A randomized trial of dietary sodium restriction in CKD

There is a paucity of quality evidence regarding the effects of sodium restriction in patients with CKD, particularly in patients with pre-end stage CKD, where controlling modifiable risk factors may be especially important for delaying CKD progression and cardiovascular events. We conducted a double-blind placebo-controlled randomized crossover trial assessing the effects of high versus low sodium intake on ambulatory BP, 24-hour protein and albumin excretion, fluid status (body composition monitor), renin and aldosterone levels, and arterial stiffness (pulse wave velocity and augmentation index) in 20 adult patients with hypertensive stage 3-4 CKD as phase 1 of the LowSALT CKD study. Overall, salt restriction resulted in statistically significant and clinically important reductions in BP (mean reduction of systolic/diastolic BP, 10/4 mm Hg; 95% confidence interval, 5 to 15 /1 to 6 mm Hg), extracellular fluid volume, albuminuria, and proteinuria in patients with moderate-to-severe CKD. The magnitude of change was more pronounced than the magnitude reported in patients without CKD, suggesting that patients with CKD are particularly salt sensitive. Although studies with longer intervention times and larger sample sizes are needed to confirm these benefits, this study indicates that sodium restriction should be emphasized in the management of patients with CKD as a means to reduce cardiovascular risk and risk for CKD progression.

The malnutrition screening tool versus objective measures to detect malnutrition in hip fracture

BACKGROUND

The Malnutrition Screening Tool (MST) is the most commonly used screening tool in Australia. Poor screening tool sensitivity may lead to an under-diagnosis of malnutrition, with potential patient and economic ramifications. The present study aimed to determine whether the MST or anthropometric parameters adequately detect malnutrition in patients who were admitted to a hip fracture unit.

METHODS

Data were analysed for a prospective convenience sample (n = 100). MST screening was independently undertaken by nursing staff and a nutrition assistant. Mid upper arm circumference (MUAC) was measured by a trained nutrition assistant. Nutritional risk [MST score ≥ 2, body mass index (BMI) < 22 kg m(-2) , or MUAC < 25 cm] was compared with malnutrition diagnosed by accredited practicing dietitians using International Classification of Diseases version 10-Australian Modification (ICD10-AM) coding criteria.

RESULTS

Malnutrition prevalence was 37.5% using ICD10-AM criteria. Delirium, dementia or preadmission cognitive impairment was present in 65% of patients. The BMI as a nutrition risk screen was the most valid predictor of malnutrition (sensitivity 75%; specificity 93%; positive predictive value 73%; negative predictive value 84%). Nursing MST screening was the least valid (sensitivity 73%; specificity 55%; positive predictive value 50%; negative predictive value 77%). There was only fair agreement between nursing and nutrition assistant screening using the MST (κ = 0.28).

CONCLUSIONS

In this population with a high prevalence of delirium and dementia, further investigation is warranted into the performance of nutrition screening tools and anthropometric parameters such as BMI. All tools failed to predict a considerable number of patients with malnutrition. This may result in the under-diagnosis and treatment of malnutrition, leading to case-mix funding losses.

The effect of lowering salt intake on ambulatory blood pressure to reduce cardiovascular risk in chronic kidney disease (LowSALT CKD study): protocol of a randomized trial

BACKGROUND

Despite evidence implicating dietary sodium in the pathogenesis of cardiovascular disease (CVD) in chronic kidney disease (CKD), quality intervention trials in CKD patients are lacking. This study aims to investigate the effect of reducing sodium intake on blood pressure, risk factors for progression of CKD and other cardiovascular risk factors in CKD.

METHODS/DESIGN

The LowSALT CKD study is a six week randomized-crossover trial assessing the effect of a moderate (180 mmol/day) compared with a low (60 mmol/day) sodium intake on cardiovascular risk factors and risk factors for kidney function decline in mild-moderate CKD (stage III-IV). The primary outcome of interest is 24-hour ambulatory blood pressure, with secondary outcomes including arterial stiffness (pulse wave velocity), proteinuria and fluid status. The randomized crossover trial (Phase 1) is supported by an ancillary trial (Phase 2) of longitudinal-observational design to assess the longer term effectiveness of sodium restriction. Phase 2 will continue measurement of outcomes as per Phase 1, with the addition of patient-centered outcomes, such as dietary adherence to sodium restriction (degree of adherence and barriers/enablers), quality of life and taste assessment.

DISCUSSION

The LowSALT CKD study is an investigator-initiated study specifically designed to assess the proof-of-concept and efficacy of sodium restriction in patients with established CKD. Phase 2 will assess the longer term effectiveness of sodium restriction in the same participants, enhancing the translation of Phase 1 results into practice. This trial will provide much-needed insight into sodium restriction as a treatment option to reduce risk of CVD and CKD progression in CKD patients.

TRIAL REGISTRATION

Universal Trial Number: U1111-1125-2149. Australian New Zealand Clinical Trials Registry Number: ACTRN12611001097932.

Beyond malnutrition screening: appropriate methods to guide nutrition care for aged care residents

BACKGROUND

Malnutrition is common in older adults and early and appropriate nutrition intervention can lead to positive quality of life and health outcomes.

OBJECTIVE

The purpose of our study was to determine the concurrent validity of several malnutrition screening tools and anthropometric parameters against validated nutrition assessment tools in the long-term-care setting.

STUDY DESIGN

This work was a cross-sectional, observational study.

PARTICIPANTS/SETTING

Older adults (aged >55 years) from two long-term-care facilities were screened.

MAIN OUTCOMES

Nutrition screening tools used included the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment-Short Form (MNA-SF), and the Simplified Nutritional Assessment Questionnaire. Nutritional status was assessed by Subjective Global Assessment (SGA), Mini Nutritional Assessment (MNA), body mass index (BMI), corrected arm muscle area, and calf circumference. Residents were rated as either well nourished or malnourished according to each nutrition assessment tool.

STATISTICAL ANALYSIS

A contingency table was used to determine the sensitivity and specificity of the nutrition screening tools and objective measures in detecting patients at risk of malnutrition compared with the SGA and MNA.

RESULTS

One hundred twenty-seven residents (31.5% men; mean age 82.7 ± 9 years, 57.5% high care) consented. According to SGA, 27.6% (n=31) of residents were malnourished and 13.4% were rated as malnourished by MNA. MST had the best sensitivity and specificity compared with the SGA (sensitivity 88.6%, specificity 93.5%, ?=0.806), followed by MNA-SF (85.7%, 62%, ?=0.377), MUST (68.6%, 96.7%, ?=0.703), and Simplified Nutritional Assessment Questionnaire (45.7%, 77.2%, ?=0.225). Compared with MNA, MNA-SF had the highest sensitivity of 100%, but specificity was 56.4% (?=0.257). MST compared with MNA had a sensitivity of 94.1%, specificity 80.9% (?=0.501). The anthropometric screens ranged from ?=0.193 to 0.468 when compared with SGA and MNA.

CONCLUSIONS

MST, MUST, MNA-SF, and the anthropometric screens corrected arm muscle area and calf circumference have acceptable concurrent validity compared with validated nutrition assessment tools and can be used to triage nutrition care in the long-term-care setting.

Influence of deuteration on lithium acetate dihydrate studied by inelastic X-ray scattering, density functional theory, thermal expansion, elastic and thermodynamic measurements

The influence of deuteration on the properties of lithium acetate dihydrate has been investigated by thermal expansion measurements, ultrasound spectroscopy and calorimetry. Inelastic X-ray scattering has been employed to investigate if the low temperature structural phase transition can be detected by a change in the vibrational spectrum. Density functional theory, DFT, calculations have been employed to complement the experimental investigations. The thermal expansion coefficients and the specific heat of the deuterated compound differ significantly from the protonated form. The differences in the elastic stiffness coefficients are just above the detection limit of the technique employed here. Temperature dependent inelastic X-ray spectroscopic measurements show no significant change of the vibrational spectrum when crossing the transition temperature. The DFT calculations show that the methyl group dynamics are best described in the framework of coupled rotators of opposing methyl groups. One of the coupled rotational modes corresponds to a hindered rotator with a barrier of 15 meV, while the other is a free rotator.

Maintaining nutrition in aged care residents with a train-the-trainer intervention and Nutrition Coordinator

OBJECTIVE

To investigate the impact of a train-the-trainer program on the nutritional status of older people in residential care.

DESIGN

Prospective, randomized controlled study.

SETTING

Eight nursing homes in Southeast Queensland, Australia.

PARTICIPANTS

A total of 352 residents participated - 245 were female (69.6%). The mean age was 84.2 years and the majority (79.4%) were classified as high dependency.

INTERVENTION

Residents from four nursing homes were randomly selected for a nutrition education program coordinated by Nutrition Coordinators. Residents from the other four nursing homes (control) received usual care.

MEASUREMENTS

The Subjective Global Assessment was used to determine prevalence of malnutrition at baseline and six months post intervention. The Resident Classification Scale measured functional dependency. Prescribed diet, fluids, oral hygiene status and allied health referrals were obtained by chart audit.

RESULTS

Approximately half the residents were well nourished with 49.4% moderately or severely malnourished. Residents in the intervention group were more likely to maintain or improve their nutritional status compared with the control group who were more likely to experience a deterioration (P=0.027). The odds of the control group being malnourished post test was 1.6 times more likely compared with the intervention group but this did not reach statistical significance (P=0.1).

CONCLUSION

The results of the study encourage the implementation of a Nutrition Coordinator program to maintain nutritional status of aged care residents. Nevertheless, malnutrition rates continue to be unacceptably high. In a rapidly aging society, the aged care sector needs to confront malnutrition and provide better resources for staff to take measures against this problem.

Magnetic resonance imaging and spectroscopy for monitoring liver steatosis

PURPOSE

To compare noninvasive MRI and magnetic resonance spectroscopy (MRS) methods with liver biopsy to quantify liver fat content.

MATERIALS AND METHODS

Quantification of liver fat was compared by liver biopsy, proton MRS, and MRI using in-phase/out-of-phase (IP/OP) and plus/minus fat saturation (+/-FS) techniques. The reproducibility of each MR measure was also determined. An additional group of overweight patients with steatosis underwent hepatic MRI and MRS before and after a six-month weight-loss program.

RESULTS

A close correlation was demonstrated between histological assessment of steatosis and measurement of intrahepatocellular lipid (IHCL) by MRS (r(s) = 0.928, P < 0.0001) and MRI (IP/OP r(s) = 0.942, P < 0.0001; FS r(s) = 0.935, P < 0.0001). Following weight reduction, four of five patients with >5% weight loss had a decrease in IHCL of >or=50%.

CONCLUSION

These findings suggest that standard MRI protocols provide a rapid, safe, and quantitative assessment of hepatic steatosis. This is important because MRS is not available on all clinical MRI systems. This will enable noninvasive monitoring of the effects of interventions such as weight loss or pharmacotherapy in patients with fatty liver diseases.

Randomized controlled trial of nutritional counseling on body composition and dietary intake in severe CKD

BACKGROUND

Progressive loss of kidney function results in an increased risk of malnutrition. Despite this, there is little evidence informing the impact of nutrition intervention on predialysis patients with chronic kidney disease (CKD; stages 4 and 5).

STUDY DESIGN

Randomized controlled trial.

SETTING & PARTICIPANTS

56 outpatients (men, 62%; mean age, 70.7 +/- 14.0 [SD] years) with CKD were randomly allocated to intervention (n = 29) or control (n = 27) by using a concealed computer-generated sequence.

INTERVENTION

The intervention group, provided with individualized dietary counseling with regular follow-up aimed at achieving an intake of 0.8 to 1.0 g/kg of protein and greater than 125 kJ/kg of energy, or control, receiving written material only.

OUTCOMES & MEASURES

Change in body composition (body cell mass, measured by means of total-body potassium, in 40 of 56 participants), nutritional status (Subjective Global Assessment), and energy and protein intake (3-day food record).

RESULTS

During the 12 weeks, the intervention group had 3.5% (95% confidence interval, -2.1 to 9.1) less decrease in body cell mass, 17.7-kJ/kg/d (95% confidence interval, 8.2 to 27.2) greater increase in energy intake, greater improvement in Subjective Global Assessment (P < 0.01), and no significant difference in protein intake compared with the control group (-0.04 g/kg/d; 95% confidence interval, -0.73 to 0.16). The intervention was associated with greater increases in energy and protein intake in women than men (interaction P < 0.001 for both).

LIMITATIONS

Power to detect change in body cell mass, potential bias in ascertainment of Subjective Global Assessment.

CONCLUSIONS

In predialysis patients with CKD, structured nutrition intervention had a greater effect on energy and protein intake in women than men. Additional investigations are warranted to determine the impact on body composition.

Nutrition Support Using the American Dietetic Association Medical Nutrition Therapy Protocol for Radiation Oncology Patients Improves Dietary Intake Compared with Standard Practice

BACKGROUND

A randomized controlled trial previously conducted in radiation oncology patients demonstrated that nutrition intervention had a beneficial impact on body weight, nutritional status, and quality of life compared with standard practice, but it did not report on dietary intake data.

OBJECTIVE

To determine the impact of nutrition intervention compared with standard practice on dietary intake in outpatients receiving radiotherapy.

DESIGN

Prospective, randomized, controlled trial.

SUBJECTS

Sixty consecutive radiation oncology outpatients (51 men and nine women; age 61.9+/-14 years [mean+/-standard deviation]).

SETTING

Australian private radiotherapy facility.

INTERVENTION

Patients were randomly assigned to receive either nutrition intervention (n=29) (nutrition counseling following the American Dietetic Association [ADA] medical nutrition therapy [MNT] protocol for radiation oncology) or standard practice (n=31) (general nutrition talk and booklet).

MAIN OUTCOME MEASURE

Dietary intake (protein, energy, fiber) assessed at baseline and at 4, 8, and 12 weeks after starting radiotherapy.

STATISTICAL ANALYSES

Repeated-measures analysis of variance done on an intention to treat basis.

RESULTS

The nutrition intervention group had a higher mean total energy (P=0.029) and protein intake (P<0.001) compared with the standard practice group. Mean intake per kilogram of body weight for the nutrition intervention group ranged from 28 to 31 kcal/kg/day compared with 25 to 29 kcal/kg/day for the standard practice group (P=0.022). The nutrition intervention group had a higher mean protein intake (1.1 to 1.3 g/kg/day) compared with the standard practice group (1.0 to 1.1 g/kg/day) (P=0.001). Although the change in fiber intake between the groups was not significant, there was a trend in the anticipated direction (P=0.083).

CONCLUSIONS

Intensive nutrition intervention following the ADA MNT protocol results in improved dietary intake compared with standard practice and seems to beneficially impact nutrition-related outcomes previously observed in oncology outpatients receiving radiotherapy. The ADA MNT protocol for radiation oncology is a useful guide to the level of nutrition support required.

Principal component, Varimax rotation and cost analysis of volume effects in rectal bleeding in patients treated with 3D-CRT for prostate cancer

We investigate the utility of principal component analysis as a tool for obtaining dose-volume combinations related to rectal bleeding after radiotherapy for prostate cancer. A direct implementation of principal component analysis reduces the number of degrees of freedom from the patient's dose-volume histograms that are associated with bleeding. However, when low-variance principal components are strongly correlated to outcome, their interpretation is problematic. A Varimax rotation is employed to aid in interpretability of the low-variance principal components. This procedure brings us closer to finding unique dose-volume combinations related to outcome but reintroduces correlation, requiring analysis of the overlap of information contained in such modes. Finally, we present examples of cost-benefit analyses for candidate dose-volume constraints for use in treatment planning.

Palifermin improves severe mucositis, swallowing problems, nutrition impact symptoms, and length of stay in patients undergoing hematopoietic stem cell transplantation

GOAL OF WORK

The aim of this study was to compare palifermin, a recombinant form of human keratinocyte growth factor, with standard treatment on outcomes in patients receiving a high dose of chemotherapy conditioning regimen, undergoing hematopoietic stem cell transplantation (HSCT).

MATERIALS AND METHODS

Over a 1-year period, a series of 59 patients were included: 32 patients (palifermin) were compared with 27 patients (standard treatment). Outcomes assessed at day 8 posttransplantation were mucositis, swallowing, nutrition impact symptoms, dietary intake, time to engraftment, length of stay, infection, and cumulative dose and duration of narcotic administration.

MAIN RESULTS

There was a significant reduction in the incidence of severe oral mucositis (13 vs 48%, p=0.003), swallowing problems (p=0.044), number of nutrition impact symptoms experienced (4.9 vs 6.0, p=0.003), and length of stay (14 vs 18 days, p=0.026) in the palifermin group compared to standard care. There was no significant difference in infection, dietary intake, time to engraftment or cumulative dose and duration of narcotic administration between groups.

CONCLUSIONS

Beneficial outcomes were observed from the use of palifermin in patients undergoing HSCT after a high dose of chemotherapy conditioning regimen. A randomized clinical trial is needed to confirm these results.

Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients

BACKGROUND & AIMS

The extent of malnutrition in hospitalised stroke patients and its influence on outcomes including hospital complications, length of stay and discharge destination are important issues. The aim of this study was to determine the nutritional status of patients admitted to an acute stroke unit and the association between nutritional status and health outcomes.

METHODS

Nutritional status was determined prospectively using the scored patient generated subjective global assessment (PG-SGA) in patients (n=73) admitted to an acute stroke unit within 48 h of admission to an Australian private hospital. Outcome data were collected by retrospective audit.

RESULTS

On admission, 19.2% of patients were malnourished and this was associated with a significantly greater PG-SGA score (15 vs. 5) and lower body weight (59.8 kg vs. 75.8 kg) compared to well-nourished patients. In terms of health outcomes, malnourished patients had longer length of stay (13 vs. 8 days), increased complications (50% vs. 14%), increased frequency of dysphagia (71% vs. 32%) and enteral feeding (93% vs. 59%). No association was found between nutritional status and serum albumin level or discharge destination.

CONCLUSIONS

Malnutrition on admission to hospital after acute stroke is associated with poor outcomes including increased length of stay and increased prevalence of dysphagia and complications. The scored PG-SGA is a nutrition assessment tool that allows quick identification of malnourished stroke patients.

Nutrition intervention improves outcomes in patients with cancer cachexia receiving chemotherapy--a pilot study

GOALS OF THE WORK

The aim of this study was to examine the effect of nutrition intervention on outcomes of dietary intake, body composition, nutritional status, functional capacity and quality of life in patients with cancer cachexia receiving chemotherapy.

PATIENTS AND METHODS

Patients received weekly counselling by a dietitian and were advised to consume a protein- and energy-dense oral nutritional supplement with eicosapentaenoic acid for 8 weeks. The medical oncologist determined the chemotherapy protocol. Eight patients enrolled and seven completed the study.

MAIN RESULTS

There were significant improvements in total protein intake (median change 0.3 g/kg per day, range -0.1 to 0.8 g/kg per day), total energy intake (median change 36 kJ/kg per day, range -2 to 82 kJ/kg per day), total fibre intake (median change 6.3 g/day, range -3.4 to 20.1 g/day), nutritional status (patient-generated subjective global assessment score, median change 9, range -5 to 17), Karnofsky performance status (median change 10, range 0-30) and quality of life (median change 16.7, range 0-33.3). There were clinically significant improvements in weight (median change 2.3 kg; range -2.7 to 4.5 kg) and lean body mass (median change 4.4 kg, range -4.4 to 4.7 kg), although these were not statistically significant. Change in nutritional status was significantly associated with change in quality of life, change in Karnofsky performance status and change in lean body mass.

CONCLUSIONS

Nutrition intervention together with chemotherapy improved outcomes in patients with pancreatic and non-small-cell lung cancer over 8 weeks. Supplement intake does not inhibit meal intake.

Nutrition intervention is beneficial in oncology outpatients receiving radiotherapy to the gastrointestinal or head and neck area

Malnutrition occurs frequently in patients with cancer of the gastrointestinal (GI) or head and neck area and can lead to negative outcomes. The aim of this study is to determine the impact of early and intensive nutrition intervention (NI) on body weight, body composition, nutritional status, global quality of life (QoL) and physical function compared to usual practice in oncology outpatients receiving radiotherapy to the GI or head and neck area. Outpatients commencing at least 20 fractions of radiotherapy to the GI or head and neck area were randomised to receive intensive, individualised nutrition counselling by a dietitian using a standard protocol and oral supplements if required, or the usual practice of the centre (general advice and nutrition booklet). Outcome parameters were measured at baseline and 4, 8 and 12 weeks after commencing radiotherapy using valid and reliable tools. A total of 60 patients (51M : 9F; mean age 61.9±14.0 years) were randomised to receive either NI (n=29) or usual care (UC) (n=31). The NI group had statistically smaller deteriorations in weight (P<0.001), nutritional status (P=0.020) and global QoL (P=0.009) compared with those receiving UC. Clinically, but not statistically significant differences in fat-free mass were observed between the groups (P=0.195). Early and intensive NI appears beneficial in terms of minimising weight loss, deterioration in nutritional status, global QoL and physical function in oncology outpatients receiving radiotherapy to the GI or head and neck area. Weight maintenance in this population leads to beneficial outcomes and suggests that this, rather than weight gain, may be a more appropriate aim of NI.

Detailed measurements of a diffusive supersonic wave in a radiatively heated foam

We have made the first detailed measurements of a diffusive supersonic radiation wave in the laboratory. A 10 mg/cm(3) SiO2 foam is radiatively heated by the x-ray flux from a laser-irradiated hohlraum. The resulting radiation wave propagates axially through the optically thick foam and is measured via time-resolved x-ray imaging as it breaks out the far end. The data show that the radiation wave breaks out at the center prior to breaking out at the edges, indicating a significant curvature in the radiation front. This curvature is primarily due to energy loss into the walls surrounding the foam.

An assessment of a premedical program in terms of its ability to serve black Americans

If special programs to increase the number of blacks gaining entry into health professional schools can identify whom they best serve, changes in either the selection process or the curriculum can increase their effectiveness. As one part of an evaluation of the effectiveness of the various components of the prehealth professions program at Xavier University of Louisiana (XU), black freshmen entering the university from 1981 to 1983 in the university's premedical program were tracked to determine who gained entry into medical and related mainline health professional schools upon graduation.The analyses indicate that high-ability black freshmen entering Xavier are more than twice as likely to gain admission into medical school than are their black counterparts nationally, and that this difference is statistically significant beyond the 99 percent level. Fifty-seven percent of high-ability black freshmen (those with American College Testing [ACT] composite scores of 24 or above, the top 2 percent of blacks nationally) who entered XU's biology or chemistry programs during the period under study gained entry into medical school upon graduation, whereas a study by the Educational Testing Service indicates that only 24 percent of similar blacks nationally gain entry into any graduate or professional school.The present study suggests that XU's premedical program serves those blacks who are not in the high-ability group (those whose ACT scores are below 24) at least as well (relative to the national average) as it does the top students. It therefore seems reasonable to assume that XU's premedical program is successful because it increases the probability that students gain admission into health professional schools rather than because of any preselection of students. These results are similar to those obtained from a comparable analysis of XU's prepharmacy program, the other component of prehealth at Xavier.