a PG-SGA cut-off of ≥ 5, and loss of appetite, anorexia, was defined as either ESAS ≥ 3 or FAACT-ACS ≤ 37. Results: Of 165 cancer patients that were approached, 100 (61%) completed the prospective survey. The average (SD) age was 61.6 years old (11.5). The majority of patients were female gender (52%), Caucasian (75%), were married (80%), and the most common cancers were gastrointestinal (22%) and genitourinary (21%). At the time of the survey, 14% of patients were noted to have a BMI < 20, 60% of patients reported anorexia (ESAS ≥ 3), 53% patients screened positive for the FAACT-A/CS (≤ 37), 69% were malnourished (PGSGA ≥ 5), and 55% had body image dissatisfaction (BIS ≥ 4). Documented weight loss of >10% in the medical records was recorded in 59% of patients with an average (SD) of -12.8% (15.3). Patient self-reported weight loss of > 5% over 6 months and > 10% over a lifetime was noted in 56% and 62% of the patients, respectively. Conclusions: Advanced cancer patients seen in an outpatient SCC are at high risk of malnutrition and roughly 60% experience complications of anorexia-cachexia syndrome. Routine screening for malnutrition and weight loss should be incorporated into all Supportive Care encounters, and nutritional counseling and support should be offered to the majority of cancer patients.

231 An evaluation of the dietetic service in a Geriatric Assessment Unit—nutritional status and outcomes

Abstract Background In 2021 the Geriatric Assessment Unit (GAU) was established, a 0.5 WTE dietitian was appointed to the multidisciplinary team. The Comprehensive Older Age Assessment (COAA) developed by the MDT included two nutritional screening tools—Malnutrition Universal Screening Tool (MUST) and the SARC-F questionnaire for sarcopenia. A MUST score of ≥2 and a SARC-F score of ≥4 were automatic dietetic referrals, referrals were also sent if a clinical concern was identified by the MDT. The aim of this review is to investigate the dietetic referral rates, nutritional status and compile a summary clinical outcomes. Methods A review of the dietetic excel database for the GAU, 2021 and 2022 was completed. The review included statistics on: (1) Referral rate, (2) Total number of dietetic interventions and a breakdown of new versus review patients, (3) MUST and SARRC- F score, (4) Body Mass Index (BMI) & weight status and (5) Review of the dietetic outcome following intervention e.g. follow up versus discharge rate and weight status at review appointments. Results The data for 2021 and 2022 were combined—77.5% of patients attending the GAU were referred to the dietitian, 80% of patients referred attended a one to one consultation. 55% of all dietetic interventions were for new patients and 45% review patients. Average BMI was 25.5 kg/m2 and 27.7 kg/m2 in 2021 and 2022 respectively. 13% had a MUST score of ≥2. 49.8% had a SCAR –F score ≥ 4. 41% of patients had reported or documented weight loss. 70% required dietetic review. At dietetic review 39.5% had desirable weight gain, 39.5% were weight stable, with only 16% having an undesirable weight loss. Conclusion The requirements and benefits of a dietetic service can be seen in the high referral rate, documented concerns of weight loss and percentage of patients with a SARC-F score ≥ 4, leading to patient specific dietetic intervention, with a stable or improved weight status at dietetic review.

ODP157 A Case of Pancreatic Insulinoma With Hypoglycemia Unawareneness

Abstract Clinical Case An 84-year-old woman with hypertension, type 2 diabetes, and a history of frequent falls, presented to the hospital after one week of recurrent falls with progressive worsening right-sided weakness, speech difficulties, and urinary incontinence. She was found to have a 2.8cm subacute subdural hematoma with midline shift and underwent successful subdural evacuation placement, nevertheless, her course was complicated by asymptomatic hypoglycemia. During her prolonged hospitalization, she experienced a 15-pound weight loss, initially attributed to poor oral intake. She was previously on glimepiride for her diabetes but this was discontinued about two months prior for low sugars. The patient did not meet Whipple's triad, as she denied symptoms of hypoglycemia and felt no different once her glucoses normalized. However, nursing staff noticed a slight difference in her cognition and behavior during these hypoglycemic episodes, which improved after correction. Laboratory testing: A fasting protocol was initiated. After seven hours, her finger stick blood glucose dropped to 42 mg/dL. Her Insulin 23.8 uU/mL (1.9-23), Proinsulin 46.9 pmol/L (<10), and C-peptide 5.3 ng/mL (0.9-7.1) were relatively high at this time, despite a confirmed low plasma glucose of 47 mg/dL. Beta-hydroxybutyrate was 0.24 mmol/L (<0.3) with Hemoglobin 16.5 G/dL (11.7-15),and HbA1c 5.6%. Her blood glucoseimproved to 126 mg/dL after administration of 1mg glucagon. Anti-Insulin antibody <5 uU/mL and a sulfonylurea screen were negative. The fasting protocol was discontinued and she was started on Dextrose 10% infusion, then transitioned to diazoxide. A dedicated MRI of the abdomen did not demonstrate any pancreatic lesions. An esophagogastroduodenoscopy was then performed, revealing a 12-mm mass in the head/uncinate of the pancreatic body. FNA confirmeda low-grade, well-differentiated neuroendocrine tumor. Immunohistochemical stains were positive for Insulin and Synaptophysin, and negative for Chromogranin, supporting the diagnosis of insulinoma. Endoscopic ultrasound with successful ethanol ablation was completed. Subsequently, her hypoglycemia rapidly improved off treatment. Conclusion Per the 2009 Endocrine Society guidelines, evaluation of recurrent low blood sugar is only recommended if Whipple's triad is present. However, this case highlights that hypoglycemia unawareness can mask Whipple's triad. It is not unusual for patients with longstanding hypoglycemia to lose neurogenic and neuroglycopenic symptoms. This can complicate and delay the diagnosis of insulinoma, as it did in this patient with multiple falls. Her documented weight loss, decreased oral intake, and relatively high HbA1c are not classic of insulinoma and were further obstacles for diagnosis. Endocrine guidelines should incorporate the importance of hypoglycemia unawareness into its algorithm. In this setting, we should consider a lower threshold to initiate fasting protocol and biochemical testing during a hypoglycemic event (<55mg/dL). Presentation: No date and time listed

294. AN UNUSUAL CASE OF EPIPHRENIC DIVERTICULUM COEXISTING WITHIN ESOPHAGEAL LEIOMYOMA

Abstract Oesophageal leiomyoma and epiphrenic diverticulum are two rare entities to be simultaneously occurring together. The preoperative diagnosis in such coexisting conditions is often difficult and leiomyoma is mostly an incidental finding. Till date there is no evidence of the pathogenesis that if the diverticulum causes leiomyoma or vice versa?: We report a case of 32-year-old male with no known co-morbids, previous history of accidental kerosine oil intake 7 months ago, with dysphagia and retrosternal burning pain since 4 weeks with no history of documented weight loss. General physical and systemic examinations were unremarkable. Contrast studies showed left sided epiphrenic diverticulum. CECT was suggestive of traction diverticulum. Endoscopy showed a large diverticulum on left side of esophagous 38 cm from incisors. On laparoscopy a mass extending to GEJ was appreciated and patient underwent laparoscopy assisted transhiatal esophagectomy and esophagogastric anastomosis with feeding jejunostomy. Peroperatively a mass of 15 x 8 cm was arising from distal oesophagus histopathology of which came out to be a leiomyoma. On POD ‘0’ patient developed Rt sided pneumothorax for which chest intubation was done. Repeat contrast studies showed a patent anastomosisand patient was discharged home. A careful history, thorough investigations, and surgeon’s awareness of possible synchronous disease processes helps in the management of such patients.

Lenalidomide in cancer cachexia: a randomized trial of an anticancer drug applied for anti‐cachexia

AbstractBackgroundCancer cachexia (CC) impacts quality of life, physical function, anticancer treatment response, and survival. Inflammation is a prominent pathomechanism of CC. This small‐scale study sets out to investigate the immunomodulatory drug lenalidomide in inflammatory CC in a randomized, double‐blind, placebo‐controlled trial.MethodsPatients with advanced solid malignancies, documented weight loss, no or unchanged anticancer treatment, and C‐reactive protein > 30 mg/L were included. In a 2:2:1 randomization, patients received either lenalidomide 25 mg once daily or C‐reactive protein‐guided dose, starting with 5 mg lenalidomide once daily or placebo once a day for 8 weeks. Dose adaption and safety were assessed twice a week. Treatment response was defined as an increase of lean body mass of more than 2% in a lower lumbar computed tomography and an increase in dynamometer‐assessed handgrip strength of 4 kg. Secondary endpoints included adverse events, C‐reactive protein response, nutritional intake, and symptoms.ResultsOf 24 eligible patients, 16 were included (25% female). At baseline, the mean age was 67 (range 51–88) years, and mean body weight was 64.7 kg (range 39.8–87.2 kg). Five were diagnosed with mesothelioma, two with non‐small‐cell lung cancer, two with renal cell carcinoma, two with neuroendocrine tumours, and five with other malignancies. Mean survival was 43 days. Eleven adverse events (four of which were severe) were recorded with a probable link to study participation. Nine patients completed the study. No participant showed a treatment response. C‐reactive protein‐guided dosing did not result in lower doses of lenalidomide. Lean body mass decreased less in the treatment groups. For the lenalidomide and placebo groups respectively, handgrip strength decreased by 2.3 vs. 5.5 kg, nutritional intake decreased by 249 vs. 32 kcal/day, and C‐reactive protein increased by 35 mg/dL vs. decreased by 17 mg/dL. The study was closed prematurely due to slow accrual and the need for concurrent anticancer treatments.ConclusionsNo treatment response on muscle mass and muscle strength was observed with lenalidomide. Because of several limiting factors, including low recruitment caused in part by an ambitious study design and concomitant anticancer treatment, this study did not generate adequate data to draw reliable conclusions.

Splenic abscess by Cutibacterium propionicum in poorly controlled type 2 diabetes

A 45-year-old farmer presented with intermittent high-grade fever associated with anorexia, dull-aching abdominal pain over left upper quadrant and a documented weight loss of around 20 kg over the preceding...

Malnutrition is a predisposing factor for developing recurrent fever following febrile neutropenia in children with acute lymphoblastic leukemia

IntroductionThe factors that predict recurrence of fever following defervescence (DS) during febrile neutropenia (FN) episode have not been studied. The objective was to estimate the incidence and risk factors for recurrent fever (RF) in children with FN during the intensive phase of acute lymphoblastic leukemia (ALL) treatment. MethodsThe study included 113 consecutive patients diagnosed with ALL. Total of 256 FN episodes in these patients between January 2016 and June 2017 were analysed retrospectively. RF was defined as recurrent febrile event with absolute neutrophil count <500/mm3 that developed after an afebrile interval of 24 h but not exceeding 7 days following a febrile neutropenia episode. ResultsRF developed in 38/256 FNE (14.85%). Evidence of documented focus of infection was observed in 26/38 RF. Risk factors associated with development of RF were: non-remission status of bone marrow, profound neutropenia, persistent neutropenia, clinically or microbiologically documented infection, severe underweight and documented weight loss. Multivariate analysis revealed significant association between RF and non-remission status of bone marrow, profound neutropenia and severe underweight. ConclusionSevere underweight, profound neutropenia and non-remission status of bone marrow predispose the development of RF. These patients require close observation and may require prolonged administration of antibiotics irrespective of DS status.

PROFILE OF GASTRIC MALIGNANCIES PRESENTING AS GASTRIC OUTLET OBSTRUCTION – A ONE AND A HALF YEAR PROSPECTIVE STUDY FROM KASHMIR VALLEY

Background: Gastric adenocarcinoma is one of the frequent cancers seen in Kashmir valley. Patients often present with advanced disease and Gastric Outlet obstruction (GOO). We studied the profile and management of patients presenting with malignant GOO due to Gastric cancer at our center.&#x0D; Methods: A prospective one and half year study from May 2018 to Dec 2019 was done in the Department of Surgical Gastroenterology, Government Medical College, Srinagar. All adult patients with clinical and endoscopic evidence of malignant gastric outlet obstruction and features of gastric cancer were included.&#x0D; Results: Twenty three patients with GOO due to Gastric malignancies were noted in this period with a M:F ratio of 1.9:1 and age range of 32 to 79 years. Vomiting was the most common symptom present in 83 % patients followed by early satiety which was present in 74% of cases. Though patients gave history suggestive of weight loss but only 17 % patients had a documented weight loss. Palliative gastrojejunostomy was done in 21 patients and Radical Distal gastrectomy was done in 2 patients. Surgical site infection was the most common (06 cases; 26%) complication in our group followed by delayed gastric emptying (04 cases; 17.4%) and pulmonary complications (03 cases; 13%).&#x0D; Conclusion: Gastrojejunostomy offers good palliation of symptoms in patients with GOO due to GC. It can be offered with equally good results by laparoscopic access.

Palaeolithic Diet in Diabesity and Endocrinopathies - A Vegan's Perspective.

Introduction: The Palaeolithic diet is designed to resemble that of human hunter-gatherer ancestors thousands to millions of years ago. This review summarises the evidence and clinical application of this diet in various disorders. An empiric vegan variant of it has been provided, keeping in mind vegan food habits. Review of the literature: different types of Palaeolithic diets in vogue include the 80/20, the autoimmune, the lacto, the Palaeolithic vegan and the Palaeolithic ketogenic. We have developed an Indian variant of the Palaeolithic vegan diet, which excludes all animal-based foods. The Palaeolithic diet typically has low carbohydrate and lean protein of 30–35% daily caloric intake in addition to a fibre diet from non-cereal, plant-based sources, up to 45–100 g daily. In different observational studies, beneficial effects on metabolic syndrome, blood pressure, glucose tolerance, insulin secretion, lipid profiles and cardiovascular risk factors have been documented with the Palaeolithic diet. Short-term randomised controlled trials have documented weight loss, and improved glycaemia and adipo-cytokine profiles. Few concerns of micronutrient deficiency (e.g. calcium) have been raised. Conclusion: Initial data are encouraging with regard to the use of the Palaeolithic diet in managing diabesity. There is an urgent need for large randomised controlled trials to evaluate the role of the Palaeolithic diet with different anti-diabetes medications for glycaemic control and the reversal of type 2 diabetes.

A Short Weight Loss Intervention in a Neurosurgical Subspecialist Clinical Setting.

Context:The relationship between back pain and obesity is well characterized; therefore, the neurosurgical consultant visit for back pain may be a key interventional opportunity for weight loss.Aims:The aim of this project was to evaluate efficacy of an educational intervention for back pain.Methods:A retrospective study was undertaken to evaluate effectiveness of an educational intervention (Show patient's own MRI, Explain degenerative disc disease, Relate to weight issues, Reference other weight-related comorbidities, and Encourage a plan of action for weight loss [SERRE]). This has been performed since 2014 for patients presenting to the first author's neurosurgical spine clinic with nonsurgical back pain and body mass index (BMI) over 35.Results:The average BMI was 50.7. Fifty-five percent of patients had additional weight-related comorbidities. After SERRE intervention, 82% of patients were open to weight loss interventions. However, only 22% of patients went on to follow-up with a formal weight management program and only 9% of patients went on to have a documented weight loss. The lack of success was largely attributed to social issues and severe medical comorbidities within the specific population.Conclusions:Incorporation of patient education regarding the relationship of weight loss to back pain and other weight-related comorbidities is well received in a rural specialist consultation setting. Improved communication with primary care physicians regarding this message and further supportive actions may improve follow-through, and therefore success of ultimate weight loss interventions.

Sa1042 Recommending Weight Loss in Patients With GERD Is Effective: Validation of a Quality Measure

Introduction: Elevated body mass index (BMI) is a risk factor for gastroesophageal reflux disease (GERD) and weight loss has been shown to improve GERD symptoms. In our recent development of quality metrics for GERD management via application of RAND/UCLA Appropriateness Methodology, the following was adopted as a measure of GERD care: If a patient with GERD is overweight or obese, then weight loss should be advised. Despite expert panel agreement that this is a highly valid measure, evidence is lacking to support the effectiveness of advising weight loss. The objective of this study was to determine whether physician adherence to this measure resulted in increased weight change and improvement in GERD symptoms. Methods: We identified all outpatients with a GERD diagnosis at a single academic medical center over one year (7/1/2012-7/1/2013). Patients were included if seen in the internal medicine, gastroenterology, or otolaryngology clinics with an index ICD-9 code for GERD (530.81 & 530.11). 993 (71%) had a BMI ≥ 25 kg/m2, of which a representative (by age/BMI) random sample of 250 patients was selected for analysis. Electronic health records were reviewed to assess physician documentation of weight loss recommended, change in patient weight/BMI at follow-up and GERD symptom control. Results: Physicians documented weight loss advice for only 47/250 (18.8%) patients (7 patients did not follow-up in clinic and were excluded from final analysis). The remaining group of 40 patients for whom weight loss advice was documented was matched with 33 patients from the random sample who did not have documented weight loss advice (Table, Figure). Weight loss was more likely to occur in the group with documented weight loss advice compared to those who did not have documented weight loss advice (50% vs. 30%, p=0.07). While mean weight and BMI increased in both groups, there was a significantly lower change in weight (+0.4 kg vs. +1.75 kg, p=0.05) and BMI (+0.13 kg/m2 vs. +0.58 kg/m2, p=0.05) in the weight loss advice group. 30 of all 73 patients achieved weight loss. Of these, 13/30 (43%) reported improvement in GERD symptoms compared to the 9/43 (20%) that did not lose weight (p=0.04). There was a trend towards a higher likelihood of discontinuing PPI use due to GERD resolution in patients who lost weight compared to those who did not (20% vs. 2%, p=0.18). Discussion: Physician documentation of weight loss recommendation for patients with a BMI ≥ 25 kg/m2 was associated with less gain in weight and BMI. In addition, weight loss was associated with improvement in GERD symptoms. Physician adherence to the quality measure: If a patient with GERD is overweight or obese, then weight loss should be advised should be encouraged and measured, as it positively impacts patient adherence and may be linked with improved patient outcomes. Baseline characteristics and clinical outcomes for GERD patients with a BMI > 25 kg/m2

Primary Care Management of Non-Alcoholic Fatty Liver Disease at the Atlanta VA Medical Center: A Quality Improvement Project

Purpose: Non-alcoholic fatty liver disease (NAFLD) and its severe clinical form, non-alcoholic steatohepatitis (NASH), are becoming increasingly prevalent in the U.S., along with the epidemic of obesity. It has been recommended that weight loss, exercise, reduction of sedentary lifestyle, and dietary changes should be implemented as first-line therapy, ideally on a long-term basis, in all patients. Primary care physicians (PCPs) who are at the first-line of management of patients with hepatosteatosis have a crucial role in diagnosing and managing this condition. The aim of this study was to determine the quality of care provided by PCPs for patients with NAFLD, who visited the Atlanta VA hospital. Methods: We retrospectively reviewed the charts of 100 veterans who visited with their PCP between October, 2011 and October, 2012 with a diagnosis of elevated liver enzymes on routine blood testing. PCP notes were carefully reviewed to look at the work-up and management for NAFLD, including if liver imaging was ordered, monitoring weight loss, counseling for exercise, dietary intervention, referral to GI specialist, and primary care follow-up intervals. Patients with history of alcohol abuse and chronic viral hepatitis were excluded. Results: Of the 100 patients we reviewed, 70 had the diagnosis of NAFLD based on some imaging modality. In 70% of the notes, exercise counseling was documented; 75% documented dietary counseling, and 66 % documented weight loss counseling. However, the objective amount of weight loss from the time of diagnosis to the most recent weight was only 1%. Thirty-five percent documented referral for dietary counseling to a nutritionist, and only 5% were referred to hepatology. Two percent of the PCPs arranged a visit specifically to discuss lifestyle modification as the primary objective. Conclusion: NAFLD is the most common cause of elevated liver enzymes in the U.S. According to AASLD, loss of at least 3-5% of body weight appears necessary to improve steatosis, but up to 10% may be needed to improve inflammation. In our patient cohort, although over half of the PCPs documented weight loss, dietary, and exercise counseling, the majority of patients were not meeting even the minimum weight loss goal. The PCP's ability to sustain the change in lifestyle and maintain patient compliance with weight loss, diet, and exercise is sub-optimal. PCPs should consider setting more objective weight loss goals, arranging patient visits specifically to discuss life style modification, and use a multidisciplinary approach to patients with NAFLD, including referral to nutrition and hepatology. Quality improvement measures need to be taken that will facilitate optimization of treatment delivery to this group of patients, soas to prevent the complications of cirrhosis and HCC.

Influence of additional criteria from a definition of cachexia on its prevalence—good or bad thing?

Cachexia is a state of involuntary weight loss. The latest generic definition states that aside from weight loss, patient needs to fulfill additional criteria to be diagnosed with cachexia. New, condition-specific definitions also take the weight loss as a principal criterion, and additional criteria are not mandatory but are a part of further assessment. The aim of this study was to reveal the influence of additional criteria on the prevalence of cachexia in patients with various diseases linked to cachexia. Owing to this, we used the last generic definition. Possible differences in clinical presentations of patients with documented weight loss, with the respect of fulfillment of additional criteria were sought. Clinical and anthropometric data on 137 consecutive patients with malignant diseases and chronic heart failure from a single institution were collected. Fourty-two (30.6%) patients had >5% weight loss in the last 12 months. Only 30 (21.8%) of them were found to meet additional three out of five criteria proposed by the new definition. This observed difference in the prevalence of cachexia diagnosed with or without using additional criteria was found to be significant (P=0.0006). Comparison of clinical/laboratory data showed significantly higher levels of C-reactive protein and lower levels of albumin, as well as lower measurements of mid-arm circumference, triceps and suprailiac skinfolds in patients that fulfilled additional criteria. Survival analysis did not show reduced survival of patients fulfilling additional criteria. Additional criteria 'reduce' the prevalence of cachexia. They are indicative of differences in laboratory and clinical features of cachectic patients but do not influence their survival.

A systematic review of health-related quality of life instruments in patients with cancer cachexia

Assessing the health-related quality of life (HRQOL) of cancer patients with cachexia is particularly important because treatments for cachexia are currently aimed at palliation and treatment efficacy must be measured in ways other than survival. The aim of this systematic review was to evaluate HRQOL assessment in cancer patients with cachexia. Using guidance from the Centre for Reviews and Dissemination, relevant databases were searched from January 1980 to January 2012 with terms relating to cancer, cachexia and HRQOL for papers including adult cancer patients with cachexia or documented weight loss at baseline. We found one cachexia-specific instrument, the Functional Assessment of Anorexia/Cachexia Therapy, but the tool has not been fully validated, does not cover all the relevant domains and the consensus-based standards for the selection of health status measurement instruments checklist highlighted a number of weaknesses in the methodological quality of the validation study. Sixty-seven studies assessed HRQOL in cachectic or weight-losing cancer patients. Most used generic cancer HRQOL instruments, limiting the amount of useful information they provide. A modified version of the Efficace minimum data checklist demonstrated that the quality of reporting on HRQOL tool use was inadequate in many of the studies. A negative relationship between HRQOL and weight loss was found in 23 of the 27 studies which directly examined this. There is a pressing need for a well-designed HRQOL tool for use with this patient group in both clinical trials and clinical practice.

Evaluation of Hypertrophic Pyloric Stenosis by Pediatric Emergency Physician Sonography

The objective was to evaluate the accuracy of pediatric emergency physician (EP) sonography for infants with suspected hypertrophic pyloric stenosis (HPS). This was a prospective observational pilot study in an urban academic pediatric emergency department (PED). Patients were selected if the treating physician ordered an ultrasound (US) in the department of radiology for the evaluation of suspected HPS. Sixty-seven patients were enrolled from August 2009 through April 2012. When identifying the pylorus, pediatric EPs correctly identified all 10 positive cases, with a sensitivity of 100% (95% confidence interval [CI] = 62% to 100%) and specificity of 100% (95% CI = 92% to 100%). There was no statistical difference between the measurements obtained by pediatric EPs and radiology staff for pyloric muscle width or length (p = 0.5 and p = 0.79, respectively). Trained pediatric EPs can accurately assess the pylorus with US in the evaluation of HPS with good specificity.

Liraglutide: Clinical Pharmacology and Considerations for Therapy

Liraglutide is a United States Food and Drug Administration (FDA)-approved glucagon-like peptide-1 (GLP-1) analog that is 97% homologous to native human GLP-1. The additional 16-carbon fatty acid chain causes noncovalent binding to albumin, which slows absorption from the injection site and protects the molecule from degradation by the enzyme dipeptidyl peptidase-4, allowing for protraction of action. Albumin binding and an elimination half-life of 13 hours combine to allow for once-daily dosing. Liraglutide 1.2 and 1.8 mg/day given as monotherapy for up to 52 weeks produced mean reductions in hemoglobin A1c (A1C) of 0.6-1.6%; combination therapy of liraglutide with oral antidiabetic agents demonstrated mean A1C reductions up to 1.5%. The satiety effect of GLP-1 receptor agonists and documented weight loss as great as 3.38 kg in clinical trials may make liraglutide ideal for obese patients with type 2 diabetes mellitus. Like other incretin-based agents, preliminary studies suggest liraglutide may also increase β-cell mass and function. Hypoglycemia is rare with liraglutide and tends to occur when used in combination with sulfonylureas; liraglutide in combination with insulin is not yet FDA approved. The pharmacokinetic parameters of liraglutide are unaffected by age, sex, race, or ethnicity, and no special recommendations for altered dosing of liraglutide need apply to populations with hepatic or renal impairment. Results from clinical trials have not shown an increased risk of medullary thyroid cancer, pancreatitis, or poor cardiovascular outcomes with liraglutide treatment. Ongoing, long-term monitoring studies continue to evaluate the safety of liraglutide treatment in these outcomes.

Illicit Drug, Ischemic Bowel

h m 2 PRESENTATION In the young adult or middle-aged patient with abdominal pain and bloody diarrhea, a history of cocaine abuse is an important consideration in the differential diagnosis, as illustrated in this case. A 44-year-old male construction worker presented to our general medicine clinic reporting 1 year of recurrent, sharp, left-sided abdominal pain associated with frequent loose stools. For a few days before presentation, he had been unable to sleep because of the pain. The painful episodes were associated with some rectal bleeding and a documented weight loss of 40 lb but no nausea, vomiting, abdominal distension, food intolerance, or change in appetite. The patient denied urinary problems (hematuria, frequency, urgency, dysuria) and fever. His medical and surgical history were unremarkable except for an appendectomy 15 years previously; he had never had a colonoscopy. His social history was significant for smoking (20 pack-years) and occasional alcohol use. He denied use of illicit drugs.

Childhood Sexual Abuse in the Palliative Care Setting: Comorbidities and Management Strategies (410-C)

Results. In the algorithm, patients with KPS > 90%, 80% without weight loss, 60e80% with weight loss, and less than 60% were identified with median survivals of 411, 255, 124, and 37 days, respectively. Patient distress from weight loss was closely correlated with documented weight loss (r 1⁄4 0.48, p < 0.0001). In the validation set, median Kaplan Meier survivals were 173, 180, 102, and 50 days, (p < 0.0001). For 620 cancer pts, median survivals were 417, 102, 45 and 14 days, (p < 0.0001), and (blank), 276, 181 and 100 days for 163 non-cancer diagnosis pts (p non-significant). Conclusion. An RPA that incorporates KPS and patient-rated weight loss developed four prognostic groups in palliative care cancer patients. A larger sample is needed in pts with non-cancer diagnoses. Supported by VA HSRD, PDIA, and NJCCR. Implications for research, policy, or practice. This algorithm may be useful for research and practice in stratifying patients for survival.