Coronary angiotomography in patients with acute coronary syndrome without ST elevation

BACKGROUND

In patients presenting with acute coronary syndrome (ACS) current clinical practice guidelines recommend coronary angiography for its study. This study aims to describe the role of coronary tomography (CT) in non-ST-segment elevation acute coronary syndromes (NSTE-ACS).

RESULTS

Patients over 18 years with a diagnosis of NSTE-ACS who did not meet high-risk criteria and consulted the emergency department of our institution were included. A total of 410 patients were included, in 7% of them, the study was not continued due to an elevated calcium score (>400 AU). 27% had no coronary lesions, 38% had non-obstructive coronary disease (plaques <50%), 27% had plaques over 50%, and 8% were not assessable. Of the total patients, 39% underwent coronary angiography, and 22% required percutaneous angioplasty.

CONCLUSIONS

Performing CT in low and moderate-risk NSTE-ACS patients was feasible, avoiding invasive studies in a significant number of patients and providing extensive anatomical information.

Effects of co-ingesting glucose and whey protein on blood glucose, plasma insulin and glucagon concentrations, and gastric emptying, in older men with and without type 2 diabetes

AIM

To investigate whether co-ingestion of dietary protein with, or before, carbohydrate may be a useful strategy to reduce postprandial hyperglycaemia in older men with type 2 diabetes (T2D).

MATERIALS AND METHODS

Blood glucose, plasma insulin and glucagon concentrations were measured for 180 minutes following ingestion of a drink containing 30 g of glucose (G; 120 kcal), 30 g of whey protein (120 kcal), 30 g of glucose plus 30 g of whey protein (GP; 240 kcal), or control (~2 kcal) in older men with T2D (n = 10, 77 ± 1 years; 31 ± 1.7 kg/m² ) and without T2D (n = 10, 78 ± 2 years; 27 ± 1.4 kg/m² ). Mixed model analysis was used.

RESULTS

GP versus G markedly reduced the increase in blood glucose concentrations (P < .001) and had a synergistic effect on the increase in insulin concentrations (P < .001), in men both with and without T2D. Glucose concentrations were higher in men with T2D compared with those without T2D, whereas insulin and glucagon concentrations were largely unaffected by the presence of T2D. Gastric emptying was faster in men with T2D than in those without T2D.

CONCLUSIONS

The ability of whey protein to reduce carbohydrate-induced, postprandial hyperglycaemia is retained in older men with T2D compared with those without T2D, and whey protein supplementation may be a useful strategy in the prevention and management of T2D in older people.

Cardiac magnetic resonance diagnosis of Fabry disease leads to incidental diagnosis of Klinefelter syndrome: a case report

Background

Fabry disease is an X-linked lysosomal storage disorder resulting in deficient activity of alpha-galactosidase. Males are general more severely affected however heterozygous females can variably express the disease depending on the degree of random X chromosome inactivation (Lyonization). We present a case where cardiac magnetic resonance diagnosis of late onset Fabry Disease leads to an incidental diagnosis of Klinefelter syndrome.

Case summary

A 55-year-old male was referred for cardiology assessment after developing atrial fibrillation. Echocardiography demonstrated moderate, concentric LVH (left ventricular hypertrophy). Cardiac magnetic resonance imaging confirmed the presence of concentric increase in LV wall thickness and increased LV (left ventricular) mass. T₁ mapping values (Shortened Modified Look-Locker Inversion recovery sequences) were elevated in the basal-mid inferolateral segments and low in the remaining segments. Late gadolinium acquisition showed a pattern suggestive of Fabry disease. Genetic testing of the GLA gene revealed a null variant classified as pathogenic. The variant was found to be heterozygous. This raised the possibility of Klinefelter's syndrome and the diagnosis was confirmed by chromosomal microarray and karyotype. The patient was then referred to Fabry clinic for consideration of enzyme replacement therapy and to the endocrine clinic for testosterone replacement.

Discussion

The atypical ’cardiac variant‘ Fabry disease should be included in differential diagnosis of left ventricular hypertrophy. In a ‘late onset’ presentation of Fabry Disease, the concomitant presence of Klinefelter syndrome cannot be excluded due to GLA variant present in the heterozygous state.

Acute effects of whey protein, alone and mixed with other macronutrients, on blood pressure and heart rate in older men

BACKGROUND

Caloric supplements are increasingly used by older people, aiming to increase their daily protein intake. These high caloric drinks, rich in glucose and whey-protein in particular, may result in potential harmful decreases in blood pressure (BP). The effect of ingesting whey-protein with glucose and fat on BP is unknown. It has also been assumed that the maximum fall in systolic blood pressure occurs within 2 h of a meal.

METHODS

This study aimed to determine in older men, the effects of whey-protein, alone and mixed with other macronutrients, on systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR) in older men for 3 h. Thirteen older men (age 75 ± 2yrs; body mass index (BMI) 25.6 ± 0.6 kg/m²) ingested a drink on separate study days: (i) 70 g whey-protein (P₂₈₀)_; (ii) 14 g whey-protein, 28 g carbohydrate, 12.4 g fat (M₂₈₀); (iii) 70 g whey-protein, 28 g carbohydrate, 12.4 g fat (M₅₀₄); or (iv) a non-caloric control drink (C).

RESULTS

SBP decreased after all three nutrient drinks compared to the C, with the greatest reduction after the M₅₀₄ drink (P = 0.008). Maximal decreases in SBP (C: -14 ± 2 mmHg, P₂₈₀: -22 ± 2 mmHg, M₂₈₀: -22 ± 4 mmHg, M₅₀₄: -24 ± 3 mmHg) occurred about 2 h after drink ingestion and this fall was sustained thereafter (120-180 min: P₂₈₀ and M₅₀₄ vs. C P < 0.05). Maximum DBP decreases and HR increases occurred after M₅₀₄, with no differences between the effects of the P₂₈₀ and M₂₈₀ drinks.

CONCLUSIONS

The effects of whey-protein containing drinks to lower BP and increase HR appear to be primarily dependent on their energy content rather than macronutrient composition and may persist for at least 3 h after ingestion,. Pure whey-protein drinks may represent the best approach to maximize protein intake without increasing the potential for deleterious BP falls in older people.

TRIAL REGISTRATION

ACTRN12614000846628 , 14/03/2019.

Blood Pressure and Heart Rate Responses following Dietary Protein Intake in Older Men

Postprandial hypotension (PPH) occurs frequently in older people >65 years old. Protein-rich supplements, particularly whey protein (WP), are increasingly used by older people for various health benefits. We have reported that 70 g WP drinks cause significant, and in some cases marked, falls in blood pressure (BP) in older men. The effects of lower, more widely used, doses (~30 g) on systolic (SBP) and diastolic (DBP) blood pressure and heart rate (HR) are not known. In a randomized order, eight older men (age: 72 ± 1 years; body mass index (BMI): 25 ± 1 kg/m2) after overnight fast ingested a drink containing (i) a non-caloric control (~2 kcal), (ii) 30 g of whey protein (120 kcal; ‘WP30’), or (iii) 70 g of whey protein (280 kcal; ‘WP70’). The BP and HR were measured in this pilot study with an automated device before and at 3-min intervals for 180 min following drink ingestion. Drink condition effects were determined by repeated-measures ANOVA. The SBP decreased after both WP drinks compared to the control (p = 0.016), particularly between 120 and 180 min, with no difference in the effects of WP30 and WP70. The SBP decreased by ≥20 mmHg in more than 50% of people after both WP drinks (WP30: 63%; WP70: 75%) compared to 38% after the control. The maximum fall in the SBP occurred during the third hour, with the nadir occurring latest after WP70. The DBP decreased non-significantly by several mmHg more after the WP drinks than after the control. The maximum HR increases occurred during the third hour, with the greatest increase after WP70. The SBP decreased after both WP drinks compared to the control, with the effects most evident between 120 and 180 min. Accordingly, ingestion of even relatively modest protein loads in older men has the potential to cause PPH.

Effects of age on blood pressure and heart rate responses to whey protein in younger and older men

BACKGROUND

Postprandial falls in blood pressure (BP) are more common in older compared to younger individuals. The effects of protein compared to carbohydrates and fat on postprandial BP, and the relation to gastric emptying rates, are poorly studied.

OBJECTIVES

To determine the effects of a whey protein compared to a control drink on systolic BP (SBP) and diastolic BP (DBP), and heart rate (HR) in healthy younger and older men, and to relate these effects to gastric emptying.

DESIGN

A pooled analyses of two randomized, double-blind, cross-over studies.

SETTING

Two acute clinical intervention studies with identical study design.

PARTICIPANTS

Nineteen older (age: 74 ± 1 years, body mass index: 26 ± 1 kg/m² ) and 13 younger (23 ± 1 years, 24 ± 1 kg/m² ) healthy men.

INTERVENTION

A 70 g/280 kcal whey-protein or control (water with diet cordial, ~2 kcal) drink (450 ml).

MEASUREMENTS

BP and HR were assessed with an automated device immediately before and at 3-min intervals after drink ingestion (0-180 min). Gastric emptying of the drinks was measured using 3D ultrasonography (0-180 min).

RESULTS

Older versus younger men exhibited a greater fall in SBP (-23 ± 2 vs -15 ± 2 mmHg, p = 0.001) after whey-protein versus control, as BP did not change after the two drinks in younger men (p > 0.05). The nadir in SBP occurred later in the older than younger men (114 ± 11 vs 62 ± 14 min; p < 0.001), with SBP still apparently declining 180 min after whey-protein ingestion in the older men. The magnitude of the rise in HR was greater (p < 0.05) in the younger than older men.

CONCLUSION

Following ingestion of 70 g whey protein, healthy older men exhibited a sustained fall in BP, despite an increase in HR, whereas in younger men there was no change in BP. BP may need to be monitored after high protein meals in older people at risk of postprandial hypotension.

Rational Use of Protein Supplements in the Elderly-Relevance of Gastrointestinal Mechanisms

Protein supplements are increasingly used by older people to maintain nutrition and prevent or treat loss of muscle function. Daily protein requirements in older people are in the range of 1.2 gm/kg/day or higher. Many older adults do not consume this much protein and are likely to benefit from higher consumption. Protein supplements are probably best taken twice daily, if possible soon after exercise, in doses that achieve protein intakes of 30 gm or more per episode. It is probably not important to give these supplements between meals, as we have shown no suppressive effects of 30 gm whey drinks, and little if any suppression of 70 gm given to older subjects at varying time intervals from meals. Many gastrointestinal mechanisms controlling food intake change with age, but their contributions to changes in responses to protein are not yet well understood. There may be benefits in giving the supplement with rather than between meals, to achieve protein intakes above the effective anabolic threshold with lower supplement doses, and have favourable effects on food-induced blood glucose increases in older people with, or at risk of developing, type 2 diabetes mellitus; combined protein and glucose drinks lower blood glucose compared with glucose alone in older people.

Quantitative biomonitoring of polycyclic aromatic compounds (PACs) using the Sydney rock oyster (Saccostrea glomerata)

Increasing our understanding of the bioavailable fractions of polycyclic aromatic compounds (PACs) in an aquatic environment is important for the assessment of the environmental and human health risks posed by PACs. More importantly, the behaviour of polar polycyclic aromatic hydrocarbons (polar PAHs), which are metabolites of legacy PAHs, are yet to be understood. We, therefore, carried out a study involving Sydney rock oysters (Saccostrea glomerata) sourced from two locations, that had been exposed to PAH contamination, within an Australian south-east estuary. Biomonitoring of these oysters, following relocation from the estuary to a relatively isolated waterway, was done at 24 and 72 h after deployment and subsequently at 7, 14, 28, 52 and 86 days. Control samples from Camden Haven River were sampled for PAC analyses just before deployment, after 28 days and at the end of the study (day 86). Lipid-normalised concentrations in oyster tissues across the 86-day sampling duration, elimination rate constants (k₂), biological half-lives (t_1/2) and time required to reach 95% of steady-state (t₉₅) were reported for parent PAHs and the less-monitored polar PAHs including nitrated/oxygenated/heterocyclic PAHs (NPAHs, oxyPAHs and HPAHs) for the three differently sourced oyster types. Most of the depurating PAHs and NPAHs, as well as 9-FLO (oxyPAH), had k₂ values significantly different from zero (p < 0.05). All other oxyPAHs and HPAHs showed no clear depuration, with their concentrations remaining similar. The non-depuration of polar PAHs from oyster tissues could imply greater human health risk compared to their parent analogues.

Whey Protein Drink Ingestion before Breakfast Suppressed Energy Intake at Breakfast and Lunch, but Not during Dinner, and Was Less Suppressed in Healthy Older than Younger Men

Ageing is associated with changes in feeding behavior. We have reported that there is suppression of energy intake three hours after whey protein drink ingestion in young, but not older, men. This study aimed to determine these effects over a time period of 9 h. Fifteen younger (27 ± 1 years, 25.8 ± 0.7 kg/m²) and 15 older (75 ± 2 years, 26.6 ± 0.8 kg/m²) healthy men were studied on three occasions on which they received, in a randomized order, a 30 g/120 kcal, 70 g/280 kcal whey-protein, or control (~2 kcal) drink. Ad-libitum energy intake (sum of breakfast, lunch, and dinner) was suppressed in a protein load responsive fashion (P = 0.001). Suppression was minimal at breakfast, substantial at lunch (~-16%, P = 0.001), no longer present by dinner, and was less in older than younger men (-3 ± 4% vs. -8 ± 4%, P = 0.027). Cumulative protein intake was increased in the younger and older men (+20% and +42%, P < 0.001). Visual analogue scale ratings of fullness were higher and desire to eat and prospective food consumption were lower after protein vs. control, and these effects were smaller in older vs. younger men (interaction effect P < 0.05). These findings support the use of whey-protein drink supplements in older people who aim to increase their protein intake without decreasing their overall energy intake.

Acute effects of whey protein on energy intake, appetite and gastric emptying in younger and older, obese men

BACKGROUND

Obesity is becoming more prevalent in older people. A management strategy in obese, young adults is to increase dietary protein relative to other macronutrients. It is not clear if this is effective in obese, older individuals. Obesity may be associated with diminished sensitivity to nutrients. We have reported that a 30-g whey protein drink slows gastric emptying more, and suppresses energy intake less, in older, than younger, non-obese men. The aim of this study was to determine the effect of a 30 g whey protein drink on energy intake, GE and glycaemia in obese, older and younger men.

METHODS

In randomized, double-blind order, 10 younger (age: 27 ± 2 years; BMI: 36 ± 2 kg/m²), and 10 older (72 ± 1 years; 33 ± 1 kg/m²), obese men were studied twice. After an overnight fast, subjects ingested a test drink containing 30 g whey protein (120 kcal) or control (2 kcal). Postprandial gastric emptying (antral area, 2D Ultrasound) and blood glucose concentrations were measured for 180 min. At t = 180 min subjects were given a buffet meal and ad libitum energy intake was assessed.

RESULTS

Older subjects ate non-significantly less (~20%) that the younger subjects (effect of age, P = 0.16). Whey protein had no effect on subsequent energy intake (kcal) compared to control in either the younger (decrease 3 ± 8%) or older (decrease 2 ± 8%) obese men (age effect P > 0.05, protein effect P = 0.46, age × protein interaction effect P = 0.84). Whey protein slowed gastric emptying, to a similar degree in both age groups (50% emptying time: control vs. protein young men: 255 ± 5 min vs. 40 ± 7 min; older men: 16 ± 5 min vs. 50 ± 8 min; protein effect P = 0.001, age effect P = 0.93, age × protein interaction effect P = 0.13).

CONCLUSIONS

Our data suggest that obesity may blunt/abolish the age-related effect of whey protein on suppression of energy intake.

Assessment of insulin sensitivity during hyperbaric oxygen treatment

INTRODUCTION

Previous studies using a hyperinsulinaemic, euglycaemic glucose clamp have demonstrated an increase in peripheral insulin sensitivity in men with and without Type-2 diabetes mellitus on the third and thirtieth hyperbaric oxygen treatment (HBOT) session. In two studies using different techniques for assessment of insulin sensitivity, we investigated the onset and duration of this insulin-sensitising effect of HBOT.

METHODS

Men who were obese or overweight but without diabetes were recruited. One study performed a hyperinsulinaemic euglycaemic glucose clamp (80 mU.m^-2.min^-1) at baseline and during the first HBOT exposure (n = 9) at a pressure of 203 kPa. Data were analysed by paired t-test. The other study assessed insulin sensitivity by a frequently sampled intravenous glucose tolerance test (FSIGT) at three time points: baseline, during the third HBOT and 24-hours post-HBOT (n = 9). Results were analysed by repeated-measures ANOVA.

RESULTS

There was a significant 23% increase in insulin sensitivity by clamp measured during the first HBOT exposure. The FSIGT showed no significant changes in insulin sensitivity.

CONCLUSIONS

The hyperinsulinaemic, euglycaemic glucose clamp demonstrated a significant increase in peripheral insulin sensitivity during a single, 2-hour HBOT session in a group of men who were obese or overweight but without diabetes. As an alternate technique for assessing insulin sensitivity during HBOT, the FSIGT failed to show any changes during the third HBOT and 24-hours later, however modification of the study protocol should be considered.

Additive, Curvilinear, and Interactive Relations of Anxiety and Depression With Indicators of Psychosocial Functioning

This study examines additive, curvilinear, and interactive relations of anxiety and depression with several subjective indicators of intrapersonal (i.e., hope, self-compassion, shame) and interpersonal (i.e., social connectedness, quality of social relationships) functioning in a sample of adults ( N =  547, Mage = 43.37 ± 12.02, female = 56.88%) seeking treatment for psychological difficulties. Results of complementary analyses were largely consistent with the hypothesis that increasing levels of anxiety and depression would correspond with worse psychosocial functioning, although nonlinear relations indicated that the effect of depression progressively attenuated at higher levels of symptom severity. Whereas the findings generally supported additive effects of anxiety and depression, the hypothesis that there would be synergistic effects of anxiety and depression was not supported. Supplementary group comparisons revealed that the functional implications of subsyndromal combinations of anxiety and depression may be comparable to those associated with symptoms that meet more traditional standards (i.e., syndromal or dimensional definitions) of comorbid anxiety–depression. The findings offer further insight into the complex relations of anxiety and depression with psychosocial functioning and emphasize the importance of detecting and offering appropriate treatments for anxiety and depression symptoms that coexist at subsyndromal levels.

Effects of Age on Acute Appetite-Related Responses to Whey-Protein Drinks, Including Energy Intake, Gastric Emptying, Blood Glucose, and Plasma Gut Hormone Concentrations-A Randomized Controlled Trial

Protein-rich supplements are used commonly to increase energy intake in undernourished older people. This study aimed to establish age effects on energy intake, appetite, gastric emptying, blood glucose, and gut hormones in response to protein-rich drinks. In a randomized double-blind, order, 13 older men (age: 75 ± 2 yrs, body mass index (BMI): 26 ± 1 kg/m²) and 13 younger (23 ± 1 yrs, 24 ± 1 kg/m²) men consumed (i) a control drink (~2 kcal) or drinks (450 mL) containing protein/fat/carbohydrate: (ii) 70 g/0 g/0 g (280 kcal/'P_280'), (iii) 14 g/12.4 g/28 g (280 kcal/'M_280'), (iv) 70 g/12.4 g/28 g (504 kcal/'M_504'), on four separate days. Appetite (visual analog scales), gastric emptying (3D ultrasonography), blood glucose, plasma insulin, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1) concentrations (0-180 min), and ad-libitum energy intake (180-210 min) were determined. Older men, compared to younger men, had higher fasting glucose and CCK concentrations and lower fasting GLP-1 concentrations (all p < 0.05). Energy intake by P₂₈₀ compared to control was less suppressed in older men (increase: 49 ± 42 kcal) than it was in younger men (suppression: 100 ± 54 kcal, p = 0.038). After the caloric drinks, the suppression of hunger and the desire to eat, and the stimulation of fullness was less (p < 0.05), and the stimulation of plasma GLP-1 was higher (p < 0.05) in older men compared to younger men. Gastric emptying, glucose, insulin, ghrelin, and CCK responses were similar between age groups. In conclusion, ageing reduces the responses of caloric drinks on hunger, the desire to eat, fullness, and energy intake, and protein-rich nutrition supplements may be an effective strategy to increase energy intake in undernourished older people.

Metformin Use Associated with Reduced Risk of Dementia in Patients with Diabetes: A Systematic Review and Meta-Analysis

Background:

Metformin, a first line antihyperglycemic medication, is an AMPK activator and has been hypothesized to act as a geroprotective agent. Studies on its association with various classifications of age-related cognitive decline have shown mixed results with positive and negative findings.

Objective:

To synthesize the best available evidence on the association of metformin-use with risk, progression, and severity of dementia.

Method:

Eligible research investigated the effect of metformin on dementia, Alzheimer’s disease, or any measure of cognitive impairment compared to any control group who were not receiving metformin. The initial search resulted in 862 citations from which 14 studies (seven cohort, four cross-sectional, two RCTs, and one case control) were included.

Results:

Meta-analysis of three studies showed that cognitive impairment was significantly less prevalent in diabetic metformin (Odds ratio = 0.55, 95% CI 0.38 to 0.78), while six studies showed that dementia incidence was also significantly reduced (Hazard ratio = 0.76, 95% CI 0.39 to 0.88). Mini-Mental State Examination scores were not significantly affected by metformin-use, although both RCTs showed that metformin had a neuroprotective effect compared to placebo. Some studies found negative or neutral effects for metformin use by people with diabetes; the potential mechanism of metformin-induced vitamin B12 deficiency is discussed.

Conclusions:

Metformin should continue to be used as a first line therapy for diabetes in patients at risk of developing dementia or Alzheimer’s disease. The use of metformin by individuals without diabetes for the prevention of dementia is not supported by the available evidence.

Acute Effects of Substitution, and Addition, of Carbohydrates and Fat to Protein on Gastric Emptying, Blood Glucose, Gut Hormones, Appetite, and Energy Intake

Whey protein, when ingested on its own, load-dependently slows gastric emptying and stimulates gut hormone concentrations in healthy young men. The aim of this study was to determine the effects of substitution, and addition, of carbohydrate (dextrose) and fat (olive oil) to whey protein. In randomized, double-blind order, 13 healthy young men (age: 23 ± 1 years, body mass index: 24 ± 1 kg/m²) ingested a control drink (450 mL; ~2 kcal/'control') or iso-volumetric drinks containing protein/carbohydrate/fat: (i) 14 g/28 g/12.4 g (280 kcal/'M_280'), (ii) 70 g/28 g/12.4 g (504kcal/'M_504'), and (iii) 70 g/0 g/0 g (280 kcal/'P_280'), on 4 separate study days. Gastric emptying (n = 11, 3D-ultrasonography), blood glucose, plasma insulin, ghrelin, cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1) concentrations (0⁻180 min), appetite (visual analogue scales), and ad-libitum buffet-meal energy intake (180⁻210 min) were determined. Substitution of protein with carbohydrate and fat was associated with faster gastric emptying (lower 50% emptying time (T50)), reduced suppression of ghrelin, and stimulation of GLP-1 (all P < 0.001); while the addition of carbohydrate and fat to protein did not affect gastric emptying or gut hormone responses significantly. Total energy intake (i.e., drink plus meal) was greater after all caloric drinks than control (P < 0.001). In conclusion, substitution of whey protein with dextrose and olive oil accelerated gastric emptying. Higher protein content of a mixed macronutrient drink increased gut hormone and insulin responses.

Effect of gender on the acute effects of whey protein ingestion on energy intake, appetite, gastric emptying and gut hormone responses in healthy young adults

BACKGROUND/OBJECTIVES

Protein supplements, usually drinks rich in whey protein, are used widely for weight loss purposes in overweight adults. Information comparing the effects of whey protein on appetite and energy intake in men and women is limited. The objective was to compare the acute effects of whey-protein intake on energy intake, appetite, gastric emptying and gut hormones in healthy young men and women.

SUBJECTS/METHODS

Gastric emptying (3D-ultrasonography), blood glucose and plasma insulin, glucagon, ghrelin, cholecystokinin (CCK), gastric inhibitory polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) concentrations (0-180 min), appetite (visual analogue scales), and ad libitum energy intake from a buffet meal (180-210 min) were determined after ingestion of 30 g (120 kcal) or 70 g (280 kcal) whey protein, or a flavoured-water control drink (~2 kcal) in 8 healthy young men (25 ± 2 y, 72 ± 3 kg, 23 ± 1 kg/m²) and 8 women (23 ± 1 y, 64 ± 2 kg, 24 ± 0.4 kg/m²).

RESULTS

There was a protein-load effect on gastric emptying, blood glucose, plasma insulin, glucagon, ghrelin, CCK, GIP and GLP-1 concentrations, and perceptions of hunger, desire to eat and prospective food consumption (P < 0.05). Ad libitum energy intake (average decrease of 206 ± 39 kcal (15 ± 2%) for men and of 46 ± 54 kcal (0 ± 26%) for women for the mean of the intakes after the 30 and 70 g whey-protein loads) and hunger were suppressed more by whey-protein ingestion in men than women (P = 0.046). There was no difference in suppression of energy intake between the 30 and 70 g protein loads (P = 0.75, interaction effect P = 0.19). Consequently, total energy intake (protein drink plus buffet meal) increased more compared to control in women than men (P = 0.010). The drinks emptied more slowly, and plasma glucagon, CCK and GLP-1 increased less after the protein drinks, in women than men (P < 0.05).

CONCLUSION

The acute effects of whey protein ingestion on appetite, energy intake, gastric emptying and gut hormone responses are influenced by gender in healthy young adults.

Metformin and Alzheimer's disease, dementia and cognitive impairment: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of the review is to assess the effect of metformin on the risk, progression and severity of Alzheimer's disease and other forms of dementia, as well as any measures of cognitive performance or impairment.

Serve Size and Estimated Energy and Protein Contents of Meals Prepared by 'Meals on Wheels' South Australia Inc.: Findings from a Meal Audit Study

An audit of ‘standard’ (STD) and ‘energy and protein fortified’ (HEHP) meals from Meals on Wheels (MOW) South Australia’s summer menu was conducted to evaluate the consistency, and serve size and nutrient contents, of their menu items. Twenty soups, 20 mains and 20 desserts from each of the STD and HEHP menus were prepared at the MOW South Australia’s kitchen and delivered to three ‘sham(dummy)-clients’ over a 5-week period. Each meal component was weighed in triplicate, to the nearest gram, the variation within the serve weight was calculated, and the overall energy and protein content of each meal was determined using FoodWorks (Xyris Software, Highgate Hill, Queensland, Australia). On average, the variability for soups and mains was ≤6% and for desserts was ≤10% and although the measured serve sizes of the MOW meals were consistently smaller than prescribed serve size, the differences were minor. As a percentage of recommended daily intakes (RDIs) for adults aged over 60 years, we calculated that the STD meals contained 21–39% for energy and 42–63% for protein while the HEHP meals contained 29–55% for energy and 46–69% for protein. These findings demonstrate that MOW meals currently meet the voluntary meal guidelines for energy and protein.

Effects of Substitution, and Adding of Carbohydrate and Fat to Whey-Protein on Energy Intake, Appetite, Gastric Emptying, Glucose, Insulin, Ghrelin, CCK and GLP-1 in Healthy Older Men-A Randomized Controlled Trial

Protein-rich supplements are used widely for the management of malnutrition in the elderly. We reported previously that the suppression of energy intake by whey protein is less in older than younger adults. The aim was to determine the effects of substitution, and adding of carbohydrate and fat to whey protein, on ad libitum energy intake from a buffet meal (180-210 min), gastric emptying (3D-ultrasonography), plasma gut hormone concentrations (0-180 min) and appetite (visual analogue scales), in healthy older men. In a randomized, double-blind order, 13 older men (75 ± 2 years) ingested drinks (~450 mL) containing: (i) 70 g whey protein (280 kcal; 'P₂₈₀'); (ii) 14 g protein, 28 g carbohydrate, 12.4 g fat (280 kcal; 'M₂₈₀'); (iii) 70 g protein, 28 g carbohydrate, 12.4 g fat (504 kcal; 'M₅₀₄'); or (iv) control (~2 kcal). The caloric drinks, compared to a control, did not suppress appetite or energy intake; there was an increase in total energy intake (drink + meal, p < 0.05), which was increased most by the M₅₀₄-drink. P₂₈₀- and M₅₀₄-drink ingestion were associated with slower a gastric-emptying time (n = 9), lower ghrelin, and higher cholecystokinin (CCK) and glucagon-like peptide-1 (GLP-1) than M₂₈₀ (p < 0.05). Glucose and insulin were increased most by the mixed-macronutrient drinks (p < 0.05). In conclusion, energy intake was not suppressed, compared to a control, and particularly whey protein, affected gastric emptying and gut hormone responses.

Dose-Dependent Effects of Randomized Intraduodenal Whey-Protein Loads on Glucose, Gut Hormone, and Amino Acid Concentrations in Healthy Older and Younger Men

Protein-rich supplements are used widely for the prevention and management of malnutrition in older people. We have reported that healthy older, compared to younger, adults have less suppression of energy intake by whey-protein-effects on appetite-related hormones are unknown. The objective was to determine the effects of intraduodenally administered whey-protein on glucose, gut hormone, and amino acid concentrations, and their relation to subsequent ad libitum energy intake at a buffet meal, in healthy older and younger men. Hydrolyzed whey-protein (30 kcal, 90 kcal, and 180 kcal) and a saline control (~0 kcal) were infused intraduodenally for 60 min in 10 younger (19-29 years, 73 ± 2 kg, 22 ± 1 kg/m²) and 10 older (68-81 years, 79 ± 2 kg, 26 ± 1 kg/m²) healthy men in a randomized, double-blind fashion. Plasma insulin, glucagon, gastric inhibitory peptide (GIP), glucagon-like peptide-1 (GLP-1), peptide tyrosine-tyrosine (PYY), and amino acid concentrations, but not blood glucose, increased, while ghrelin decreased during the whey-protein infusions. Plasma GIP concentrations were greater in older than younger men. Energy intake correlated positively with plasma ghrelin and negatively with insulin, glucagon, GIP, GLP-1, PYY, and amino acids concentrations (p < 0.05). In conclusion, intraduodenal whey-protein infusions resulted in increased GIP and comparable ghrelin, insulin, glucagon, GIP, GLP-1, PYY, and amino acid responses in healthy older and younger men, which correlated to subsequent energy intake.

Effect of Age on Blood Glucose and Plasma Insulin, Glucagon, Ghrelin, CCK, GIP, and GLP-1 Responses to Whey Protein Ingestion

Protein-rich supplements are used widely to prevent and manage undernutrition in older people. We have previously shown that healthy older, compared to younger, adults have less suppression of energy intake by whey protein-although the effects of age on appetite-related gut hormones are largely unknown. The aim of this study was to determine and compare the acute effects of whey protein loads on blood glucose and plasma gut hormone concentrations in older and younger adults. Sixteen healthy older (eight men, eight women; mean ± SEM: age: 72 ± 1 years; body mass index: 25 ± 1 kg/m²) and 16 younger (eight men, eight women; 24 ± 1 years; 23 ± 0.4 kg/m²) adults were studied on three occasions in which they ingested 30 g (120 kcal) or 70 g (280 kcal) whey protein, or a flavored-water control drink (~2 kcal). At regular intervals over 180 min, blood glucose and plasma insulin, glucagon, ghrelin, cholecystokinin (CCK), gastric inhibitory peptide (GIP), and glucagon-like peptide-1 (GLP-1) concentrations were measured. Plasma ghrelin was dose-dependently suppressed and insulin, glucagon, CCK, GIP, and GLP-1 concentrations were dose-dependently increased by the whey protein ingestion, while blood glucose concentrations were comparable during all study days. The stimulation of plasma CCK and GIP concentrations was greater in older than younger adults. In conclusion, orally ingested whey protein resulted in load-dependent gut hormone responses, which were greater for plasma CCK and GIP in older compared to younger adults.

Effects of Timing of Whey Protein Intake on Appetite and Energy Intake in Healthy Older Men

BACKGROUND

Protein-rich supplements are used widely to prevent and manage malnutrition in older adults. We previously showed that 30 g whey protein ingestion, 3 hours before a buffet meal, suppressed energy intake in young, but not in older men. Information about the impact of the timing of ingestion of protein drinks on the suppression of energy intake in older adults is lacking.

OBJECTIVE

The aim of the study was to determine the effect of the timing of whey protein ingestion on appetite and subsequent ad libitum energy intake in healthy older men.

DESIGN

In a single blind, randomized design, 16 older men were studied on 5 occasions, on which they consumed a whey protein drink (30 g/120 kcal, 140 mL) 3, 2, 1 hour(s), or immediately before a buffet meal, from which ad libitum energy intake was quantified, and isopalatable noncaloric drinks (∼1 kcal) at the remaining time points. On the control day, noncaloric drinks were ingested at all time points. Perceptions of appetite and gastrointestinal symptoms were determined, by visual analog scales, throughout the study days.

RESULTS

There was no effect of the timing of protein ingestion on perceptions of appetite and gastrointestinal symptoms (P > .05) or energy intake at the buffet meal (3 hours: 888 ± 49 kcal, 2 hours: 879 ± 56 kcal, 1 hours: 909 ± 47 kcal, 0 hour: 892 ± 51 kcal, control: 930 ± 49 kcal, P = .94). Total energy intake (ie, preload + test meal) was higher on the protein days compared with control (82 ± 24 kcal increase, P = .003).

CONCLUSIONS

In older men, ingestion of 30 g protein increased total energy intake, irrespective of the time of intake in relation to the meal. These observations support the use of "pure" whey protein drinks to increase overall protein and energy intake in older adults at risk of undernutrition.

Effects of randomized whey-protein loads on energy intake, appetite, gastric emptying, and plasma gut-hormone concentrations in older men and women

Background: Protein- and energy-rich supplements are used widely for the management of malnutrition in the elderly. Information about the effects of protein on energy intake and related gastrointestinal mechanisms and whether these differ between men and women is limited.Objective: We determined the effects of whey protein on energy intake, appetite, gastric emptying, and gut hormones in healthy older men and women.Design: Eight older women and 8 older men [mean ± SEM age: 72 ± 1 y; body mass index (in kg/m²): 25 ± 1] were studied on 3 occasions in which they received protein loads of 30 g (120 kcal) or 70 g (280 kcal) or a flavored water control drink (0 kcal). At regular intervals over 180 min, appetite (visual analog scales), gastric emptying (3-dimensional ultrasonography), and blood glucose and plasma gut-hormone concentrations [insulin, glucagon, ghrelin, cholecystokinin, gastric inhibitory polypeptide (GIP), glucagon-like peptide 1 (GLP-1), and peptide tyrosine tyrosine (PYY)] were measured, and ad libitum energy intake was quantified from a buffet meal (180-210 min; energy intake, appetite, and gastric emptying in the men have been published previously).Results: Energy intake at the buffet meal was ∼80% higher in older men than in older women (P < 0.001). Energy intake was not suppressed by protein compared with the control in men or women (P > 0.05). There was no effect of sex on gastric emptying, appetite, gastrointestinal symptoms, glucose, or gut hormones (P > 0.05). There was a protein load-dependent slowing of gastric emptying, an increase in concentrations of insulin, glucagon, cholecystokinin, GIP, GLP-1, and PYY, and an increase in total energy intake (drink plus meal: 12% increase with 30 g and 32% increase with 70 g; P < 0.001). Energy intake at the buffet meal was inversely related to the stomach volume and area under the curve of hormone concentrations (P < 0.05).Conclusion: In older men and women, whey-protein drinks load-dependently slow gastric emptying and alter gut hormone secretion compared with a control but have no suppressive effect on subsequent ad libitum energy intake. This trial was registered at www.anzctr.org.au as ACTRN12612000941864.

Can an Intervention with Testosterone and Nutritional Supplement Improve the Frailty Level of Under-Nourished Older People?

OBJECTIVE

To examine whether a testosterone and a high calorie nutritional supplement intervention can reduce frailty scores in undernourished older people using multiple frailty tools.

DESIGN

Randomized controlled trial.

SETTING/PARTICIPANTS

53 community-dwelling, undernourished men and women aged >65 years from South Australia, Victoria and New South Wales.

INTERVENTION

Intervention group received oral testosterone undecanoate and a high calorie supplement (2108-2416 kJ/day) whereas the control group received placebo testosterone and low calorie supplement (142-191 kJ/day).

MEASUREMENTS

Frailty was operationalized using three frailty indices (FI-lab, FI-self-report, FI-combined) and the frailty phenotype.

RESULTS

There were no significant differences in changes in frailty scores at either 6 or 12 months follow up between the two treatment groups for all scales. Participants at the intervention group were 4.8 times more likely to improve their FI-combined score at both time points compared to the placebo group.

CONCLUSION

A testosterone and a high calorie nutritional supplement intervention did not improve the frailty levels of under-nourished older people. Even so, when frailty was measured using a frailty index combining self-reported and lab data we found that participants who received the intervention were more likely to show persistent improvement in their frailty scores.

MHD marking using the MSE polarimeter optics in ILW JET plasmas

In this communication we propose a novel diagnostic technique, which uses the collection optics of the JET Motional Stark Effect (MSE) diagnostic, to perform polarimetry marking of observed MHD in high temperature plasma regimes. To introduce the technique, first we will present measurements of the coherence between MSE polarimeter, electron cyclotron emission, and Mirnov coil signals aiming to show the feasibility of the method. The next step consists of measuring the amplitude fluctuation of the raw MSE polarimeter signals, for each MSE channel, following carefully the MHD frequency on Mirnov coil data spectrograms. A variety of experimental examples in JET ITER-Like Wall (ILW) plasmas are presented, providing an adequate picture and interpretation for the MSE optics polarimeter technique.

Appendicular Skeletal Muscle Mass: Development and Validation of Anthropometric Prediction Equations

OBJECTIVES

Sarcopenia is the loss of muscle mass and function seen with increasing age. Central to making the diagnosis of sarcopenia is the assessment of appendicular skeletal muscle mass (ASM). The objective of this study was to develop and validate novel anthropometric prediction equations (PEs) for ASM that would be useful in primary or aged care.

DESIGN

PEs were developed using best subset regression analysis. Three best performing PEs (PE1, PE2, PE3) were selected and validated using the Bland-Altman and Sheiner and Beal methods.

SETTING

Community dwelling adults in South Australia.

PARTICIPANTS

188 healthy subjects were involved in the development study. 2275 older(age ≥ 50years) subjects were involved in the validation study.

MEASUREMENTS

ASM was assessed using dual x-ray abosrptiometry (DEXA). Weight and height was measured and body mass index (BMI) estimated.

RESULTS

A strong correlation between PE derived ASM and the DEXA derived ASM was seen for the three selected PEs. PE3: ASM= 10.047427 + 0.353307(weight) - 0.621112(BMI) - 0.022741(age) + 5.096201(if male) performed the best. PE3 over-estimated (P<0.001) ASM by 0.36 kg (95% CI 0.28-0.44 Kg) and the adjusted R2 was 0.869. The 95% limit of agreement was between -3.5 and 4.35 kg and the standard error of the estimate was 1.95. The root mean square error was 1.91(95% CI 1.80-2.01). PE3 also performed the best across the various age (50-65, 65-<80, 80+ years) and weight (BMI <18.5, 18.5-24.9, 25-29.9, ≥30 kg/m2) groups.

CONCLUSIONS

A new anthropometric PE for ASM has been developed for use in primary or aged care but is specific to Caucasian population groups.

Ageing Is Associated with Decreases in Appetite and Energy Intake--A Meta-Analysis in Healthy Adults

It is not well recognized that in the elderly weight loss is more common than weight gain. The aim of this analysis was to determine the effect of ageing on appetite (hunger/fullness) and energy intake, after overnight fasting and in a postprandial state, by meta-analyses of trials that included at least two age groups (>18 years). We hypothesized that appetite and energy intake would be less in healthy older compared with younger adults. Following a PubMed-database systematic search up to 30 June 2015, 59 studies were included in the random-effects-model meta-analyses. Energy intake was 16%-20% lower in older (n = 3574/~70 years/~71 kg/~25 kg/m²) than younger (n = 4111/~26 years/~69 kg/~23 kg/m²) adults (standardized mean difference: -0.77 (95% confidence interval -0.90 to -0.64)). Hunger was 25% (after overnight fasting; weighted mean difference (WMD): -17 (-22 to -13) mm) to 39% (in a postprandial state; WMD: -14 (-19 to -9) mm) lower, and fullness 37% (after overnight fasting; WMD: 6 mm (95% CI: 1 to 11 mm)) greater in older than younger adults. In conclusion, appetite and energy intake are less in healthy older than younger adults, suggesting that ageing per se affects food intake.

The Randomized Control Trial of the Effects of Testosterone and a Nutritional Supplement On Hospital Admissions in Undernourished, Community Dwelling, Older People

OBJECTIVE

In a pilot single centre study we found that treatment of undernourished older, community dwelling people for one year with oral testosterone (placebo-controlled) and a nutritional supplement (no control) was associated with a significant reduction in hospitalizations. A larger, multicentre study was conducted to investigate further this potentially important finding.

DESIGN

One year, randomized, placebo-controlled, multi-centre, double-blind, trial.

SETTING

Community.

PARTICIPANTS

53 undernourished men and women aged 65 years and older.

INTERVENTION

Oral testosterone undecanoate (40 mg/day women, 160 mg/day men) and high energy oral nutritional supplement (2108-2416 kJ/day) or placebo medication and low energy (142-191 kJ/day) "placebo" oral nutritional supplementation.

MEASUREMENTS

Hospital admissions, falls and other variables were assessed.

RESULTS

53 subjects were recruited (64% male and mean age 77 years), which was substantially less than planned. Sixteen subjects (30%) were admitted to hospital at least once, with a total of 29 admissions. Eight subjects (32%) in the placebo arm were admitted to hospital, whilst in the intervention group also there were eight (29%) subjects admitted to hospital during the study period. There was no difference in the number of hospitalisations (P = 0.842), length of hospitalization (P=0.645) or quality of life [mental health P=0.195 and physical health P=0.451) between the treatment arms.

CONCLUSIONS

In undernourished older people, treatment with testosterone and a nutritional supplementation did not reduce the number and length of hospitalisations or improve quality of life.

Lesser suppression of energy intake by orally ingested whey protein in healthy older men compared with young controls

Protein-rich supplements are used widely for the management of malnutrition in young and older people. Protein is the most satiating of the macronutrients in young. It is not known how the effects of oral protein ingestion on energy intake, appetite, and gastric emptying are modified by age. The aim of the study was to determine the suppression of energy intake by protein compared with control and underlying gastric-emptying and appetite responses of oral whey protein drinks in eight healthy older men (69-80 yr) compared with eight young male controls (18-34 yr). Subjects were studied on three occasions to determine the effects of protein loads of 30 g/120 kcal and 70 g/280 kcal compared with a flavored water control-drink (0 g whey protein) on energy intake (ad libitum buffet-style meal), and gastric emptying (three-dimensional-ultrasonography) and appetite (0-180 min) in a randomized, double-blind, cross-over design. Energy intake was suppressed by the protein compared with control (P = 0.034). Suppression of energy intake by protein was less in older men (1 ± 5%) than in young controls (15 ± 2%; P = 0.008). Cumulative energy intake (meal+drink) on the protein drink days compared with the control day increased more in older (18 ± 6%) men than young (1 ± 3%) controls (P = 0.008). Gastric emptying of all three drinks was slower in older men (50% gastric-emptying time: 68 ± 5 min) than young controls (36 ± 5 min; P = 0.007). Appetite decreased in young, while it increased in older (P < 0.05). In summary, despite having slower gastric emptying, elderly men exhibited blunted protein-induced suppression of energy intake by whey protein compared with young controls, so that in the elderly men, protein ingestion increased overall energy intake more than in the young men.

Hyperbaric oxygen therapy increases insulin sensitivity in overweight men with and without type 2 diabetes

AIMS

The onset of insulin resistance is an important metabolic event in the development of type 2 diabetes. For patients with type 2 diabetes, we recently showed that peripheral insulin sensitivity was increased during hyperbaric oxygen treatment (HBOT). This study aims to investigate whether this occurs in a non-patient population with and without type 2 diabetes, along with the mechanism of this effect.

METHODS

Overweight and obese male participants were recruited from the community, 11 without and eight with type 2 diabetes. Insulin sensitivity was measured by the glucose infusion rate (GIR) during a hyperinsulinaemic euglycaemic clamp (80 mU·m⁻²·min⁻¹) at baseline and during the third HBOT session. Monocyte chemo-attractant protein-1 (MCP-1), tumour necrosis factor-α (TNF-α) and interleukin-6 (IL-6) were measured in fasting serum and adipose tissue samples taken for their gene expression at baseline and immediately following four HBOT sessions. Additional fasting serum samples were collected during the first HBOT at 0, 60 and 120 minutes, and 24-hours after the last HBOT.

RESULTS

In response to HBOT, GIR was increased by 29±32% in those without (n=10, P=0.01), and by 57±66% in those with type 2 diabetes (n=7, P=0.04). This increase was maintained for 30 minutes post HBOT. Reduced MCP-1 and TNF-α were observed after HBOT, whereas IL-6 was increased only in individuals without diabetes and this correlated with the increase in insulin sensitivity (r²=0.72, P=0.004).

CONCLUSIONS

Peripheral insulin sensitivity was increased following HBOT in overweight or obese males with and without type 2 diabetes; this increase was maintained for at least 30 minutes post HBOT. Changes in inflammatory cytokines may partly explain this effect.

Effects of intraduodenal protein on appetite, energy intake, and antropyloroduodenal motility in healthy older compared with young men in a randomized trial

BACKGROUND

Protein-rich supplements are used widely for the prevention and management of undernutrition in older people. The use of protein supplements in older people could, however, be counterproductive by reducing appetite and overall energy intake.

OBJECTIVE

The objective was to determine whether aging influences the effects of protein loads, administered directly into the small intestine, on energy intake, antropyloroduodenal motility, and appetite.

DESIGN

Intraduodenal infusions (240 mL, 60 min) of saline (0 kcal, control) and protein (hydrolyzed whey) loads of 30, 90, and 180 kcal were followed by an ad libitum buffet meal in 10 young (19-29 y) and 10 healthy older (68-81 y) men. Suppression of energy intake (kcal) at the meal by protein infusion compared with control was calculated.

RESULTS

In young subjects, a dose-responsive suppression (±SEM) of energy intake was found at the buffet meal by protein (suppression at 30 kcal: 7 ± 8%, P = 0.189; 90 kcal: 17 ± 8%, P = 0.054; 180 kcal: 33 ± 7%, P = 0.002), whereas suppression was observed only after the 180-kcal load in older subjects (30 kcal: 7 ± 4% increase, P = 0.126; 90 kcal: 6 ± 7% increase, P = 0.291; 180 kcal: 17 ± 6% suppression, P = 0.016). Suppression of energy intake by protein was less in older than in young subjects (P < 0.005). In young subjects, total energy intake (meal + infusion) on the 180-kcal protein-infusion day was lower than that on the control day (P = 0.041), whereas in older subjects it was greater on the 30-kcal (P = 0.033) and 90-kcal (P = 0.016) infusion days. Energy intake was inversely related to isolated pyloric pressure waves (r = -0.32, P = 0.013) and positively related to antral (r = 0.30, P = 0.021) and duodenal (r = 0.35, P = 0.006) pressure waves. Suppression of energy intake by protein was inversely related to the change in isolated pyloric pressure waves (r = -0.35, P = 0.027) and positively related to duodenal pressure waves (r = 0.32, P = 0.044).

CONCLUSIONS

Intraduodenal protein suppresses appetite and energy intake less in healthy older than in young adults. In older subjects, intraduodenal protein at low doses increased overall energy intake, which supports the use of protein supplements in undernourished older people. This trial was registered at www.anzctr.org.au as 12612000906853.

An anthropometric prediction equation for appendicular skeletal muscle mass in combination with a measure of muscle function to screen for sarcopenia in primary and aged care

OBJECTIVES

Sarcopenia is the presence of low muscle mass and poor physical function. We have developed an anthropometric prediction equation (PE). We compared the accuracy of our previously developed anthropometric prediction equation (PE) to dual absorptiometry x-ray (DXA) in predicting low muscle mass and sarcopenia.

DESIGN

Cross-sectional study design.

SETTING

Community dwelling.

PARTICIPANTS

Men and women aged 65 years and older.

MEASUREMENTS

Gender-specific low muscle mass cutoffs were identified using the lowest 20% of the skeletal muscle index (SMI) where muscle mass was determined using PE in 611 men and 375 women aged 65 years and older. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PE derived low muscle mass were compared with DXA-derived low muscle mass. The cohort was randomized into a development and validation group to identify various cutoffs for low muscle mass via the PE method and test its performance against the DXA method.

RESULTS

The PE cutoff for low muscle mass was less than 8.05 kg/m(2) in men and less than 5.35 kg/m(2) in women. On validation of various cutoffs with improving sensitivity values from 70% to 97%, specificity increased from 45.5% to 85.7%, PPV increased from 31.3% to 56.9%, and NPV increased from 93.0% to 98.6% in men. In women, specificity improved from 42% to 72%, PPV reduced from 56.9% to 31.3%, and NPV improved from 93.0% to 98.6%. When the PE method was combined with a measure of muscle performance, a similar pattern of performance was observed.

CONCLUSION

The PE when combined with a measure of muscle function to create a screening tool performs as a "rule-out" test with high sensitivity values and NPVs.

Frailty and functional decline indices predict poor outcomes in hospitalised older people

BACKGROUND

admission to a Geriatric Evaluation and Management Unit (GEMU) can optimise a patient's chance of functional recovery.

OBJECTIVE

to evaluate the ability of several commonly used frailty and functional decline indices to predict GEMU outcomes, both at discharge and at 6 months.

DESIGN

prospective, observational study.

SETTING AND PARTICIPANTS

consecutive GEMU patients aged ≥70 years.

METHODS

patients were classified as 'frail' or 'at high risk of functional decline' using several frailty and functional decline instruments. Predictive ability was evaulated using logistic regression and area under receiver operator characteristic (ROC) curves (auROC).

RESULTS

a total of 172 patients were included. Frailty prevalence varied from 24 to 94% depending on the instrument used. Several instruments predicted patients at risk of poor outcome, including the Frailty Index of Accumulative Deficits (FI-CD), Fried's Cardiovascular Health Study index, the Study of Osteoporotic Fractures index, an adapted Katz score of activities of daily living (ADL), Instrumental ADL, the Score Hospitalier d'Evaluation du Risque de Perte d'Autonomie (SHERPA) and grip strength [odds ratio (OR) range of 2.06-6.47]. Adequate discriminatory power for discharge outcome was achieved by the FI-CD (auROC = 0.735, P < 0.001) and an adapted Katz score (auROC = 0.704, P = < 0.001). The FI-CD also showed adequate discriminatory power for a poor 6-month outcome (auROC = 0.702, P < 0.001).

CONCLUSION

frailty and functional decline instruments can predict older patients at risk of poor outcome. However, only the FI-CD showed adequate discriminatory power for outcome prediction at both follow-up time-points.

Medication Regimen Complexity and Unplanned Hospital Readmissions in Older People

BACKGROUND

Medication-related problems and adverse drug events are leading causes of preventable hospitalizations. Few previous studies have investigated the possible association between medication regimen complexity and unplanned rehospitalization.

OBJECTIVE

To investigate the association between discharge medication regimen complexity and unplanned rehospitalization over a 12-month period.

METHOD

The prospective study comprised patients aged ≥70 years old consecutively admitted to a Geriatrics Evaluation and Management (GEM) unit between October 2010 and December 2011. Medication regimen complexity at discharge was calculated using the 65-item validated Medication Regimen Complexity Index (MRCI). Cox proportional-hazards regression was used to compute unadjusted and adjusted hazard ratios (HRs) with 95% CIs for factors associated with rehospitalization over a 12-month follow-up period.

RESULT

Of 163 eligible patients, 99 patients had one or more unplanned hospital readmissions. When adjusting for age, sex, activities of daily living, depression, comorbidity, cognitive status, and discharge destination, MRCI (HR = 1.01; 95% CI = 0.81-1.26), number of discharge medications (HR = 1.01; 95% CI = 0.94-1.08), and polypharmacy (≥9 medications; HR = 1.12; 95% CI = 0.69-1.80) were not associated with rehospitalization. In patients discharged to nonhome settings, there was an association between rehospitalization and the number of discharge medications (HR = 1.12; 95% CI = 1.01-1.25) and polypharmacy (HR = 2.24; 95% CI = 1.02-4.94) but not between rehospitalization and MRCI (HR = 1.32; 95% CI = 0.98-1.78).

CONCLUSION

Medication regimen complexity was not associated with unplanned hospital readmission in older people. However, in patients discharged to nonhome settings, the number of discharge medications and polypharmacy predicted rehospitalization. A patient's discharge destination is an important factor in unplanned medication-related readmissions.

Nutritional screening tools and anthropometric measures associate with hospital discharge outcomes in older people

AIM

To examine the association of nutritional screening tools (NSTs) and anthropometric measures with hospital outcomes in older people.

METHODS

In 172 patients aged ≥70 years admitted to a Geriatric Evaluation Management Unit (GEMU), nutritional status was measured using the Mini-Nutritional Assessment (MNA), MNA-short form (MNA-SF), Geriatric Nutritional Risk Index (GNRI), Simplified Nutritional Appetite Questionnaire, calf circumference (CC), mid-arm circumference (MAC) and BMI.

RESULTS

Malnutrition according to the MNA occurred in 53 (31%) patients. Functional change was associated with GNRI (Beta coefficient (β), 95% CI = 0.17, 0.001-0.33) and CC (β, 95% CI = 0.17, 0.01-0.33); GEMU length of stay was associated with MNA-SF-BMI (β, 95% CI = -0.02, -0.003 to -0.004) and MNA-SF-CC (β, 95% CI = -0.02, -0.003 to -0.001). MAC was associated with discharge to higher level of care (OR, 95% CI = 0.88, 0.81-0.96).

CONCLUSION

In hospitalised older people, admission NSTs and anthropometric measures associate with discharge outcomes.

Lean body mass: the development and validation of prediction equations in healthy adults

Background

There is a loss of lean body mass (LBM) with increasing age. A low LBM has been associated with increased adverse effects from prescribed medications such as chemotherapy. Accurate assessment of LBM may allow for more accurate drug prescribing. The aims of this study were to develop new prediction equations (PEs) for LBM with anthropometric and biochemical variables from a development cohort and then validate the best performing PEs in validation cohorts.

Methods

PEs were developed in a cohort of 188 healthy subjects and then validated in a convenience cohort of 52 healthy subjects. The best performing anthropometric PE was then compared to published anthropometric PEs in an older (age ≥ 50 years) cohort of 2287 people. Best subset regression analysis was used to derive PEs. Correlation, Bland-Altman and Sheiner & Beal methods were used to validate and compare the PEs against dual X-ray absorptiometry (DXA)-derived LBM.

Results

The PE which included biochemistry variables performed only marginally better than the anthropometric PE. The anthropometric PE on average over-estimated LBM by 0.74 kg in the combined cohort. Across gender (male vs. female), body mass index (< 22, 22- < 27, 27- < 30 and ≥30 kg/m²) and age groups (50–64, 65–79 and ≥80 years), the maximum mean over-estimation of the anthropometric PE was 1.36 kg.

Conclusions

A new anthropometric PE has been developed that offers an alternative for clinicians when access to DXA is limited. Further research is required to determine the clinical utility and if it will improve the safety of medication use.

The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project)

Background

Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.

Methods/Design

A pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.

Discussion

Unplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.

Trial registration

ACTRN12611000020987

Hospital admissions in poorly nourished, compared with well-nourished, older South Australians receiving 'Meals on Wheels': findings from a pilot study

AIM

To evaluate whether 'Meals on Wheels' (MOW) improves health and reduces hospital admissions in poorly nourished (PN) older people.

METHODS

Two hundred and fifty older South Australians were retrospectively classified: (i) PN (MNA score <24) receiving MOW (MOW PN); (ii) PN not receiving MOW (non-MOW PN); and (iii) well-nourished (WN). Data regarding their health were compared.

RESULTS

Health outcomes at baseline for MOW PN and non-MOW PN were not different, but both were worse than the WN. Over 12 months, weight loss was ∼2-3 times greater in both PN than WN groups. Hospital admissions were not different for MOW PN compared with non-MOW PN and WN, but non-MOW PN had 2.9 as many admissions and spent 5 days more in hospital than WN (all Ps < 0.05).

CONCLUSION

Providing MOW to nutritionally vulnerable older people may not prevent age-related decline in health, although a potential reduction in hospital admissions warrants investigation.

Nutritional screening tools as predictors of mortality, functional decline, and move to higher level care in older people: a systematic review

This systematic review assessed whether nutritional screening tools (NSTs) predict mortality, functional decline, and move to higher level care in older adults residing in the community or in institutions. In total, 37 prospective studies published between 1999 and 2012 met inclusion criteria and were included in this review. The most commonly used NST in these studies was the Mini Nutritional Assessment (MNA). Comparison of NSTs was limited by variation in follow-up time, lack of uniform definition of functional decline, and biases in many studies. Results of MNA, MNA-Short Form (MNA-SF), and Geriatric Nutrition Risk Index (GNRI) assessments were significantly associated with subsequent mortality, with good negative predictive power (∼0.83), but only modest positive predictive power (PPV∼0.32). MNA-SF and MNA results had a low to moderate association with functional decline (PPV∼0.34). Move to higher level care was less strongly associated with NST scores (PPV∼0.25). Overall, there is evidence that NSTs can predict those at low risk of mortality, functional decline, and, to a lesser extent, move to higher level care in older people.