Potential sources of mouth drying in beverages fortified with dairy proteins: A comparison of casein- and whey-rich ingredients.

Oral nutritional supplement drinks (ONS) are beverages high in dairy proteins that are prescribed to individuals at risk of malnutrition. Consumption of ONS is poor in elderly care facilities, with patients commenting that the sensory attributes of these drinks reduce their enjoyment and willingness to consume. Mouth drying is an attribute of ONS found to build with repeated consumption, which may further limit liking of these products. This study investigated the sources of drying sensations by sequential profiling, with a trained sensory panel rating a range of model milk systems and ONS over repeated sips and during after-effects. Sequential profiling found that fortification of milk with both caseinate and whey protein concentrate significantly increased the perception of mouth drying over repeated consumption, increasing by between 35 and 85% over consumption of 40mL. Enrichment of ONS with either whey protein concentrate or milk protein concentrate to a total protein content of 8.7% (wt/wt) resulted in whey and casein levels of 4.3:4.4% and 1.7:7.0% respectively. The product higher in whey protein was substantially more mouth drying, implying that whey proteins may be the most important contributor to mouth drying in ONS. However, efforts to mask mouth drying of protein-fortified milk by increasing sweetness or fat level were unsuccessful at the levels tested. Increasing the viscosity of protein-fortified milk led to a small but significant reduction in mouth drying. However, this approach was not successful when tested within complete ONS. Further analysis is required into the mechanism of protein-derived mouth drying to mask negative sensations and improve the enjoyment and consumption of protein-rich ONS.

Psychosocial impact of visual impairment in working-age adults.

AIM: To review the evidence for the presence of lower levels of psychosocial well-being in working-age adults with visual impairment and for interventions to improve such levels of psychosocial well-being. METHODS: Systematic review of quantitative studies published in English from 2001 to July 2008 that measured depression/mental health, anxiety, quality of life, social functioning or social support. RESULTS: Included were 29 studies that measured one or more outcomes (N = 52). Working-age adults with visual impairment were significantly more likely to report lower levels of mental health (mean difference = 14.51/100), social functioning (MD = 11.55/100) and quality of life. Studies regarding the prevalence of depressive symptoms produced inconsistent results but had methodological limitations. CONCLUSIONS: Future research is required into the prevalence of loneliness, anxiety and depression in adults with visual impairment, and to evaluate the effectiveness of interventions for improving psychosocial well-being such as counselling, peer support and employment programmes.

Effect of micronutrient supplementation on mood in nursing home residents.

One third of older people in nursing and/or residential homes have significant symptoms of depression. In younger people, deficiencies in selenium, vitamin C and folate are associated with depression. This study examines the association between micronutrient status and mood before and after supplementation. The objective was to determine whether the administration of selenium, vitamin C and folate improved mood in frail elderly nursing home residents. Mood was assessed using the Hospital Anxiety and Depression rating scale (HAD), and Montgomery-Asberg Depression Rating Scale (MADRS). Micronutrient supplementation was provided for 8 weeks in a double-blinded randomised controlled trial. Significant symptoms of depression (29%) and anxiety (24%) were found at baseline. 67% of patients had low serum concentrations of vitamin C, but no-one was below the reference range for selenium. Depression was significantly associated with selenium levels, but not with folate or vitamin C levels. No individual with a HAD depression score of >or=8, had selenium levels >1.2 microM. In those patients with higher HAD depression scores, there was a significant reduction in the score and a significant increase in serum selenium levels after 8 weeks of micronutrient supplementation. Placebo group scores were unchanged. This small study concluded that depression was associated with low levels of selenium in frail older individuals. Following 8 weeks of micronutrient supplementation, there was a significant increase in selenium levels and improved symptoms of depression occurred in a subgroup.

Privacy for defecation and fecal incontinence in older adults.

INTRODUCTION: Privacy during defecation is important to individuals and society at large and it has not been studied in older people with fecal incontinence. METHODS: One hundred twenty adults aged 65 years and with fecal incontinence who were either living in their own homes or in a nursing home or receiving care in an acute or rehabilitation elderly care ward were surveyed with a questionnaire that included questions on privacy during defecation. RESULTS: Privacy while defecating was often least achieved in the patients with fecal incontinence living in nursing homes (NH) (n=7, 23%) but usually was achieved in those living at home (H) (n=28, 93%) and by some being cared for in rehabilitation wards (R) (n=16, 53%) or in acute wards (AC) (n=15, 50%; P<.001). Very few participants with fecal incontinence were aware of leakage (NH: n=3, 10%; R: n=9, 30%; AC: n=9, 30%; H: n=15, 50%), able to clean themselves (NH: n=0, 0%; R: n=2, 7%; AC: n=5, 17%; H: n=24, 80%) or had access to patient information leaflets about fecal incontinence (NH: n=3, 10%; R: n=4, 13%; AC: n=1, 3%; H: n=16, 53%). CONCLUSION: Older people, especially those who are dependent, lack privacy during bowel movements. They are usually unaware of being incontinent of stool and are unable to clean themselves afterwards. Access to information about fecal incontinence is poor.

The knowledge of healthcare professionals regarding elderly persons' oral care.

OBJECTIVE: The aim of this study was to compare the knowledge and views of nursing staff on both acute elderly care and rehabilitation wards regarding elderly persons' oral care with that of carers in nursing homes. SUBJECTS: One hundred nurses working on acute, sub-acute and rehabilitation wards for elderly people (Group 1) and 75 carers in nursing homes (Group 2) were surveyed. DESIGN: A semi-structured questionnaire. RESULTS: Similar percentages of each group of nurses were registered with a dentist (86% and 88% respectively), although more hospital-based nurses were anxious about dental treatment compared with the nursing home group (40% and 28% respectively). More carers in nursing homes gave regular advice about oral care than the hospital-based nurses (54% and 43% respectively). Eighteen per cent of each group thought that edentulous individuals did not require regular oral care. Eighty-five per cent of hospital-based nurses and 95% of nursing home carers incorrectly thought that dentures were 'free' on the NHS. Although trends were observed between the two groups, no comparisons were statistically significant (Chi-square; level p < 0.05). CONCLUSIONS: Deficiencies exist in the knowledge of health care workers both in hospital and in the community setting, although the latter were less knowledgeable but more likely to give advice to older people.

Anxiety and depression in an older research population and their impact on clinical outcomes in a randomised controlled trial.

INTRODUCTION: Anxiety and depression are common in older people living in the community. The aim of the study was to investigate their impact on clinical outcomes during a randomised controlled trial investigating the cost benefits of influenza vaccination in fit and healthy, independent living 65-74 year olds. SUBJECTS AND METHODS: A total of 729 people were recruited. Participants completed the hospital anxiety and depression scale (HADS) and EuroQol EQ-5D quality of life questionnaire immediately before receiving vaccination and every two months for the next six months after this. Side effects three days after vaccination and Barthel score at baseline were also recorded. RESULTS: At baseline the prevalence of "definite" anxiety in this sample (HADS score > or =11) was 4% and 1.2% of individuals had definite depression (HADS score > or =11). Individuals with anxiety or depression (HADS score > or =8) were more likely to complain of systemic side effects after vaccination and have a lower Barthel index score (p<0.001). Quality of life as measured by the EQ-5D visual analogue scale was reduced (p<0.001) at all time periods in those individuals with both anxiety and depression (HADS score > or =8 on both scales). CONCLUSION: Although the prevalence of anxiety and depression in this sample was low, people with anxiety or depression were more likely to suffer from perceived side effects after influenza vaccine and have a lower Barthel and EQ-5D visual analogue score. In future studies the effect of anxiety and depression on older participants should be remembered and care taken to ensure that they do not affect results more than the intervention under study.

A proton magnetic resonance spectroscopy study of age-related changes in frontal lobe metabolite concentrations.

Ageing is associated with reduction of grey matter volume and it is reported that the frontal lobes are preferentially affected. We have applied quantitative magnetic resonance spectroscopy (MRS), incorporating measurement of brain tissue water content and metabolite T(2) relaxation times, to determine absolute concentrations of the putative neuronal marker N-acetylaspartate (NAA), creatine (Cr) and choline (Cho) compounds in the frontal lobe of 50 male subjects aged between 20 and 70 years (10 per decade). The fractional brain water content (beta(MR)) did not change significantly as a function of age (r = 0.07, P = 0.65) and had a mean value of 81% (CV = 2%). The concentration (in millimoles per litre brain tissue) of NAA decreased significantly with age (r = -0.42, P = 0.003), with an overall decrease of 12% between the third and seventh decades. The concentrations of Cr and Cho did not change significantly with age. The interpretation of the age-dependent decrease in NAA concentration as reflecting either a reduction in neuronal volume, number or function is discussed.

Murmurs, infective endocarditis and dentistry.

Patients with cardiac murmurs may have a predisposition to infective endocarditis, and the dental practitioner must be aware of this potential problem. This article reviews cardiac murmurs and how they are investigated by physicians to assess their significance. Practical advice is offered concerning the need to refer patients with a suspected heart murmur. The emergency and elective dental management of patients with heart murmurs is included, together with recommended regimens for antibiotic prophylaxis.

Oral care of elderly patients: nurses' knowledge and views.

It is important that healthcare professionals caring for the elderly in hospitals have a core knowledge of the orodental care requirements of their patients. The aim of this study was to determine the knowledge and views of nurses working on acute and rehabilitation care of the elderly wards about orodental care. One hundred nurses and healthcare assistants took part in this questionnaire study of which 58 were qualified nurses and 70 had been employed on care of the elderly wards for two or more years. Although the majority of the respondents were registered with a dentist and attended regularly, 40 did have 'some anxiety' about visiting their dentist. Approximately half of the study population regularly gave advice to their patients about dental care but their knowledge of and reasons for providing oral care and advice was often incorrect. The group's understanding of the availability of dental treatment provided by the National Health Service was also often inaccurate. It was concluded that a better core knowledge of the orodental care of older patients is required by all healthcare professionals who care for this group. It is also important that individuals in whom anxiety is associated with their own dental experience do not neglect to give orodental health advice to their patients.

The orodental status of a group of elderly in-patients: a preliminary assessment.

OBJECTIVE: To provide a preliminary assessment of the orodental status and dental treatment requirements of a group of elderly in-patients. DESIGN: Cross-sectional. SETTING: Acute Care of the Elderly and Stroke Rehabilitation units at teaching hospitals in Merseyside. SUBJECT: 150 patients aged 58 to 94 years, in which a history could be validated at interview. INTERVENTION: Questionnaire administered by dentist and clinical examination. MAIN OUTCOME MEASURES: Registration with a dentist, prosthetic status and difficulties with dentures, denture hygiene and identification marking, dental treatment needs and evidence of mucosal pathology. RESULTS: Only 27% of patients claimed registration with a dentist. Three quarters of the patients were edentulous and 66 patients wore full dentures; 18 had no prostheses. Difficulties were experienced by one quarter of patients with upper dentures, compared with a half of lower denture wearers. Of the dentures available for inspection, 61% had removable soft debris, 66% were left out at night and 75% were cleaned by the patient, whilst on the ward. No dentures had evidence of identification marking. Of the 39 partially dentate patients, 75% required interventive dental treatment. Denture stomatitis was diagnosed in 29% of patients and 19 had evidence of benign mucosal pathology. CONCLUSIONS: The orodental status of this group of elderly in-patients was poor, with a high proportion being edentulous. Few were registered with a dentist and denture hygiene was inadequate. Lack of identification marking is a matter of concern. Closer liaison between hospital staff responsible for elderly in-patients is required, to improve the orodental health and quality of life of this medically compromised group of patients.

Oral flora of elderly patients following acute medical admission.

The human oral microflora is diverse and is usually predominately composed of Gram-positive bacteria. It is uncommon to find Gram-negative bacilli (GNB) in healthy mouths. The incidence of infection with GNB rises in institutionalised, frail elderly subjects. There is also evidence of an association between intra-oral GNB presence and denture wearing. There have been few studies which have investigated intra-oral GNB carriage in acutely ill elderly patients. The aim of this study was to evaluate the oral flora of a group of elderly patients during an acute medical admission and to investigate any associations between the oral microflora and existing medical or oral factors. A total of 28 patients (17 females and 11 males; age: 74-93 years) on a care for the elderly ward were studied. Epidemiological data, detailed medical histories and oral examinations were undertaken. In addition, oral swabs of the palate area were taken to determine their oral flora. Twelve (43%) of the patients had GNB in their oral cavities. These patients were suffering from a variety of medical conditions and were on various drug regimes. There was a correlation between oral GNB presence and denture use. There was no association between GNB presence and denture hygiene. As oropharyngeal GNB colonisation can be associated with infections such as aspiration pneumonia, it is important in patients at risk that intra-oral organisms are identified and managed.

Pseudomonas aeruginosa septicaemia from an oral source.

Oral colonisation with aerobic Gram-negative bacilli (AGNB) is abnormal and usually indicates a medically compromised state in the host. It has been postulated that oral colonisation with AGNB may predispose a patient to serious systemic infection, but proof of this assertion is lacking. This report describes an elderly patient who had oral colonisation of Pseudomonas aeruginosa and developed septicaemia from an identical strain of this bacterium.

Assessing attentiveness in older hospital patients: global assessment versus tests of attention.

OBJECTIVES: Impairment of attentiveness is a cardinal symptom of delirium. We examined the relationship between bedside tests of attention and a global rating of attentiveness in older hospital patients and sought to identify cut-off points on the tests of attention that might be helpful in the diagnosis of delirium. SETTING AND PARTICIPANTS: Subjects were 110 patients admitted to an acute geriatric unit. MEASUREMENTS: Subjects were assessed by two physicians. One physician rated global attentiveness on a 10-cm visual analog scale following general conversation with the patient. The second physician determined whether patients met DSM-3 criteria for delirium or dementia and administered four tests of attentiveness: Digit Span Forwards (DSF), Digit Span Backwards (DSB), Vigilance "A' test (VAT), and a timed Digit Cancellation Test (DCT). MAIN RESULTS: Of the 87 patients who completed the study, 18 were delirious and 17 demented. There was no difference between demented and delirious patients on the VAT, DSF, or MMSE tests; other comparisons between demented and delirious patients and between delirious patients and those with neither delirium nor dementia were significant. All tests of attention except DSF were significantly correlated with the global rating. CONCLUSION: Simple bedside tests of attention can aid identification of delirium.

Orthostatic hypotension and vasodilatory peptides in bronchial carcinoma.

AIM: To determine whether inappropriately secreted vasodilatory peptides have a role in the pathogenesis of orthostatic (postural) hypotension, a recognised paraneoplastic effect of bronchial malignancies usually attributed to immune mediated destruction of autonomic ganglia. METHODS: Serum concentrations of three vasodilatory peptides, atrial natriuretic peptide (ANP), vasoactive intestinal polypeptide (VIP) and calcitonin gene related peptide (CGRP), were measured in 111 patients with bronchial carcinoma and 35 controls prospectively screened for orthostatic hypotension (> 20 mmHg drop in systolic blood pressure on repeated occasions on standing from the supine position) and in whom other causes of this condition were excluded. RESULTS: Twenty two (20%) patients with carcinoma and two (6%) controls had orthostatic hypotension according to the criteria used. Serum concentrations of ANP, VIP and CGRP were elevated above normal in, respectively, 25 (23%), 10 (9%) and eight (7%) patients with carcinoma and in six (18%), zero and three (9%) controls. There was no correlation between orthostatic hypotension and concentrations of any of the vasodilatory peptides. CONCLUSION: Elevated serum concentrations of ANP and CGRP were no more frequent in subjects with bronchial carcinoma than in controls and could not be attributed to the tumour, although there was a possible association for VIP. Orthostatic hypotension was more common in patients with carcinoma, but there was no evidence that the peptides measured played a role in its pathogenesis.

Reliability of commercially available immunocytochemical markers for identification of neuroendocrine differentiation in bronchoscopic biopsies of bronchial carcinoma.

BACKGROUND: Although neuroendocrine differentiation occurs quite commonly in non-small cell bronchial malignancies, its biological significance and implications for management remain uncertain. Determining these facts requires its recognition early, ideally at diagnosis, which is usually made on tissue from bronchoscopy, but the best means of its detection in such material is unclear. A prospective comparative study was performed of 10 commercially available antisera to a series of markers of neuroendocrine differentiation, to test their efficacy when applied to fibreoptic bronchoscopy biopsy specimens. METHODS: Expression of chromogranin A, synaptophysin, neurone-specific enolase, protein gene product 9.5, the BB isoenzyme of creatine kinase, gastrin releasing peptide, adrenocorticotrophic hormone, calcitonin, calcitonin gene related peptide, and leucine enkephalin was sought by immunolabelling of bronchoscopic biopsy tissue from 83 primary bronchial carcinomas, 22 of them of small cell type. RESULTS: Only synaptophysin and chromogranin were sensitive and specific enough for neuroendocrine differentiation to discriminate between small cell and non-small cell lesions, whereas protein gene product 9.5 and creatine kinase were neither particularly sensitive nor specific and neurone-specific enolase actually labelled more non-small cell tumours than small cell lesions. Of the five secretory products sought, only gastrin releasing peptide was detectable in just one tumour. Three squamous and two morphologically undifferentiated tumours immunolabelled for synaptophysin and chromogranin, almost certainly indicating neuroendocrine differentiation in the absence of small cell morphology. CONCLUSIONS: Of the markers studied, only synaptophysin and chromogranin were sufficiently specific and sensitive for neuroendocrine differentiation to justify their inclusion in any panel of antibodies used in its detection in tissue obtained at fibreoptic brochoscopy.

Exposure to cigarette smoke and expression of the protein encoded by the p53 gene in bronchial carcinoma.

Mutation of the onco-suppressor gene encoding the protein known as p53 may cause synthesis of a mutant p53 protein which can bind to and inactivate its wild-type equivalent. This protein is detectable in many malignant neoplasms, including bronchial carcinoma, and has been associated with cigarette smoking. Of 59 tissue biopsy specimens of primary bronchial malignancies immunolabeled for p53 by the avidin-biotin technique using the antibodies PAb 1801, CM1, and D07, 13 (22%) expressed the protein. Of these 13 patients, 10 (77%) smoked more than 20 cigarettes a day and their mean total exposure was 53 pack-years. Corresponding figures for those with p53-negative tumors were 21 (46%) smoking more than 20 cigarettes a day with a mean total exposure of 36 pack-years. There was, however, no difference between the groups in total duration of exposure (46 vs. 47 years). Although p53 was expressed more commonly in adenocarcinoma (30% of 10) and squamous carcinoma (28% of 29) than in small cell tumors (10% of 20), this could be accounted for by the smoking history. This study supports a relationship between mutations of the p53-encoding gene associated with overexpression of its protein product and intensity of exposure to cigarette smoke.

Plasma growth hormone and digital clubbing in carcinoma of the bronchus.

Growth hormone is a secretory product of some primary bronchial neoplasms and has been associated with the development of hypertrophic pulmonary osteoarthropathy and acromegaly in occasional patients with such tumours; it has not, however, generally been considered important in the pathogenesis of digital clubbing. Plasma levels of growth hormone at the time of diagnostic bronchoscopy were measured in 60 patients with histologically proved bronchial carcinoma, divided according to whether clubbing was present (n = 21) or absent (n = 39), and in 13 control subjects undergoing the same procedure but with no neoplasm. The median plasma level of growth hormone ( and interquartile range) was 0.74 (0.5-1.0) mU/l in five control subjects with no pulmonary disease, 0.83 (0.4-1.3) mU/l in eight subjects with non-neoplastic pulmonary disease, 1.1 (0.6-3.3) mU/l in patients with carcinoma but without clubbing, and 3.1 (0.8-9.0) mU/l in 21 patients with carcinoma and clubbing. The highest growth hormone level was seen in a patient with a small cell carcinoma and pronounced clubbing; levels had fallen to normal by the time chemotherapy was completed and clubbing completely resolved. Thus growth hormone or a similar substance might have a role in the pathogenesis of clubbing in patients with bronchial neoplasms.

c-myc oncoprotein in bronchial carcinoma: expression in all major morphological types.

We have studied the prevalence of a 62 kd protein product of the c-myc oncogene in tissue biopsies from 79 primary bronchial carcinomata using the monoclonal antibody Myc 1-9E10 and the avidin-biotin complex (ABC) technique. This oncoprotein was strongly expressed in 43% of 37 squamous lesions, 29% of 14 adenocarcinomata, 42% of 7 non-small cell lesions not further classifiable and 19% of 21 small cell neoplasms, all of classical morphology. There was no statistical difference between groups in the prevalence of its expression, nor was it related to survival. This oncoprotein is commonly expressed in non-small cell as well as small cell bronchial carcinomata and, in the latter, is not confined to those variant tumours which possess a "large cell" morphology and carry a poor prognosis.