Potentially modifiable determinants of malnutrition in older adults: A systematic review.

BACKGROUND & AIMS: Malnutrition in older adults results in significant personal, social, and economic burden. To combat this complex, multifactorial issue, evidence-based knowledge is needed on the modifiable determinants of malnutrition. Systematic reviews of prospective studies are lacking in this area; therefore, the aim of this systematic review was to investigate the modifiable determinants of malnutrition in older adults. METHODS: A systematic approach was taken to conduct this review. Eight databases were searched. Prospective cohort studies with participants of a mean age of 65 years or over were included. Studies were required to measure at least one determinant at baseline and malnutrition as outcome at follow-up. Study quality was assessed using a modified version of the Quality in Prognosis Studies (QUIPS) tool. Pooling of data in a meta-analysis was not possible therefore the findings of each study were synthesized narratively. A descriptive synthesis of studies was used to present results due the heterogeneity of population source and setting, definitions of determinants and outcomes. Consistency of findings was assessed using the schema: strong evidence, moderate evidence, low evidence, and conflicting evidence. RESULTS: Twenty-three studies were included in the final review. Thirty potentially modifiable determinants across seven domains (oral, psychosocial, medication and care, health, physical function, lifestyle, eating) were included. The majority of studies had a high risk of bias and were of a low quality. There is moderate evidence that hospitalisation, eating dependency, poor self-perceived health, poor physical function and poor appetite are determinants of malnutrition. Moderate evidence suggests that chewing difficulties, mouth pain, gum issues co-morbidity, visual and hearing impairments, smoking status, alcohol consumption and physical activity levels, complaints about taste of food and specific nutrient intake are not determinants of malnutrition. There is low evidence that loss of interest in life, access to meals and wheels, and modified texture diets are determinants of malnutrition. Furthermore, there is low evidence that psychological distress, anxiety, loneliness, access to transport and wellbeing, hunger and thirst are not determinants of malnutrition. There appears to be conflicting evidence that dental status, swallowing, cognitive function, depression, residential status, medication intake and/or polypharmacy, constipation, periodontal disease are determinants of malnutrition. CONCLUSION: There are multiple potentially modifiable determinants of malnutrition however strong robust evidence is lacking for the majority of determinants. Better prospective cohort studies are required. With an increasingly ageing population, targeting modifiable factors will be crucial to the effective treatment and prevention of malnutrition.

The associations between training load and baseline characteristics on musculoskeletal injury and pain in endurance sport populations: A systematic review.

OBJECTIVES: To determine the associations between training load, baseline characteristics (e.g. age or previous injury) and rate of musculoskeletal injury and/or pain specifically within an Endurance Sporting Population (ESP). DESIGN: Prospectively registered systematic review. METHODS: Eight electronic databases were searched by two independent reviewers. Studies were required to prospectively monitor both (i) training loads and (ii) musculoskeletal injury and/or pain for >3 months. Methodological quality and risk of bias were determined utilising the Critical Skills Appraisal Program (CASP). Reported effect sizes were categorised as small, medium or large. RESULTS: Twelve endurance sport studies were eligible (running, triathlon, rowing). Increased injury and/or pain risk was associated with: (i) high total training distances per week/month (medium effect size) (ii) training frequency <2 sessions/week (medium effect size) and (iii) both low weekly (<2hours/week) and high monthly (large effect size) training durations. None of the studies reported internal training load data or acute:chronic workload ratios. Baseline characteristics found to increase the rate of injury and/or pain included: (i) a history of previous injury (medium effect size), (ii) age >45 years (small effect size), (iii) non-musculoskeletal comorbidities (large effect size), (iv) using older running shoes (small effect size) and (v) non-competitive behaviour. CONCLUSIONS: This review identifies a range of external training load factors and baseline characteristics associated with an increased rate of injury and/or pain within ESPs. There is an absence of research relating to internal training loads and acute:chronic workload ratios in relation to rate of injury and/or pain within ESPs.

Long-term impact of the low-FODMAP diet on gastrointestinal symptoms, dietary intake, patient acceptability, and healthcare utilization in irritable bowel syndrome.

BACKGROUND: The low-FODMAP diet is a frequently used treatment for irritable bowel syndrome (IBS). Most research has focused on short-term FODMAP restriction; however, guidelines recommend that high-FODMAP foods are reintroduced to individual tolerance. This study aimed to assess the long-term effectiveness of the low-FODMAP diet following FODMAP reintroduction in IBS patients. METHODS: Patients with IBS were prospectively recruited to a questionnaire study following completion of dietitian-led low-FODMAP education. At baseline and following FODMAP restriction (short term) only, gastrointestinal symptoms were measured as part of routine clinical care. Following FODMAP reintroduction, (long term), symptoms, dietary intake, acceptability, food-related quality of life (QOL), and healthcare utilization were assessed. Data were reported for patients who continued long-term FODMAP restriction (adapted FODMAP) and/or returned to a habitual diet (habitual). KEY RESULTS: Of 103 patients, satisfactory relief of symptoms was reported in 12% at baseline, 61% at short-term follow-up, and 57% at long-term follow-up. At long-term follow-up, 84 (82%) patients continued an 'adapted FODMAP' diet (total FODMAP intake mean 20.6, SD 14.9 g/d) compared with 19 (18%) of patients following a 'habitual' diet (29.4, SD 22.9 g/d, P=.039). Nutritional adequacy was not compromised for either group. The 'adapted FODMAP' group reported the diet cost significantly more than the 'habitual' group (P<.001) and affected social eating (P<.01) but there was no effect on food-related QOL. Healthcare utilization was similar between both groups. CONCLUSION AND INFERENCES: Low-FODMAP education is effective for long-term IBS management, enables a nutritionally adequate diet, and is broadly acceptable to patients.

Impact of medium and long chain triglycerides consumption on appetite and food intake in overweight men.

BACKGROUND: Medium chain triglycerides (MCT) enhance thermogenesis and may reduce food intake relative to long chain triglycerides (LCT). The goal of this study was to establish the effects of MCT on appetite and food intake and determine whether differences were due to differences in hormone concentrations. METHODS: Two randomized, crossover studies were conducted in which overweight men consumed 20 g of MCT or corn oil (LCT) at breakfast. Blood samples were obtained over 3 h. In Study 1 (n=10), an ad lib lunch was served after 3 h. In Study 2 (n=7), a preload containing 10 g of test oil was given at 3 h and lunch was served 1 h later. Linear mixed model analyses were performed to determine the effects of MCT and LCT oil on change in hormones and metabolites from fasting, adjusting for body weight. Correlations were computed between differences in hormones just before the test meals and differences in intakes after the two oils for Study 1 only. RESULTS: Food intake at the lunch test meal after the MCT preload (Study 2) was (mean±s.e.m.) 532±389 kcal vs 804±486 kcal after LCT (P<0.05). MCT consumption resulted in a lower rise in triglycerides (P=0.014) and glucose (P=0.066) and a higher rise in peptide YY (PYY, P=0.017) and leptin (P=0.036) compared with LCT (combined data). Correlations between differences in hormone levels (glucagon-like peptide (GLP-1), PYY) and differences in food intake were in the opposite direction to expectations. CONCLUSIONS: MCT consumption reduced food intake acutely but this does not seem to be mediated by changes in GLP-1, PYY and insulin.

Sleep duration and disorders in pregnancy: implications for glucose metabolism and pregnancy outcomes.

Humans have an innate requirement for sleep that is intrinsically governed by circadian and endocrine systems. More recently, reduced sleep duration has gained significant attention for its possible contribution to metabolic dysfunction. Significant evidence suggests that reduced sleep duration may elevate the risk for impaired glucose functioning, insulin resistance and type 2 diabetes. However, to date, few studies have determined the implications of reduced sleep duration with regard to glucose control during pregnancy. With the high prevalence of overweight and obesity in women of reproductive age, the occurrence of gestational diabetes mellitus (GDM) is increasing. GDM results in elevated risk of maternal and fetal complications, as well as increased risk of type 2 diabetes postpartum. Infants born to women with GDM also carry a life-long risk of obesity and type 2 diabetes. The impact of reduced sleep on glucose management during pregnancy has not yet been fully assessed and a paucity of literature currently exits. Herein, we review the association between reduced sleep and impaired carbohydrate metabolism and propose how reduced sleep during pregnancy may result in further dysfunction of the carbohydrate axis. A particular focus will be given to sleep-disordered breathing, as well as GDM-complicated pregnancies. Putative mechanisms of action by which reduced sleep may adversely affect maternal and infant outcomes are also discussed. Finally, we will outline important research questions that need to be addressed.

Informed consent in refractive eye surgery: learning from patients and the courts.

Refractive eye laser surgery involves ablation of the cornea using excimer laser to correct short or long sightedness and thus negate the need for glasses and/or contact lenses. With the doctrine of informed consent often central to claims of medical negligence in this area, we examine the attitudes, understanding and recall of patients to consent for refractive surgery and outline the relevant law. 102 patients undergoing first time refractive surgery were analysed to examine their understanding and recall of the consenting process. Only 2 patients remembered all 5 risks outlined preoperatively, while 11 remembered no risks at all. 65% of patients consulted the internet to learn more about the operation. Our study demonstrates that patient understanding and recall remains poor. A signed consent form is not, of itself a full defence to allegations of uninformed consent, and the consent process must be comprehensive.

Tag rugby: a safe alternative? A review of hand injuries sustained playing tag rugby (2007 season).

INTRODUCTION: Tag rugby is a non-contact, seven-a-side, team sport in which each player wears specially designed shorts with velcro 'tags' attached to them. While tag rugby is a relatively new sport it has grown rapidly in popularity. As a result of its increasing popularity an increased frequency of attendances at plastic surgery clinics was observed and it was decided a review of all hand injuries associated with this new sport was required. MATERIALS AND METHODS: A retrospective case note review of all hand injuries occurring during the tag rugby season for 2007 (March-August) was conducted, with any tag rugby-related hand injuries being selected for further examination. RESULTS: Tag rugby, while being a non-contact sport, is certainly not without a definite injury risk with 12 patients having single digit injuries, ranging from tendon avulsions to phalangeal fractures. The mean age of the injured patients was 26.8 years. DISCUSSION: All of the hand injuries were sustained while 'tackling' during regular play, the hand injuries sustained were all treated using well-described methods and all the patients are recovering well. While the risk of a severe, life-threatening injury is unlikely while playing tag rugby, there is a real risk of sustaining a potentially debilitating hand injury.

Children's estimates of food portion size: the effect of timing of dietary interview on the accuracy of children's portion size estimates.

For food intakes to be converted into nutrient intakes a measure or estimate of the amount of food consumed is required. A number of methods have been developed to assist subjects in providing an estimate of portion size. Children's ability to use perception, conceptualisation and memory skills to estimate food portion size has not been investigated systematically. The aim of the present study was to test the effect of the timing of a dietary interview on the accuracy of estimates of food portion sizes made by children, using food photographs, food models and an interactive portion size assessment system, developed for use with children and based on portion sizes of foods consumed by children. Children (n 108) aged 4-14 years were supplied with known quantities of foods and asked to estimate the portion size of each food using each of the three portion size assessment tools. Interviews took place (a) with the food in view, (b) just after the child had eaten the food or (c) 24 h after the child had eaten the food. There were no significant differences in children's ability to estimate food portion size (either as served or as eaten) with timing of interview. That is, children were as accurate in their estimates of portion size 24 h after consuming the food as when the food was in view. Under these conditions many children were able to estimate food portion size utilising perception, conceptualisation and memory skills.

Investigation of the causes for the occurrence of residues of the anticoccidial feed additive nicarbazin in commercial poultry.

Investigations were undertaken to identify causes for the occurrence of high levels of the zootechnical feed additive nicarbazin in broiler liver at slaughter. The first investigation on 32 commercial broiler flocks involved sampling and analysis for nicarbazin (as dinitrocarbanilide, DNC) in liver from birds during a 3-10-day period after withdrawal of nicarbazin from their feed and before commercial slaughter. DNC residues in liver samples of broilers scheduled as being withdrawn from nicarbazin for > or =6 days ranged from 20 to >1600 microg kg(-1) (the specified withdrawal period for nicarbazin is 5 days and the Joint Expert Committee on Food Additives (JECFA) maximum residue limit (MRL) is 200 microg kg(-1) liver). Further on-farm investigations on 12 of these flocks, selected on the basis of the feeding system in use and the levels of DNC residues determined in liver, identified issues in feed management contributing to elevated residues in broiler liver. A significant correlation (0.81, p < 0.01, n = 10) between DNC residues in liver samples and in feed samples from the feeding pans was observed. The second investigation on 12 commercial broiler flocks involved sampling and analysis for DNC in liver samples and feed samples from feeding pans and from the feed mill at the three thinnings of birds for commercial slaughter. In the case of one flock, a clear relationship between nicarbazin in feed from the feed mill (10.5 mg kg(-1) DNC), in feed from the feeding pans (6.6 mg kg(-1) DNC) and in liver (583 microg kg(-1) DNC) at first thinning (9 days scheduled withdrawal from nicarbazin) was observed. Such a clear relationship was not observed in other cases, particularly at second and third thinnings, pointing to re-exposure of birds to nicarbazin late in the flock production cycle, probably from the litter. Guidelines outlining best farm practice to eliminate nicarbazin residues in poultry have been published in booklet and poster format for broiler producers and deal with feed system cleaning, feed bin management, feed deliveries, feed usage and records.

Evaluation of the Premi Test and comparison with the One-Plate Test for the detection of antimicrobials in kidney.

The Premi Test, a test kit designed for the rapid screening of antimicrobial residues in meat, fish and eggs, was evaluated and compared with the (modified) One-Plate Test, an agar diffusion assay. The performance characteristics described for qualitative, screening methods in Commission Decision 2002/657/EC were used for the evaluation. The Premi Test was found to detect a range of antimicrobials to MRL levels in kidney fluid but to have poorer sensitivity for some antimicrobials such as tetracyclines, sulphonamides, flumequine and streptomycin. The test was found not to be sensitive for the banned antimicrobial chloramphenicol. The One-Plate Test was found to detect most tetracyclines and flumequine to MRL levels but to be less sensitive than the Premi Test for most of the other classes of antimicrobials. Neither test alone provides a comprehensive screening test for antimicrobial residues in kidney at MRL levels. However, the Premi Test is fast, easy to use and rugged and, in combination with other antimicrobial tests, may be used to provide a comprehensive screening system for antimicrobials in tissues.

Five year follow up of laser in situ keratomileusis for all levels of myopia.

AIMS: To assess the long term refractive and visual outcome of patients who have laser in situ keratomileusis (LASIK) surgery. METHODS: This was a retrospective study of visual and refractive outcome of patients who had LASIK surgery performed in 1998 and 1999. All levels of myopia were included in the study. 49 patients attended for follow up. The main outcome measures were safety, predictability, efficacy, and stability. Postoperative complications and aberrations were also recorded. The mean preoperative spherical equivalent was -4.85. RESULTS: At 2 months postoperatively 67% of eyes were within plus or minus 0.5D of attempted correction with 81% within plus or minus 1.0D. At 5 years postoperatively 60% of eyes were within plus or minus 0.5D of attempted correction with 83% within plus or minus 1.0D. 88% of eyes had a vision of 6/12 or better at 2 months compared to 89% of eyes at 5 years. Best spectacle corrected visual acuity (BSCVA) was unchanged or improved in 51%. No eye lost more than one line of BSCVA. Overall, there was regression towards myopia with a mean change in refraction of -0.5D over the 5 years. As expected, severely myopic patients regressed more with a mean change of -1.06D. However, there was a high level of patient satisfaction with the surgery. CONCLUSION: LASIK surgery offers predictable results in terms of refractive and visual outcome with mild regression in refraction over time.

Cystoid macular oedema in paediatric aphakia and pseudophakia.

AIM: To assess the incidence of cystoid macular oedema (CMO), following lensectomy, anterior vitrectomy (limbal and pars plicata), and primary posterior capsulorhexis following surgery for congenital and developmental cataract. METHODS: A prospective study was carried out involving 30 eyes (20 children) with cataract. Lensectomy, primary posterior capsulorhexis, and anterior vitrectomy were performed on all eyes. Vitrectomy was performed using either a limbal or pars plicata approach. Fluorescein angiography was carried out 4-7 weeks after surgery. Fluorescein was administered intravenously and visualised using the Retcam. RESULTS: Anterior vitrectomy was carried out via the limbal approach in 12 eyes and, of these, six were implanted with an intraocular lens. The pars plicata approach was carried out in 18 eyes and 10 received an implant. CMO was not detected in any eye. CONCLUSION: CMO was not detected in the early postoperative period irrespective of approach to anterior vitrectomy or presence of an intraocular lens. Intravenous fluorescein angiography was performed without complication.

A case control study to examine the pharmacological factors underlying ventricular septal defects in the North of England.

BACKGROUND: Amphetamine exposure is associated with congenital cardiac abnormalities in animals. We previously reported an association between recreational use of 2,4-methylenedioxymethamphetamine (ecstasy, MDMA) and ventricular septal defect in babies born to users. We have carried out a case control study to investigate risks in the occurrence of ventricular septal defect in a cohort of babies born in the North East of England. METHODS: Cases were identified from paediatric cardiology units in Newcastle upon Tyne and Leeds, and controls were recruited from the mothers of babies born in the same hospital as the index case. Research nurses carried out interviews using a structured questionnaire. RESULTS: A total of 296 case control pairs were studied. There was insufficient exposure to ecstasy to test the primary hypothesis. Increased risk of ventricular septal defect was found to be associated with consumption of cough and cold remedies [pre-conception OR 2.2, 95% CI 1.41, 3.51; pregnancy OR 5.1, 95% CI 2.56, 11.27; exposure in either OR 2.83, 95% CI 1.85, 4.45; P<0.005] and in the case of non-steroidals for exposures in pregnancy (OR 4.2, 95% CI 1.54, 14.26; P<0.005). CONCLUSIONS: These findings suggest that ventricular septal defect is associated with consuming the medications identified. They are also compatible with the hypothesis that sympathomimetics (pseudoephedrine, phenylephrine and phenylpropanolamine) present in cough mixtures cause the increased risk, and with our original hypothesis that sympathomimetics and amphetamines are potentially cardiotoxic in utero.

Application of a modified Oszlányi and Süto ab initio charge-flipping algorithm to experimental data.

The structures of two crystals have been solved using a new iterative phasing method. The iterative phasing algorithm is developed from the 'charge-flipping' method proposed by Oszlányi & Süto [Acta Cryst. (2004), A60, 134-141]. Positivity and point-atom constraints are incorporated within this extremely simple and effective algorithm by flipping (sign reversal) of less-positive density values during the iterations. Convergence is reliably achieved and the two structures were solved. This structure solution method does not require information on atomic scattering factors or symmetry. Heavy atoms can be distinguished from light ones by their charge-density values.

Bridging the gap between health and education: words are not enough.

OBJECTIVES: When using specific terminology for childhood developmental disorders, paediatricians make assumptions about what teachers know and believe. If these assumptions are incorrect, collaborative management may be compromised. We surveyed primary school teachers in North Brisbane regarding their beliefs about developmental disorders and their views on collaboration between medical and educational professionals. METHODS: A survey questionnaire was written specifically, and then piloted with professional colleagues and 40 teachers. Questions examined teachers' opinions about, and personal experience with various developmental disorders. Free comments addressed barriers to collaboration with doctors, and how this might be improved. Responses were analysed using descriptive statistics. RESULTS: Responses were received from all of the 41 schools surveyed. Overall, completed questionnaires were obtained from 297 of 397 (75%) primary classroom teachers surveyed. Several apparent misconceptions were held, either by the majority (e.g. 70% felt dietary modification is commonly successful treatment for ADHD), or by a significant minority of teachers (e.g. 23% believed autistic spectrum disorder is not a permanent neurological condition). Responses to many questions concurred with the authors' assumptions. Teachers reported high levels of concern about lack of training and resource support for managing special-needs children. Over three-quarters of teachers did not access doctors for information, relying instead on special education professionals (96%) or parents (94%). Few group differences were noted by age, sex, years teaching experience, or system (Catholic, State). Free comments identified significant barriers to the collaboration process, and suggested strategies to address these. CONCLUSIONS: Doctors cannot assume teachers' beliefs about developmental disorders are similar to their own. Furthermore, doctors should recognize constraints that teachers work under, and can take the initiative to improve collaboration with topic-based as well as child-specific information.

Structural study of new hydrocarbon nano-crystals by energy-filtered electron diffraction.

A new brittle hydrocarbon has been successfully synthesized in polycrystalline form, and its crystal structure solved by quantitative electron diffraction. By 3D tilting of the nano-crystals, the lattice type and unit cell parameters were determined. (Triclinic, [Formula: see text] A, [Formula: see text] A, [Formula: see text] A, [Formula: see text] degrees, [Formula: see text] degrees, and [Formula: see text] degrees.) Spot diffraction patterns were obtained at -165 degrees C using the Koehler selected-area mode on a LEO 912 TEM fitted with an omega in-column elastic energy filter. The direct methods algorithm was then applied to merged intensities and a trial structure obtained assuming single scattering. This was further refined to obtain good agreement with a small residual of about 10% using multiple scattering calculations. A diagram of the proposed structure is given.

Preliminary evaluation of a lateral flow immunoassay device for screening urine samples for the presence of sulphamethazine.

A lateral flow immunoassay (LFIA) device was developed and applied to testing urine samples for residues of the antimicrobial sulphamethazine (SMZ). This report describes the preparation of a rat monoclonal antibody to SMZ and its characterisation in an ELISA format. Apart from SMZ, the antibody showed high (> or =50%) cross-reactivity to N4-acetyl-sulphamethazine (55%), sulphamerazine (59%) and sulphisoxazole (50%) and lower cross-reactivity of 18% to sulphachlorpyridazine and sulphadiazine. The LFIA device consisted of a nitrocellulose membrane spotted with SMZ-ovalbumin and goat anti-mouse antibody as capture line and control line, respectively. Mouse anti-rat IgG F(ab')2 fragment specific antibody, adsorbed to colloidal carbon, was used as the detection ligand in the LFIA. The LFIA device had a cut-off value of 6.3 ng/ml in diluted (1/10) urine. Urine samples from SMZ-treated pigs, and bovine and porcine urine samples fortified with SMZ were used for a blind, four-laboratory evaluation of the performance of the LFIA device. Concentrations of SMZ in the test samples (n=29), as determined by LC-MS/MS, ranged from 0 (<3) to 1174 ng/ml. The evaluation of the LFIA device showed an overall sensitivity of 100%, a specificity of 71%, and positive and negative prediction values of 73% and 100%, respectively. The LFIA device has been fabricated as a test kit for determining SMZ residues in animals produced for slaughter.

Charge density and chemical bonding in rutile, TiO2.

The low-order structure factors of rutile (TiO(2)) have been measured with an accuracy of up to 0.09% by quantitative convergent-beam electron diffraction (QCBED). This error is an order of magnitude smaller than that in conventional Bragg X-ray diffraction and equivalent to the accuracy of the X-ray Pendellösung method. It is sufficient to distinguish atomic, covalent and ionic bonding. By refinement of the combined data of low-order reflections measured by electron diffraction with high-order reflections from X-ray diffraction, accurate charge-density maps are obtained and used to understand the role of the 3d electrons in Ti-O bonding. The results are combined with electron energy-loss spectra (EELS) in a study of the electronic structure.

Methods for generation of monoclonal antibodies to the very small drug hapten, 5-benzimidazolecarboxylic acid.

Drug-specific monoclonal antibodies (MAbs) were produced against the very small drug hapten (162.15 Da), 5-benzimidazolecarboxylic acid, an analogue of 2-(4-Thiazolyl)benzimidazole (TBZ) but lacking the thiol group. TBZ is widely used as a broad-spectrum anthelmintic in various animal species and humans and also as a food preservative and agricultural fungicide. The anti-5-benzimidazolecarboxylic acid antibodies produced have potential use for extraction and/or detection of protein-bound residue forms of TBZ. Three in vivo immunisation regimes (with combinations of two related small drug haptens and two different adjuvants/carrier molecules) and an in vitro immunisation procedure using a combination of three related unconjugated small drug haptens were investigated. Specificity for the hapten immunogen/s was initially determined using two different ELISA procedures. BIACORE analysis, in conjunction with drug binding inhibition studies, was used to confirm the specificity of a small number of selected clones. In vivo immunisation with a drug molecule conjugated to a lipopeptide/T-cell epitope, which acts both as a carrier molecule and an adjuvant was the most useful of the methods tested for the production of specific MAbs to a typically very small hapten with low immunogenic properties.