Mediterranean-Type Diet and Brain Structural Change from 73 to 79 Years in the Lothian Birth Cohort 1936.

OBJECTIVES: To test whether Mediterranean-type Diet (MeDi) at age 70 years is associated with longitudinal trajectories of total brain MRI volume over a six-year period from age 73 to 79. DESIGN: Cohort study which uses a correlational design. SETTING: Participants residing in the Lothian region of Scotland and living independently in the community. PARTICIPANTS: A relatively healthy Scottish sample drawn from the Lothian Birth Cohort 1936. MEASUREMENTS: Total brain volume measurements were available at ages 73, 76 and 79 (N ranged 332 to 563). Adherence to the MeDi was based on food frequency questionnaire data collected three years before the baseline imaging scans, and was used in growth curve models to predict the trajectory of total brain volume change. RESULTS: No association was found (p>.05) between adherence to the MeDi at age 70 and total brain volume change from 73 to 79 years in minimally-adjusted (sex) or fully adjusted models controlling for additional health confounders. CONCLUSIONS: Variation in adherence to the MeDi was not predictive of total brain atrophy over a six-year period. This suggests that previous findings of dietary associations with brain volume are not long lasting or become less important as ageing-related conditions account for greater variation in brain volume change. More frequent collection of dietary intake data is needed to clarify these findings.

Posterior reversible encephalopathy syndrome with Lilliputian hallucinations secondary to Takayasu's arteritis.

Posterior Reversible Encephalopathy Syndrome (PRES) is a rare complication of Takayasu's Arteritis. A 54-year-old, right-handed woman presented with Lilliputian visual hallucinations, postprandial abdominal pain, blurred vision and headaches. She then had a tonic-clonic seizure. Neuroimaging revealed characteristic white matter oedema of the occipital lobes, in keeping with PRES. Renal infarcts and abnormalities of the abdominal aorta, subclavian, mesenteric, and internal carotid arteries were demonstrated on further imaging. The combination of hypertension, absent peripheral pulses, postprandial claudication, and imaging abnormalities of the aorta as well as its branches, lead to the diagnosis of PRES secondary to Takayasu's Arteritis. Treatment with oral steroids resulted in complete resolution of the patient's symptoms and abnormalities found on CT and MRI brain imaging. Takayasu's Arteritis is a rare vasculitis, more common in women and PRES is an unusual complication. Symptoms of PRES may include headache, seizures, hallucinations, confusion, and altered consciousness. Risk factors for PRES include; pregnancy, immunosuppression, renal disease, hypertension and rheumatological disorders. Vasogenic oedema in affected lobes, most often occipital, is characteristic of PRES on neuroimaging. Prompt treatment of PRES can avoid catastrophic consequences such as death and can achieve complete resolution of symptoms and imaging abnormalities.

The accuracy of standard multiple sclerosis MRI brain sequences for the diagnosis of optic neuropathy.

BACKGROUND: Detection of optic neuropathy on MRI has potential implications for the diagnosis and management of Multiple Sclerosis (MS). OBJECTIVE: This study assessed the accuracy of T2 sagittal MRI brain for detection of optic neuropathy, compared to coronal STIR orbit. METHODS AND MATERIALS: Retrospective single-center blinded diagnostic accuracy study of 100 consecutive patients who underwent both T2 sagittal brain and coronal STIR orbit MRI. All were performed on 1.5T scanners. T2 sagittal slice thickness was 4 mm for the first 50 patients (group1) and 3 mm for the second 50 (group2). The MRIs were reviewed in a blinded fashion to determine the presence of optic neuropathy. Coronal STIR orbit sequences were considered the diagnostic reference standard. RESULTS: The sensitivity of T2 sagittal brain imaging for ON was 44% in group 1 and 85% in group 2 (p = 0.007). The specificities were 98% and 97% respectively (p = 0.9). Sensitivity was poorest for evaluation of the intraorbital nerve segment (56% grp1, 69% grp2, p = 0.4). CONCLUSION: T2 sagittal MRI brain has high specificity for the detection of optic neuropathy when compared to coronal STIR orbit. Sensitivity is increased when slice thickness is reduced, but remains poor for evaluation of the intraorbital segment.

A self-help diet and physical activity intervention with dietetic support for weight management in men treated for prostate cancer: pilot study of the Prostate Cancer Weight Management (PRO-MAN) randomised controlled trial.

Overweight and obesity may increase risk of disease progression in men with prostate cancer, but there have been few studies of weight loss interventions in this patient group. In this study overweight or obese men treated for prostate cancer were randomised to a self-help diet and activity intervention with telephone-based dietitian support or a wait-list mini-intervention group. The intervention group had an initial group meeting, a supporting letter from their urological consultant, three telephone dietitian consultations at 4-week intervals, a pedometer and access to web-based diet and physical activity resources. At 12 weeks, men in both groups were given digital scales for providing follow-up weight measurements, and the wait-list group received a mini-intervention of the supporting letter, a pedometer and access to the web-based resources. Sixty-two men were randomised; fifty-four completed baseline and 12-week measurements, and fifty-one and twenty-seven provided measurements at 6 and 12 months, respectively. In a repeated-measures model, mean difference in weight change between groups (wait-list mini-intervention minus intervention) at 12 weeks was -2·13 (95 % CI -3·44, -0·82) kg (P = 0·002). At 12 months the corresponding value was -2·43 (95 % CI -4·50, -0·37) kg (P = 0·022). Mean difference in global quality of life score change between groups at 12 weeks was 12·3 (95 % CI 4·93, 19·7) (P = 0·002); at 12 months there were no significant differences between groups. Results suggest the potential of self-help diet and physical activity intervention with trained support for modest but sustained weight loss in this patient group.

Contrast media and cutaneous reactions. Part 2: Delayed hypersensitivity reactions to iodinated contrast media.

Contrast media (CM) are an indispensable part of modern medical imaging. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two-part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 covers the classification of CM, immediate hypersensitivity reactions to CM and the newly described condition, gadolinium deposition disease. Given that there has only been two case reports to our knowledge of a delayed adverse reaction to gadolinium-based CM, this second part will focus on cutaneous delayed reactions caused by iodinated CM (ICM). Delayed hypersensitivity reactions to ICM commonly present as maculopapular exanthems, but more rarely, they can manifest as fixed drug eruptions, acute generalized exanthematous pustulosis, drug-related eosinophilia and systemic symptoms, Stevens-Johnson syndrome/toxic epidermal necrolysis, symmetrical drug-related intertriginous and flexural exanthema, graft-versus-host disease, vasculitis and iododerma. Delayed reactions to ICM may be underdiagnosed, as cutaneous symptoms may be attributed to oral medications, particularly if patients are on multiple drugs.

Contrast media and cutaneous reactions. Part 1. Immediate hypersensitivity reactions to contrast media and gadolinium deposition.

Contrast media (CM) are commonly used worldwide to enhance the quality of imaging, which is invaluable for diagnostic accuracy. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two-part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 will classify CM, address immediate hypersensitivity reactions and review the newly described condition, gadolinium deposition disease. Part 2 will cover the delayed hypersensitivity reactions of iodinated contrast medium including severe cutaneous adverse reactions and iododerma.

A pilot study to improve sugar and water consumption in Maltese school children.

BACKGROUND: Excessive sugar consumption remains implicated as one of the key dietary factors that has been linked to overweight and obesity in children. Schools have been identified as an important setting for health promotion interventions in children and can be successful in bringing about dietary behavioral change when well designed. OBJECTIVE: The main aim of the study was to conduct a pilot intervention study and assess the possible effects of educational and environmental methodological components on sugar intake and water consumption in Maltese school children. SUBJECTS AND METHODS: Face-to-face educational sessions for children and parents were supported by written materials and provision of free drinking water for children for a 12 week period in the school setting. Two main dietary outcomes were measured: non-milk extrinsic sugars(NMES) intake (measured as g/day) and water consumption (measured as servings/day), measured in the pre- and post-intervention periods. The dietary outcomes were measured at school using the novel online dietary assessment tool, REALITYMALTA™. RESULTS: 55 children, aged 10-11 years, were recruited, and 48 provided diet data at baseline and end. A reduction in mean energy intakes was noted from 7733 kJ/day (SD 2046) to 6809 (SD 2224) kJ/day (p = 0.03), with water servings intake increased and NMES intake decreased but results not statistically significant. Parent attendance at the educational sessions was low. CONCLUSIONS: A larger scale study, including multi-level analysis is recommended. Modifying the content of the intervention and finding ways to increase parent engagement should be considered in future.

Maternal gestational weight gain and offspring's risk of cardiovascular disease and mortality.

OBJECTIVE: To examine the effect of maternal gestational weight gain (GWG) on adult offspring mortality, cardiovascular morbidity and cerebrovascular morbidity. METHODS: The Aberdeen Children of the Nineteen Fifties (ACONF) is a population-based cohort of adults born in Aberdeen, Scotland between 1950 and 1956. GWG of the mothers of cohort members was extracted from original birth records and linked to the data on offspring morbidity and mortality up to 2011 obtained from Scottish national records. HRs for cardiovascular events and mortality in offspring according to maternal weight gain in pregnancy were estimated adjusting for maternal and offspring confounders using a restricted cubic spline model. RESULTS: After exclusions, 3781 members of the original ACONF cohort were analysed. Of these, 103 (2.7%) had died, 169 (4.5%) had suffered at least one cardiovascular event and 73 (1.9%) had had a hospital admission for cerebrovascular disease. Maternal weight gain of 1 kg/week or more was associated with increased risk of cerebrovascular event in the offspring (adjusted HR 2.70 (95% CI 1.19 to 6.12)). There was no association seen between GWG and offspring's all-cause mortality or cardiovascular event. Adult offspring characteristics (smoking, body mass index (BMI) and diabetes) were strongly associated with each outcome. CONCLUSIONS: Maternal GWG above 0.9 kg/week may increase the risk of cerebrovascular disease in the adult offspring, but not all-cause mortality or cardiovascular disease. Health and lifestyle factors such as smoking, BMI and diabetes in the adult offspring had a stronger influence than maternal and birth characteristics on their mortality and morbidity.

Using food intake records to estimate compliance with the Eatwell Plate dietary guidelines.

BACKGROUND: The UK Eatwell Plate is consumer based advice recommending the proportions of five food groups for a balanced diet: starchy foods, fruit and vegetables, dairy foods, nondairy sources of protein and foods and drinks high in fat or sugar. Many foods comprise ingredients from several food groups and consumers need to consider how these fit with the proportions of the Eatwell Plate. This involves disaggregating composite dishes into proportions of individual food components. The present study aimed to match the diets of adults in Scotland to the Eatwell Plate dietary recommendations and to describe the assumptions and methodological issues associated with estimating Eatwell Plate proportions from dietary records. METHODS: Foods from weighed intake records of 161 females and 151 males were assigned to a single Eatwell group based on the main ingredient for composite foods, and the overall Eatwell Plate proportions of each subject's diet were calculated. Food group proportions were then recalculated after disaggregating composite foods. RESULTS: The fruit and vegetables and starchy food groups consumed were significantly lower than recommended in the Eatwell Plate, whereas the proportions of the protein and foods high in fat or sugar were significantly higher. Failing to disaggregate composite foods gave an inaccurate estimate of the food group composition of the diet. CONCLUSIONS: Estimating Eatwell Plate proportions from dietary records is not straightforward, and is reliant on methodological assumptions. These need to be standardised and disseminated to ensure consistent analysis.

Our approach to changing the culture of caring for the acutely unwell patient at a large UK teaching hospital: A service improvement focus on Early Warning Scoring tools.

INTRODUCTION: Early Warning Scoring tools (EWS) play a major role in the detection of the deteriorating ward patient. EWS tools have been in place in Nottingham University Hospitals NHS Trust for over five years but compliance has been low. A service improvement project commenced across all admission wards in 2013, initiated through a financially driven CQUIN. Prior to the project, only one out of five clinical care targets set were achieved. STRATEGY: An established framework for service improvement was used to guide delivery. The approach has consisted of multi-faceted, inter-professional high impact interventions including ward delivered education, human factors training and clinician feedback, combined with regular performance audits. RESULTS: Since introduction of the service improvement team, consistent signs of improvement have been visible across the admission areas in four out of five of the clinical care targets. CONCLUSION: The first 12 months of the project has seen tangible benefits in patient care and staff experience. Personal feedback both to medical and nursing staff has been effective where a top-down approach may not have been.

Prevalence and year-on-year trends in childhood thinness in a whole population study.

BACKGROUND: The burden of childhood thinness in the UK is poorly understood. The aim of this study was to describe the prevalence and year-on-year trends of childhood thinness in a population born between 1970 and 2006 in North East Scotland. METHODS: Measurements were routinely collected by school nurses as part of school medical entry. Trends in International Obesity Task Force thinness grades 1, that is, body mass index (BMI) corresponding to adult BMI <18.5 kg/m(2) but ≥ 17 kg/m(2) or grade ≥ 2, that is, corresponding to adult BMI <17 kg/m(2) were analysed over time by sex and socioeconomic deprivation quintile. RESULTS: Data were obtained for 194 391 children, 52% boys, mean age 5.6 years (SD 0.8). The prevalence of thinness grade 1 was 6.5% (95% CI 5.9% to 7.2%) and 4.8% (4.2% to 5.5%) for those born in 1970 and 2006, respectively, but between these years was variable with the fluctuations being greater for boys than girls. The prevalence of thinness grade ≥ 2 fell for those born between 1974 and 1985 from 6.1% (5.5% to 6.8%) to 1.3%, (1.0% to 1.6%) and remained relatively stable thereafter in boys and girls. Thinness grade ≥ 2 was initially less prevalent in more affluent communities, but for those born in 1990 and afterwards, prevalence was equal across deprivation quintiles. In contrast, there was no interaction between deprivation quintile and year of birth for thinness grade 1. CONCLUSIONS: Thinness has become less common in this population. While thinness was initially more prevalent among deprived communities, this association is no longer apparent.

A genome-wide association study implicates the APOE locus in nonpathological cognitive ageing.

Cognitive decline is a feared aspect of growing old. It is a major contributor to lower quality of life and loss of independence in old age. We investigated the genetic contribution to individual differences in nonpathological cognitive ageing in five cohorts of older adults. We undertook a genome-wide association analysis using 549 692 single-nucleotide polymorphisms (SNPs) in 3511 unrelated adults in the Cognitive Ageing Genetics in England and Scotland (CAGES) project. These individuals have detailed longitudinal cognitive data from which phenotypes measuring each individual's cognitive changes were constructed. One SNP--rs2075650, located in TOMM40 (translocase of the outer mitochondrial membrane 40 homolog)--had a genome-wide significant association with cognitive ageing (P=2.5 × 10(-8)). This result was replicated in a meta-analysis of three independent Swedish cohorts (P=2.41 × 10(-6)). An Apolipoprotein E (APOE) haplotype (adjacent to TOMM40), previously associated with cognitive ageing, had a significant effect on cognitive ageing in the CAGES sample (P=2.18 × 10(-8); females, P=1.66 × 10(-11); males, P=0.01). Fine SNP mapping of the TOMM40/APOE region identified both APOE (rs429358; P=3.66 × 10(-11)) and TOMM40 (rs11556505; P=2.45 × 10(-8)) as loci that were associated with cognitive ageing. Imputation and conditional analyses in the discovery and replication cohorts strongly suggest that this effect is due to APOE (rs429358). Functional genomic analysis indicated that SNPs in the TOMM40/APOE region have a functional, regulatory non-protein-coding effect. The APOE region is significantly associated with nonpathological cognitive ageing. The identity and mechanism of one or multiple causal variants remain unclear.

Breastfeeding and introduction of complementary foods during infancy in relation to the risk of asthma and atopic diseases up to 10 years.

BACKGROUND: It has been hypothesized that changes in diet during early life may have contributed to the increase in childhood asthma and atopy. The long-term effect of the timing and content of infant feeding on the incidence of asthma and atopic diseases in children is unclear. OBJECTIVE: To investigate the associations between duration of breastfeeding and the timing of introduction of complementary foods during the first 6 months and parental-reported asthma, wheeze and atopic eczema up to 10 years of age. METHODS: Infant feeding practices (breastfeeding and introduction of complementary foods) of 1924 singleton children participating in the Study of Eczema and Asthma To Observe the influence of Nutrition (SEATON) birth cohort were prospectively collected up to 6 months with outcomes (wheeze, atopic eczema and asthma) being assessed at 1, 2, 5 and 10 years. Data were analysed using generalized estimating equations and discrete hazards models with adjustment for confounders. RESULTS: By 6 months, 59% and 35% of mothers had stopped exclusive and total breastfeeding, respectively. Although formula feeding was adversely associated with wheeze in the past 12 months (adjusted OR for no formula feeding: 070, 95% CI 0.50-0.97), and the introduction of biscuits/bread after 5 months of age adversely associated with atopic eczema (adjusted OR 1.34, 95% CI 1.06-1.69), these results lost their statistical significance after adjustment for multiple testing. Stratification of the results by the presence of eczema by 6 months of age and family atopic history did not substantially differ from the results of the whole study population. CONCLUSION AND CLINICAL RELEVANCE: Our results suggest that the nature of infant feeding during the first 6 months seems not to substantially influence the long-term risk of asthma and atopic diseases in children, nor in children at high risk of atopic disease because of a family history of atopic disease.

"It was an education in portion size". Experience of eating a healthy diet and barriers to long term dietary change.

The aim of the study was to explore the expectations and experience of actually eating a healthy diet and using this experience to identify barriers to healthy eating and sustainable dietary change. Fifty participants (19-63 yrs) were provided with a healthy diet (i.e. complied with dietary recommendations) for three consecutive days. Afterwards a semi-structured interview was carried out to explore expectations, experience and barriers to healthy eating. Using a thematic analysis approach eight dominant themes emerged from the interviews. Four related to expectations and experience of healthy eating; realisation of what are appropriate portion sizes, an expectation to feel hungry, surprise that healthy diets comprised normal food, the desire for sweet snacks (e.g. chocolate). This demonstrated there are some misconception about healthy eating and distorted views of portion size. Four more themes emerged relating to barriers to healthy eating; competing priorities, social, peer and time pressure, importance of value for money, a lack of desire to cook. Poor knowledge of healthy eating or a lack of cooking skills were the least common barrier, suggesting that future interventions and policy to improve dietary intakes need to focus on social, cultural and economic issues rather than on lack of knowledge or skills.

Do either early warning systems or emergency response teams improve hospital patient survival? A systematic review.

BACKGROUND: For critical care to be effective it must have a system in place to achieve optimal care for the deteriorating ward patient. OBJECTIVES: To systematically review the available literature to assess whether either early warning systems or emergency response teams improve hospital survival. In the event of there being a lack of evidence regarding hospital survival, secondary outcome measures were considered (unplanned ICU admissions, ICU mortality, length of ICU stay, length of hospital stay, cardiac arrest rates). METHODS: The Ovid Medline, EMBASE, CINAHL, Web of Science, Cochrane library and NHS databases were searched in September 2012 along with non-catalogued resources for papers examining the effect of early warning systems or emergency response teams on hospital survival. Inclusion criteria were original clinical trials and comparative studies in adult inpatients that assessed either an early warning system or emergency response team against any of the predefined outcome measures. Exclusion criteria were previous systematic reviews, non-English abstracts and studies incorporating paediatric data. Studies were arranged in to sections focusing on the following interventions: Early warning systems - Single parameter systems - Aggregate weighted scoring systems (AWSS) Emergency response teams - Medical emergency teams - Multidisciplinary outreach services . In each section an appraisal of the level of evidence and a recommendation has been made using the SIGN grading system. RESULTS: 43 studies meeting the review criteria were identified and included for analysis. 2 studies assessed single parameter scoring systems and 4 addressed aggregate weighted scoring systems. A total of 20 studies examined medical emergency teams and 22 studies examined multidisciplinary outreach teams. LIMITATIONS: The exclusion of non English studies and those including paediatric patients does limit the applicability of this review. CONCLUSIONS: Much of the available evidence is of poor quality. It is clear that a 'whole system' approach should be adopted and that AWSS appear to be more effective than single parameter systems. The response to deterioration appears most effective when a clinician with critical care skills leads it. The need for service improvement differs between health care systems.

Radiation-induced aortic occlusion.

Arterial occlusion is a late complication of radiotherapy usually seen in extracranial vessels following treatment for head and neck malignancy. Determining the etiology behind vessel occlusion can be difficult and involves consideration of several factors. We present a case of radiotherapy induced aortic occlusion and discuss the relevant clinical and imaging factors that allow the diagnosis to be made.