Associations of body size with all-cause and cause-specific mortality in healthy older adults

In the general population, body mass index (BMI) and waist circumference are recognized risk factors for several chronic diseases and all-cause mortality. However, whether these associations are the same for older adults is less clear. The association of baseline BMI and waist circumference with all-cause and cause-specific mortality was investigated in 18,209 Australian and US participants (mean age: 75.1 ± 4.5 years) from the ASPirin in Reducing Events in the Elderly (ASPREE) study, followed up for a median of 6.9 years (IQR: 5.7, 8.0). There were substantially different relationships observed in men and women. In men, the lowest risk of all-cause and cardiovascular mortality was observed with a BMI in the range 25.0-29.9 kg/m2 [HR25-29.9 vs 21-24.9 kg/m2: 0.85; 95% CI, 0.73-1.00] while the highest risk was in those who were underweight [HRBMI <21 kg/m2 vs BMI 21-24.9 kg/m2: 1.82; 95% CI 1.30-2.55], leading to a clear U-shaped relationship. In women, all-cause mortality was highest in those with the lowest BMI leading to a J-shaped relationship (HRBMI <21 kg/m2 vs BMI 21-24.9 kg/m2: 1.64; 95% CI 1.26-2.14). Waist circumference showed a weaker relationship with all-cause mortality in both men and women. There was little evidence of a relationship between either index of body size and subsequent cancer mortality in men or women, while non-cardiovascular non-cancer mortality was higher in underweight participants. For older men, being overweight was found to be associated with a lower risk of all-cause mortality, while among both men and women, a BMI in the underweight category was associated with a higher risk. Waist circumference alone had little association with all-cause or cause-specific mortality risk.Trial registration ASPREE https://ClinicalTrials.gov number NCT01038583.

GFR Variability, Survival, and Cardiovascular Events in Older Adults

Rationale & Objective

Variability in estimated glomerular filtration rate (eGFR) over time is often observed, but it is unknown whether this variation is clinically important. We investigated the association between eGFR variability and survival free of dementia or persistent physical disability (disability-free survival) and cardiovascular disease (CVD) events (myocardial infarction, stroke, hospitalization for heart failure, or CVD death).

Study Design

Post hoc analysis.

Setting & Participants

12,549 participants of the ASPirin in Reducing Events in the Elderly trial. Participants were without documented dementia, major physical disability, previous CVD, and major life-limiting illness at enrollment.

Predictors

eGFR variability.

Outcomes

Disability-free survival and CVD events.

Analytical Approach

eGFR variability was estimated using the standard deviation of eGFR measurements obtained from participants' baseline, first, and second annual visits. Associations between tertiles of eGFR variability with disability-free survival and CVD events occurring after the eGFR variability estimation period were examined.

Results

During median follow-up of 2.7 years after the second annual visit, 838 participants died, developed dementia, or acquired a persistent physical disability; 379 had a CVD event. The highest tertile of eGFR variability had an increased risk of death/dementia/disability (HR, 1.35; 95% CI, 1.14-1.59) and CVD events (HR, 1.37; 95% CI, 1.06-1.77) compared with the lowest tertile after covariate adjustment. These associations were present in patients with and without chronic kidney disease at baseline.

Limitations

Limited representation of diverse demographics.

Conclusions

In older, generally healthy adults, higher variability in eGFR over time predicts increased risk of future death/dementia/disability and CVD events.

Long-Term Blood Pressure Variability and Kidney Function in Participants of the ASPREE Trial

BACKGROUND

Whether long-term blood pressure variability (BPV) predicts kidney function decline in generally healthy older adults is unknown. We investigated this association in ASPirin in Reducing Events in the Elderly (ASPREE) trial participants.

METHODS

Between 2010 and 2014, Australian and US individuals aged ≥70 years (≥65 if US minority) were recruited and followed with annual study visits for a median of 4.7 years. Time-to-event analyses and linear mixed effects models were used to examine associations between incident chronic kidney disease (CKD), and trajectories of estimated glomerular filtration rate (eGFR) and log albumin-creatinine ratio (log ACR) with systolic BPV as a continuous measure, and, by tertile of SD of systolic blood pressure (BP). BPV was estimated using systolic BP measures from baseline through the second annual visit, and kidney outcomes were assessed following this period.

RESULTS

Incident CKD occurred in 1,829 of 6,759 participants (27.2%), and more commonly in BPV tertiles 2 (27.4%) and 3 (28.3%) than tertile 1 (25.5%); however, the risk was not significantly increased after covariate adjustment (tertile 3 hazard ratio = 1.02; 95% confidence interval: 0.91-1.14). Analysis of eGFR (n = 16,193) and log ACR trajectories (n = 15,213) showed individuals in the highest BPV tertile having the lowest eGFR and highest log ACR, cross-sectionally. However, the trajectories of eGFR and log ACR did not differ across BPV tertiles.

CONCLUSIONS

CKD and markers of reduced kidney function occur more commonly in individuals with higher BPV; however, BPV does not influence trajectory of decline in kidney function over time in older adults who are in generally good health.

CLINICAL TRIALS REGISTRATION

Trial Number NCT01038583 and ISRCTN83772183.

Test-Retest Reliability and Minimal Detectable Change of Four Cognitive Tests in Community-Dwelling Older Adults

BACKGROUND

Cognitive test-retest reliability measures can be used to evaluate meaningful changes in scores.

OBJECTIVE

This analysis aimed to develop a comprehensive set of test-retest reliability values and minimal detectable change (MDC) values for a cognitive battery for community-dwelling older individuals in Australia and the U.S., for use in clinical practice.

METHODS

Cognitive scores collected at baseline and year 1, in the ASPirin in Reducing Events in the Elderly clinical trial were used to calculate intraclass correlation coefficients (ICC) for four tests: Modified Mini-Mental State examination (3MS), Hopkins Verbal Learning Test-Revised (HVLT-R), single-letter Controlled Oral Word Association Test (COWAT-F), and Symbol Digit Modalities Test (SDMT). 16,956 participants aged 70 years and over (65 years and over for U.S. minorities) were included. ICCs were used to calculate MDC values for eight education and ethno-racial subgroups.

RESULTS

All four cognitive tests had moderate (ICC > 0.5) to good (ICC > 0.7) test-retest reliability. ICCs ranged from 0.53 to 0.63 (3MS), 0.68 to 0.77 (SDMT), 0.56 to 0.64 (COWAT-F), 0.57 to 0.69 (HVLT-R total recall), and 0.57 to 0.70 (HVLT-R delayed recall) across the subgroups. MDC values ranged from 6.60 to 9.95 (3MS), 12.42 to 15.61 (SDMT), 6.34 to 8.34 (COWAT-F), 8.13 to 10.85 (HVLT-R total recall), and 4.00 to 5.62 (HVLT-R delayed recall).

CONCLUSION

This large cohort of older individuals provides test-retest reliability and MDC values for four widely employed tests of cognitive function. These results can aid interpretation of cognitive scores and decline instead of relying on cross-sectional normative data alone.

Patient-Reported Outcomes of Split-Thickness Skin Grafts for Floor of Mouth Cancer Reconstruction

INTRODUCTION

Patient-reported outcome measures (PROM) on quality of life (QOL) for early-stage floor of mouth carcinoma (FOM-CA) undergoing surgical resection and split-thickness skin graft (STSG) reconstruction have not been established. We have performed a cross-sectional QOL analysis of such patients to define functional postoperative outcomes.

METHODS

Patients with pathologic stage T1/T2 FOM-CA who underwent resection and STSG reconstruction at a tertiary academic cancer center reported outcomes with the University of Washington QOL (v4) questionnaire after at least 6 months since surgery.

RESULTS

Twenty-four out of 49 eligible patients completed questionnaires with a mean follow-up of 41 months (range: 6-88). Subsites of tumor involvement/resection included the following: (1) lateral FOM (L-FOM) (n = 17), (2) anterior FOM (A-FOM) (n = 4), and (3) alveolar ridge with FOM, all of whom underwent lateral marginal mandibulectomy (MM-FOM) (n = 3). All patients reported swallowing scores of 70 ("I cannot swallow certain solid foods") or better. Ninety-six percent (23/24) reported speech of 70 ("difficulty saying some words, but I can be understood over the phone") or better. A-FOM patients reported worse chewing than L-FOM patients (mean: 50.0 vs. 85.3; p = 0.01). All 4 A-FOM patients reported a low chewing score of 50 ("I can eat soft solids but cannot chew some foods"). Otherwise, there were no significant differences between subsite groups in swallowing, speech, or taste.

CONCLUSION

STSG reconstructions for pathologic T1-T2 FOM-CA appear to result in acceptable PROM QOL outcomes with the exception of A-FOM tumors having worse chewing outcomes.

Patient-Reported Quality of Life After Resection With Primary Closure for Oral Tongue Carcinoma

OBJECTIVES/HYPOTHESIS

For early-stage oral tongue carcinoma and carcinoma in situ (ESOTCCIS), we evaluated patient-reported quality-of-life (QOL) outcomes following resection with primary closure (R-PC).

STUDY DESIGN

Retrospective review at an academic cancer center.

METHODS

Thirty-nine ESOTCCIS patients (Tis, T1, T2) who underwent R-PC without radiation completed the University of Washington Quality of Life Questionnaire Version 4 (UW-QOL) at least 6 months since R-PC (mean = 2.39 years; range = 0.5-6.7 years). We compared UW-QOL scores for pain, swallowing, chewing, speech, and taste to established normative population scores. Multivariable regression analysis evaluated factors associated with QOL impairment.

RESULTS

ESOTCCIS patients who underwent R-PC in comparison to the normative population reported significantly worse mean speech (87.7 vs. 98, P < .001) and taste (85.6 vs. 95, P = .002) scores and no significant differences in mean pain (91.7 vs. 86, P = .96), swallowing (100 vs. 98, P = .98), chewing (97.4 vs. 94, P = .98) scores. For speech and taste, 59% (23/39) reported no postoperative change from baseline, whereas 41% (16/39) and 35.9% (14/39) reported mild impairment, respectively. Overall, postoperative QOL was reported as good, very good, or outstanding by 87.2% (34/39). Higher American Society of Anesthesiologists class, cT1 compared to CIS, and ventral tongue involvement were independently associated with worse speech. Age < 60 years was independently associated with worse taste.

CONCLUSIONS

ESOTCCIS patients who undergo R-PC without radiation can expect long-term swallowing, chewing, and pain to be in the normative range. Although a majority of patients can expect to achieve normative speech and taste outcomes, R-PC carries the risks of mild speech and/or taste impairments.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:312-318, 2021.

Influences of Age, Gender, and Body Mass Index on the Depth of the Superficial Fascia of the Arm and Thigh

BACKGROUND

Nonsurgical skin-tightening procedures are increasing in popularity because of their noninvasiveness as the energy is transdermally applied to the subcutaneous tissues.

OBJECTIVE

To provide precise data on the depth of the superficial fascia for potentially safer and better targeted treatments of arms and thighs.

METHODS

One hundred fifty Caucasian individuals were investigated with an equal distribution of men and women (each n = 75) and a balanced distribution of age (n = 30 per decade). Ultrasound-based measurements were conducted, measuring the distance between skin and the superficial fascia in the posterior arm and the anterior, medial, and posterior thigh.

RESULTS

Deep to the skin, 5 layers were consistently and bilaterally identified in both sexes: skin, superficial fat, superficial fascia, deep fat, and deep fascia. The overall mean distance between the skin surface and the superficial fascia was for the posterior arm 4.38 ± 0.9 mm; range (2.60-6.70), for the anterior thigh 7.90 ± 2.3 mm range (3.50-13.20), for the medial thigh 5.74 ± 1.2 mm range (3.10-8.20), and for the posterior thigh 7.77 ± 3.2 mm range (3.60-14.50).

CONCLUSION

Knowing the precise depth of the superficial fascia for nonsurgical skin-tightening procedures could potentially guide practitioners toward safer and more effective outcomes.

Disciplinary boundaries and integrating care: using Q-methodology to understand trainee views on being a good doctor

BACKGROUND

Rising numbers of patients with multiple-conditions and complex care needs mean that it is increasingly important for doctors from different specialty areas to work together, alongside other members of the multi-disciplinary team, to provide patient centred care. However, intra-professional boundaries and silos within the medical profession may challenge holistic approaches to patient care.

METHODS

We used Q methodology to examine how postgraduate trainees (n = 38) on a range of different specialty programmes in England and Wales could be grouped based on their rankings of 40 statements about 'being a good doctor'. Themes covered in the Q-set include: generalism (breadth) and specialism (depth), interdisciplinarity and multidisciplinary team working, patient-centredness, and managing complex care needs.

RESULTS

A by-person factor analysis enabled us to map distinct perspectives within our participant group (P-set). Despite high levels of overall commonality, three groups of trainees emerged, each with a clear perspective on being a good doctor. We describe the first group as 'generalists': team-players with a collegial and patient-centred approach to their role. The second group of 'general specialists' aspired to be specialists but with a generalist and patient-centred approach to care within their specialty area. Both these two groups can be contrasted to those in the third 'specialist' group, who had a more singular focus on how their specialty can help the patient.

CONCLUSIONS

Whilst distinct, the priorities and values of trainees in this study share some important aspects. The results of our Q-sort analysis suggest that it may be helpful to understand the relationship between generalism and specialism as less of a dichotomy and more of a continuum that transcends primary and secondary care settings. A nuanced understanding of trainee views on being a good doctor, across different specialties, may help us to bridge gaps and foster interdisciplinary working.

'It's surprising how differently they treat you': a qualitative analysis of trainee reflections on a new programme for generalist doctors

OBJECTIVES

An increase in patients with long-term conditions and complex care needs presents new challenges to healthcare providers around the developed world. In response, more broad-based training programmes have developed to better prepare trainees for the changing landscape of healthcare delivery. This paper focuses on qualitative elements of a longitudinal, mixed-methods evaluation of the postgraduate, post-Foundation Broad-Based Training (BBT) programme in England. It aims to provide a qualitative analysis of trainees' evaluations of whether the programme meets its intentions to develop practitioners adept at managing complex cases, patient focused care, specialty integration and conviction in career choice. We also identify unintended consequences.

SETTING

9 focus groups of BBT trainees were held over a 12-month period. Discussions were audio-recorded and subjected to directed content analysis. Data were collected from trainees across all 7 participating regions: East Midlands; West Midlands; Severn; Northern; North Western; Yorkshire and Humber; Kent, Surry and Sussex.

PARTICIPANTS

Focus group participants (61 in total) from the first and second cohorts of BBT.

RESULTS

Evidence from trainees indicated that the programme was meeting its aims: trainees valued the extra time to decide on their onward career specialty, having a wider experience and developing a more integrated perspective. They thought of themselves as different and perceived that others they worked alongside also saw them as different. Being different meant benefitting from novel training experiences and opportunities for self-development. However, unintended consequences were feelings of isolation, and uncertainty about professional identity.

CONCLUSIONS

By spanning boundaries between specialties, trainee generalists have the potential to improve experiences and outcomes for patients with complex health needs. However, the sense of isolation will inhibit this potential. We employ the concept of 'belongingness' to identify challenges related to the implementation of generalist training programmes within existing structures of healthcare provision.

Infant and early childhood dietary predictors of overweight at age 8 years in the CAPS population

BACKGROUND/OBJECTIVES

Programs to address obesity are a high priority for public policy especially for young children. Research into dietary determinants of obesity is challenging but important for rational planning of interventions to prevent obesity, given that both diet and energy expenditure influence weight status. We investigated whether early life dietary factors were predictive of weight status at 8 years in a cohort of Australian children.

SUBJECTS/METHODS

We used data from the Childhood Asthma Prevention Study-a birth cohort at high risk of asthma. Dietary data (3-day weighed food records) were collected at 18 months and height, weight and waist circumference were collected at 8 years. We assessed the relationship between dietary predictor variables and measures of adiposity using linear regression.

RESULTS

Intakes of protein, meat and fruit at age 18 months were positively associated with measures of adiposity at age 8 years, namely, body mass index and/or waist circumference. We also showed a significant negative relationship between these measures of adiposity at 8 years and intake at 18 months of dairy foods as a percent of total energy, and intake of energy dense cereal-based foods such as cookies and crackers.

CONCLUSIONS

This birth cohort study with rigorous design, measures and analyses, has shown a number of associations between early dietary intake and subsequent adiposity that contribute to the growing evidence base in this important field.

Some Effects of Ionizing Radiation on Translocation in Plants

Petioles and apical regions of Phaseolus vulgaris var. Black Valentine were subjected to ionizing radiation to study the effect on the translocation process. Petiole irradiation produced no discernible effect. Inhibition of translocation to the irradiated meristems was reversed by application of the auxin naphthaleneacetic acid.

Sorbitol Translocation in Apple

A report of glucose translocation, an apparent exception to the hypothesis that sucrose is the major carbohydrate translocated in plants, was investigated. Carbon-14 studies of the carbohydrates in the bark of apple suggest that rather than glucose the sugar alcohol, sorbitol, in addition to sucrose, is a principal compound translocated in this species.

Food and nutrient consumption trends in older Australians: a 10-year cohort study

BACKGROUND/OBJECTIVES

Few longitudinal population-based cohort studies of older people have described dietary intakes over time. The objective of this study was to assess changes in the food and nutrient intake in a cohort of older Australians, using longitudinal data collected over 10 years.

SUBJECTS/METHODS

Population-based cohort of people aged 49 years and over at baseline (82% of those eligible) living in two postcode areas, west of Sydney. In 1992-1994, 3654 people were examined; 2334 were reexamined after 5 years and 1952 after 10 years (75% survivors at both examinations). A 145-item food frequency questionnaire was used to assess food and nutrient intake on each occasion, and 1166 participants provided usable dietary data at all three examinations.

RESULTS

Energy and sugar intake significantly increased among women over the 10-year period (P-value for trend <0.0001). Long-chain omega-3 fatty acid and fish intake significantly increased in both men and women (P-value for trend <0.0001). Folate intake significantly increased in both men and women (women: 325 dietary folate equivalents (DFE) vs 403 DFE; men: 346 DFE vs 425 DFE, P<0.0001). Wholemeal/grain bread consumption decreased in both men and women (P-value for trend <0.0001).

CONCLUSIONS

Many of the observed changes in diet over the 10-year period were consistent with current population dietary recommendations. Some changes, however, appear to have been due to poorer dietary choices. This information could be used to inform nutrition policy and programs targeted to older persons. These data highlight the need to identify barriers to better food choices.

Consumption of 'extra' foods by Australian adults: types, quantities and contribution to energy and nutrient intakes

OBJECTIVES

To identify the types and quantities of 'extra' foods, or energy-dense, nutrient-poor foods, consumed by Australian adults, and assess their contribution to total energy and nutrient intakes.

SUBJECT/METHODS

We used 24-h recall data from 10 851 adults, aged 19 years and over, who participated in the nationally representative 1995 National Nutrition Survey. 'Extra' foods were defined using principles outlined in the Australian Guide to Healthy Eating and by applying cut points for maximum amounts of fat and sugar within each food category.

RESULTS

'Extra' foods contributed to 36% of daily energy intake with the highest contributors being fried potatoes (2.8%), margarine (2.6%), cakes and muffins (2.5%), beer (2.4%), sugar-sweetened soft drinks (2.4%), and meat pies (2.2%). Both age and sex were important determinants of 'extra' foods intake; younger adults were more likely to consume sugar-sweetened soft drinks, fried potatoes, meat pies and savoury pastries, pizza, crisps, lollies and chocolate; whereas older adults were more likely to consume sweet and savoury biscuits, cakes and muffins, margarine and butter. In all age groups, 'extra' foods contributed more to energy intake for men than women. Overall, 'extra' foods contributed 16% protein, 41% total fat, 41% saturated fat, 47% sugar and approximately 20% of selected micronutrients to the diet.

CONCLUSIONS

'Extra' foods contribute excessively to the energy, fat and sugar intakes of Australian adults, while providing relatively few micronutrients. This is of concern for the increasing risk of overweight and chronic disease and poor micronutrient status.

Consumption of ‘extra’ foods by Australian children: types, quantities and contribution to energy and nutrient intakes

OBJECTIVE

To measure the types and quantities of energy-dense, nutrient-poor 'extra' foods consumed by Australian children and adolescents and their contribution to total energy and nutrient intakes.

DESIGN, SETTING AND SUBJECTS

We used data from 3007 children, aged 2-18 years, who participated in the nationally representative 1995 National Nutrition Survey. Intake was determined by 24-h recall and 'extra' foods were defined using principles outlined in the Australian Guide to Healthy Eating (AGHE) and by applying cut points for maximum amounts of fat and sugar within each food category.

RESULTS

All children (99.8%) consumed at least one 'extra' food and the most commonly consumed were margarine, sugar-sweetened soft drinks, cordials and sugar. 'Extra' foods contributed 41% of daily energy intake. Those foods contributing most to energy intake were fried potatoes (4.2%), sugar-sweetened soft drinks (3.3%), ice cream/ice confection (3.1%) and cordials (2.7%). Age and sex were important determinants of 'extra' food intake, with males and older children generally consuming more and different types of, 'extra' foods than females and younger children. 'Extra' foods contributed 19% protein, 47% total fat, 47% saturated fat, 54% sugar, and approximately 20-25% of selected micronutrients to the diet. Calcium and zinc intakes from core foods were below 70% of the recommended dietary intakes for adolescent girls.

CONCLUSIONS

'Extra' foods are over-consumed at two to four times the recommended limits and contribute excessively to the energy, fat and sugar intakes of Australian children, while providing relatively few micronutrients. This is of concern in terms of children's weight and nutrient status.

Folate fortification: potential impact on folate intake in an older population

OBJECTIVE

To examine the potential impact of different models of folate fortification of Australian foods on the folate intakes of older Australians.

DESIGN

Dietary data were collected using a food frequency questionnaire from people attending a population-based health study.

SETTING

Two postcode areas west of Sydney, Australia.

SUBJECTS

A total of 2895 people aged over 49 y, obtained from a door knock census (79% of 3654 subjects examined).

MAIN OUTCOME MEASURES

The folate intake in this population was estimated using four different models: (1) pre-fortification folate values; (2) current voluntary folate fortification in Australia; (3) universal fortification of all foods permitted to add folate, at 25% recommended dietary intake (RDI) per reference serve; and (4) universal fortification of all foods permitted to add folate, at 50% RDI per reference serve. The increased bioavailability of synthetic folic acid (SFA) was included in the analysis.

RESULTS

At current voluntary folate fortification, approximately 65% of this population consume 320 microg dietary folate equivalents (DFE) or more per day from diet and supplements, and 0.4% (n=10) consume greater than the recommended upper safety level of 1000 microg from SFA. More than 95% of this older population would be expected to consume more than 320 microg DFE from diet and supplements with universal fortification at 50% of the RDI, and 0.5% (n=14) may consume greater than 1000 microg/day of SFA.

CONCLUSIONS

There is unlikely to be a large increase in the proportion of older persons who are likely to consume more than the upper safety level of intake with universal folate fortification. As most of those who currently or are predicted to consume over 1000 microg SFA take supplements containing folic acid, it is highly recommended that vitamin B12 be included in any vitamin supplements containing folate.

SPONSORSHIP

This study was supported by the Australian National Health and Medical Research Council (NHMRC).

Prevalence and socio-demographic predictors of dietary goal attainment in an older population

OBJECTIVE

To describe the measured dietary intakes and anthropometry of a large, free-living population of middle-aged and older Australians who participated in the Australian Blue Mountains Eye Study (BMES), and to identify the socio-demographic characteristics associated with attainment or non-attainment of dietary goals.

METHOD

Anthropometry and dietary intakes were compared with current population dietary goals and Recommended Dietary Intakes for 2,873 people (79% of eligible residents) aged > or = 49 years who participated in the BMES. Nutrient intakes were measured by a validated food frequency questionnaire.

RESULTS

Nutrients for which mean intakes deviated most from nutrition goals included: percentages of energy from total and saturated fat, carbohydrate and alcohol (men), as well as absolute intakes of calcium, zinc and fibre. More than half the men (60%) and women (54%) were overweight or obese. Several micro-nutrient goals were more likely to be met in households where the respondents and/or their spouses were independent. Married men were more likely to meet goals for fibre and iron, but less likely to meet the goal for cholesterol. Several goals were more likely to be met by men and women who had qualifications after leaving school, those with higher job status and non-pensioners, suggesting an socio-economic status dimension.

CONCLUSIONS AND IMPLICATIONS

These results indicate that over- rather than under-nutrition is more prevalent among community-dwelling older people, although under-nutrition should not be overlooked. Particular sub-groups that are less likely to meet some dietary goals may require targeting in community nutrition interventions.

A comparison of amitriptyline, vasopressin and amitriptyline with vasopressin in nocturnal enuresis

Forty-five children aged 6-14 years with primary nocturnal enuresis were randomised to determine whether desmopressin is more effective than amitriptyline and whether the combination of amitriptyline/desmopressin is more effective than amitriptyline or desmopressin alone. Amitriptyline dosage was 25 mg for children 6-10 years and 50 mg for children aged 10-14 years. Desmopressin (20 micrograms) was given in the same dosage for all age groups. After a run-in period of 2 weeks, children were treated for 16 weeks and then observed for 12 weeks. In the amitriptyline group mean wet nights per week decreased from 5.8 +/- 0.9 to 3.3 +/- 1.9 (P < 0.0005); in the desmopressin group mean wet nights per week decreased from 6.0 +/- 0.9 to 4.7 +/- 1.7 (P < 0.02); in the amitriptyline/desmopressin group mean wet nights per week decreased from 6.3 +/- 0.9 to 3.3 +/- 2.5 (P < 0.0006). When comparing the groups, amitriptyline/desmopressin and amitriptyline were statistically more effective than desmopressin in week 6 (P < 0.009), week 8 (P < 0.03) and week 10 (P < 0.04). No significant side effects occurred. At this dose amitriptyline was more effective than desmopressin and the combination of desmopressin and amitriptyline did not confer any additional benefit.

The implications of underreporting in dietary studies

Dietary data from the Western Sydney Dietary Survey 1989-90 (n = 512) was used to investigate: 1. the prevalence and predictors of underreporting of energy intake, 2. the effects on results of excluding data from underreporters for analysis of mean nutrient intakes, and 3. the proportion of energy intake supplied by macronutrients and proportions of subjects who met dietary goals. The proportion whose measured energy intakes from a Food Frequency Questionnaire (FFQ) were below cutpoints for biologic plausibility was 28.5 per cent; it was higher for subjects who had BMI > 25 and were female. Point estimates for mean intakes of energy and nutrients were all greater when data from underreporters were excluded, but nutrient intakes expressed as percentages of energy intake remained largely unchanged. Increases in estimated mean population intake for each nutrient ranged from 7 per cent to 14 per cent for males, and 12 per cent to 17 per cent for females. Estimates of the percentages of the sample who did not meet dietary goals were significantly lower for a number of nutrients when underreporters were excluded. We conclude that: 1. results expressed as a percentage of energy intake are not affected by the exclusion of energy underreporters, and 2. estimates of the proportion of populations meeting some nutrient goals and associations between diet and disease are likely to change meaningfully and significantly with the exclusion of data from underreporters.

Cyclosporin therapy in steroid-dependent nephrotic syndrome

Five children with multiple relapsing steroid-dependent nephrotic syndrome were treated with continuous cyclosporin for periods ranging from 18 to 48 months. Renal biopsy showed mild mesangial proliferation in three of the children and minimal change in two. All children previously had been treated with cyclophosphamide. Cyclosporin was started during remission at 5 mg/kg per day. If a relapse occurred the dose was increased until a trough blood level of 100-250 ng/mL (HPLC) was achieved. In the initial 12 months of treatment, the mean number of relapses decreased from 6.4 +/- 0.54 (s.d.) per annum to 1.6 +/- 1.3 per annum (P < 0.01). Cyclosporin was effective in maintaining long-term remission in four of the five patients. Side effects included hypertrichosis (5) and gum hyperplasia (1). The mean creatinine clearance decreased from 126 +/- 16 to 97 +/- 22 mL/min per 1.73 m2 (P = NS). A renal biopsy in all five patients after 12 months therapy showed no nephrotoxicity. A further biopsy in one patient after 4 years therapy showed interstitial fibrosis. Cyclosporin should be considered in children with steroid-dependent nephrotic syndrome who show signs of steroid toxicity and have only a short remission period after cyclophosphamide. Serial renal biopsies are recommended if prolonged therapy is used.

Evaluation of automated threshold selection methods for accurately sizing microscopic fluorescent cells by image analysis

The accurate measurement of bacterial and protistan cell biomass is necessary for understanding their population and trophic dynamics in nature. Direct measurement of fluorescently stained cells is often the method of choice. The tedium of making such measurements visually on the large numbers of cells required has prompted the use of automatic image analysis for this purpose. Accurate measurements by image analysis require an accurate, reliable method of segmenting the image, that is, distinguishing the brightly fluorescing cells from a dark background. This is commonly done by visually choosing a threshold intensity value which most closely coincides with the outline of the cells as perceived by the operator. Ideally, an automated method based on the cell image characteristics should be used. Since the optical nature of edges in images of light-emitting, microscopic fluorescent objects is different from that of images generated by transmitted or reflected light, it seemed that automatic segmentation of such images may require special considerations. We tested nine automated threshold selection methods using standard fluorescent microspheres ranging in size and fluorescence intensity and fluorochrome-stained samples of cells from cultures of cyanobacteria, flagellates, and ciliates. The methods included several variations based on the maximum intensity gradient of the sphere profile (first derivative), the minimum in the second derivative of the sphere profile, the minimum of the image histogram, and the midpoint intensity. Our results indicated that thresholds determined visually and by first-derivative methods tended to overestimate the threshold, causing an underestimation of microsphere size. The method based on the minimum of the second derivative of the profile yielded the most accurate area estimates for spheres of different sizes and brightnesses and for four of the five cell types tested. A simple model of the optical properties of fluorescing objects and the video acquisition system is described which explains how the second derivative best approximates the position of the edge.

Algorithm to estimate cell biovolume using image analyzed microscopy

This paper describes an algorithm for calculating the biovolume of cells with simple shapes, such as bacteria, flagellates, and simple ciliates, from a 2-dimensional digital image. The method can be adapted to any image analysis system which allows access to the binary cell image--(i.e., the pixels, or (x,y) points, composing the cell. The cell image is rotated to a standard orientation (horizontal), and a solid of revolution is calculated by digital integration. Verification and a critical assessment of the method are presented. The algorithm accounts for irregularities in cell shape that conventional methods based on length, width, and geometrical formulas do not.

Dietary compliance among insulin-dependent diabetics

An education program to improve dietary compliance in insulin-dependent diabetics was evaluated from 1978 to 1980 at the Royal North Shore Hospital of Sydney. Dietary intake, biochemical status, health beliefs, knowledge, anthropometric and other measurements were made on 140 diabetics and their family members before and, where possible, 6 months after the program. Four aspects of compliance were assessed: dietary composition, body weight, carbohydrate spacing among meal periods and carbohydrate variation between days. There was a significant increase in the proportion of subjects who achieved the recommended goal of a high carbohydrate/low fat diet. Diabetics who complied with this recommendation were significantly more likely to have adequate glycemic control. Most of the participants were initially near ideal weight and there were few substantial weight changes. The proportions of diabetics with acceptable scores for carbohydrate spacing and variation did not change significantly. Subjects who complied with one aspect of the dietary regimen did not necessarily comply with other aspects. Dietary compliance was related to initial patterns of dietary intake but could not be predicted from any other factors such as demographic characteristics, duration of disease, knowledge or health beliefs, although this could have been due to small sample sizes.

Evaluation of a diabetes education programme

An education programme was evaluated for 140 insulin-dependent diabetics and their family members from 1978 to 1980. Dietary, biochemical and other assessments were made before and 6 months after the programme. As a group, the diabetics were initially in good metabolic control and this was maintained, or improved, over the study period. The programme recommended a diet in which complex carbohydrate constituted at least 45% of energy intake and fat was limited to 30%. The diabetics and their family members significantly increased their consumption of complex carbohydrate and decreased fat intake. On this regimen, diabetics did not gain weight and their relatives lost weight. There were also improvements in knowledge of the disorder and in perceptions of susceptibility to complications and barriers to compliance.

Ultrastructure of a marine Synechococcus possessing spinae

Two Chesapeake Bay isolates of unicellular cyanobacteria belonging to the genus Synechococcus are described. Unicellular cyanobacteria are suspected to be important primary producers in estuarine and marine waters. One isolate (P-11-16) fluoresces red and forms green colonies. The other isolate (P-11-17) fluoresces orange and forms red colonies. Their ultrastructure is very similar to other isolates of Synechococcus except that spinae are formed and are attached to an outer wall layer not found in previously described species. The spinae are straight-walled cylinders, not flared at the base, are 44.0-65.0 nm in diameter, and range up to 2.7 micrometer in length. Substructure of the spinae wall consists of either material organized into stacks of rings or a strand of material helically coiled at a low (1-6 degrees) angle. Such material yielded a 6.0-9.2 nm cross-banding periodicity. Substructure of the rings or strand appeared to consist of bar-shaped, repeating units as seen in negatively stained material. Other procaryotic cell types with spinae, which were isolated from unincubated, natural seawater, are described.

Nutrient and Oxygen Redistribution During a Spring Neap Tidal Cycle in a Temperate Estuary

Spring tidal currents produce homogeneous water columns in a number of estuaries that are moderately stratified during neap tides. In the York River estuary, this destratification redistributes ammonium and phosphate regenerated by the benthos as well as oxygen from the surface. This redistribution has significant implications for nutrient cycles, organism distributions, and the management of estuaries.

Nitrification on a coral reef

We report that the algal pavement just behind the reef crest at Enewetak Atoll produces nitrate at measurable rates. In situ and in vitro incubations with N-Serve indicate that the autotrophic pathway involving two separate organisms is effective in this oxidation of ammonia to nitrate. Significant nitrification is indicated throughout the reef environment; Nitrobacter agilis has specifically been identified as at least one of the organisms responsible for the terminal oxidation of nitrite to nitrate.

Nitrogen Fixation in a Coral Reef Community

Algal reef flats at Enewetak Atoll, Marshall Islands, fix atmospheric nitrogen at rates comparable to those in managed agriculture. The dominant nitrogen fixer appears to be the blue-green alga Calothrix crustacea. Since this nutrient enrichment contributes to the high productivity of adjacent coral reefs and undoubtedly to atoll lagoons, it is recommended that the algal reef flats receive increased conservation priority.

Amino acid flux in an estuary

Dissolved organic matter in York River estuary included 38 micrograms of free amino acids per liter. The highest concentrations were of glycine, serine, and ornithine. Of the 14 amino acids studied for uptake by planktonic bacteria, glycine, methionine, and serine had the greatest flux rates. The total amino acid flux represented from 1 to 10 percent of the daily photosynthetic carbon fixation.

Release of Dissolved Amino Acids by Marine Zooplankton

Marine net zooplankton release dissolved amino acids into the water. Release rates are positively correlated with temperature and can be estimated by the equation: Release rate, (milligrams of alpha-amino nitrogen per gram dry weight of zooplankton per day) = 1.0 x temperature ( degrees C) -5.9. Release rates appeared to be independent of the taxonomic composition of the test samples, which were variously dominated by copepods, salps, chaetognaths, coelenterates, or radiolarians. These amino acids constitute an important source of dissolved organic matter in the sea.

A relationship between boron & auxin in C translocation in bean plants

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