Mass and the Dangers of Syncope.

Introduction Syncope is defined as a transient, self-limited loss of consciousness with an inability to maintain postural tone that is followed by spontaneous recovery. We revisit situational syncope focusing on one situation, Mass. Methods We interrogated our electronic syncope database for key terms associated with situational syncope. From the most commonly encountered situation, Mass, we interrogated the results of tilt testing performed to identify evidence of orthostatic hypotension. Results There were 110 cases of situational syncope identified with 56.3% (n=62) taking place at mass. All had tilt table testing performed and 15.4% (n=17) had evidence of orthostatic hypotension. Conclusion The multiple sudden changes in position during mass from sitting to kneeling to standing can precipitate an episode of orthostatic hypotension. Consideration should be given as to whether it is safe for older mass goers to be subjected to such significant orthostatic stress.

Dedicated Orthogeriatric Service Saves the HSE a Million Euro.

Hip fracture is common in older adults and is associated with high morbidity, mortality and significant health care costs. A pilot orthogeriatrics service was established in an acute hospital. We aimed to establish the cost effectiveness of this service. Length of hospital stay, discharge destination and rehabilitation requirements were analysed for a one year period and compared to patients who received usual care prior to the service. We calculated the costs incurred and savings produced by the orthogeriatric service. Median length of stay was reduced by 3 days (p < 0.001) saving €266,976. There was a 19% reduction in rehabilitation requirements saving €192,600. Median rehabilitation length of stay was reduced by 6.5 days saving €171,093. Reductions in long term care requirements led to savings of €10,934 per week. Costs to establish such a service amount to €171,564. The introduction of this service led to improved patient outcomes in a cost effective manner.

Traditional food patterns are associated with better diet quality and improved dietary adequacy in Aboriginal peoples in the Northwest Territories, Canada.

BACKGROUND: Traditionally, the Arctic diet has been derived entirely from locally harvested animal and plant species; however, in recent decades, imported foods purchased from grocery stores have become widely available. The present study aimed to examine Inuvialuit, traditional or nontraditional dietary patterns; nutrient density of the diet; dietary adequacy; and main food sources of energy and selected nutrient intakes. METHODS: This cross-sectional study used a culturally appropriate quantitative food frequency questionnaire to assess diet. Traditional and nontraditional eaters were classified as those consuming more or less than 300 g of traditional food daily. Nutrient densities per 4184 kJ (1000 kcal) were determined. Dietary adequacy was determined by comparing participants' nutrient intakes with the Dietary Reference Intakes. RESULTS: The diet of nontraditional eaters contained, on average, a lower density of protein, niacin, vitamin B12 , iron, selenium, zinc, omega-3 fatty acids (P ≤ 0.0001), vitamin B6 , potassium, thiamin, pantothenic acid (P ≤ 0.001), riboflavin and magnesium (P ≤ 0.05). Inadequate nutrient intake was more common among nontraditional eaters for calcium, folate, vitamin C, zinc, thiamin, pantothenic acid, vitamin K, magnesium, potassium and sodium. Non-nutrient-dense foods (i.e. high fat and high sugar foods) contributed to energy intake in both groups, more so among nontraditional eaters (45% versus 33%). Traditional foods accounted for 3.3% and 20.7% of total energy intake among nontraditional and traditional eaters, respectively. CONCLUSIONS: Diet quality and dietary adequacy were better among Inuvialuit who consumed more traditional foods. The promotion of traditional foods should be incorporated in dietary interventions for this population.

Sources of vegetables, fruits and vitamins A, C and E among five ethnic groups: results from a multiethnic cohort study.

OBJECTIVES: Data are limited on how dietary sources of food and nutrients differ among ethnic groups. The objective of this study was to determine the main sources of fruit, vegetables and vitamins A, C and E for five ethnic groups. SUBJECTS/METHODS: Dietary data were collected using a validated quantitative food frequency questionnaire from participants in a multiethnic cohort in Hawaii and Los Angeles county between 1993 and 1996. Data were analyzed for 186,916 participants representing five ethnic groups: African-Americans, Japanese-Americans, native Hawaiians, Latinos and Caucasians. RESULTS: Lettuce was the most consumed vegetable (6.0-9.9%) in all ethnic-sex groups, except among African-American women and Mexican-born Latino men and women. Oranges and bananas contributed more than one-quarter to total fruit intake among all groups. Overall, more ethnic variation in food choices was observed for the top 10 vegetables than for fruits. The top sources of vitamins A, C and E were carrots, orange/grapefruit/pomelo and combined dishes, respectively. Among the micronutrients studied, the greatest ethnic variation in foods consumed was observed for the top 10 food sources of vitamin A. CONCLUSIONS: This is the first study providing data on the main types of fruit and vegetables consumed and the major sources of vitamins A, C and E among these ethnic groups in the U.S. Such data are valuable for developing and implementing public health strategies to meet the USDA dietary recommendations and for guiding ethnicity-specific nutrition education and intervention programs.

Healthy Foods North improves diet among Inuit and Inuvialuit women of childbearing age in Arctic Canada.

BACKGROUND: Healthy Foods North (HFN) is a community-based intervention designed to promote a healthy diet and lifestyle of Inuit and Inuvialuit populations in Arctic Canada. The objective of the present study was to determine the effects of HFN on the nutrient intake of women of childbearing age. METHODS: Six communities in Nunavut (n = 3) and the Northwest Territories (n = 3) were selected for programme implementation; four received a 12-month intervention and two served as controls. Quantitative food frequency questionnaires were used to assess dietary intake at baseline and 1 year post-intervention. Among women participants aged 19-44 years (n = 136), 79 were exposed to the intervention and 57 were not. Mean daily energy and nutrient intake and density were determined. Dietary adequacy was assessed by comparing the women's daily nutrient intakes with dietary reference intakes (DRI). RESULTS: Main outcomes were the pre- to post-intervention changes between intervention and control groups for energy and selected nutrient intakes, nutrient density and dietary adequacy. Among the participants, the intervention had a beneficial effect on vitamin A and D intake. The percentage of individuals with nutrient intakes below the DRI increased from pre- to post-intervention for vitamin A and D in the control group but only for vitamin A in the intervention group. The programme did not have a significant impact on calorie, sugar, or fat consumption. CONCLUSIONS: The HFN programme is effective in mitigating some of the negative impacts of the nutrition transition on dietary adequacy among Inuit and Inuvialuit women of childbearing age.

Development of a quantitative food frequency questionnaire for use among rural South Africans in KwaZulu-Natal.

BACKGROUND: South Africa is experiencing a dietary and lifestyle transition as well as increased rates of noncommunicable chronic diseases. Limited information is available on the diets of rural populations. The present study aimed to characterise the diets of men and women from rural KwaZulu-Natal (KZN) and develop a quantitative food-frequency questionnaire (QFFQ) specific for this population. METHODS: A cross-sectional study was carried out by collecting single 24-h dietary recalls from 81 adults and developing a QFFQ in Empangeni, KZN, South Africa. RESULTS: The diet of this population was limited in variety, high in plant-based foods (especially cereals and beans), and low in animal products, vegetables and fruits. Amaize meal staple (Phutu) was consumed by over 80% of subjects and accounted for almost 45% of energy intake, as well as making an important contribution to fat and protein intake. Most of the protein consumed by the study population was plant-based protein, with almost 40% being obtained from the consumption of phutu and beans. A culturally appropriate QFFQ was developed that includes 71 food and drink items, of which 16 are composite dishes unique to this population. CONCLUSIONS: Once validated, this QFFQ can be used to monitor diet-disease associations, evaluate nutritional interventions and investigate dietary changes in this population.

Nutrient intakes, major food sources and dietary inadequacies of Inuit adults living in three remote communities in Nunavut, Canada.

BACKGROUND: Inuit in Nunavut, Canada, are currently undergoing a nutritional transition that may contribute to an increased prevalence of chronic disease. Information is lacking about the extent to which contemporary Inuit diets are meeting current dietary recommendations. METHODS: A culturally appropriate quantitative food frequency questionnaire (QFFQ) developed and validated for Inuit in Nunavut, Canada, was used to assess food and nutrient intake in a cross-sectional sample of adults. RESULTS: Participants included 175 women and 36 men with mean (SD) ages of 42.4 (13.2) and 42.1 (15.0) years, respectively. The response rate for those who completed the study was 79% with 208 QFFQs included for analysis. Reported mean daily energy intakes were: men 15,171 kJ (3626 kcal); women 11,593 kJ (2771 kcal). Dietary inadequacy was expressed as the percentage of participants reporting intakes below the sex- and age-specific estimated average requirements (EARs). For nutrients without EARs, adequate intakes were used. Energy and sodium intakes exceeded the recommendations. Less than 10% of participants met recommendations for dietary fibre intake. Vitamin E intakes were below EARs for ≥97% of participants, whereas >20% reported inadequate vitamin A, folate and magnesium intakes. Among women, >50% reported inadequate calcium and vitamin D intakes. Non-nutrient-dense foods contributed 30% of energy, 73% of sugars and 22% of fat. Traditional foods contributed 56% of protein and 49% of iron. CONCLUSIONS: The present study demonstrates a relatively high prevalence of inadequate nutrient intakes among Inuit. The results may be used to monitor the nutrition transition among Inuit, evaluate nutritional interventions, and inform public health policy decision-making.

Contribution of meat to vitamin B12, iron and zinc intakes in five ethnic groups in the USA: implications for developing food-based dietary guidelines.

BACKGROUND: To describe the sources of meat and their contributions to vitamin B12, iron and zinc in five ethnic groups in the USA. METHODS: Dietary data for the Multiethnic Cohort, established in Hawaii and Los Angeles, were collected using a quantitative food frequency questionnaire from more than 215,000 subjects, aged 45-75 years at baseline (1993-1996). Participants included African American, Latino, Japanese American, Native Hawaiian and Caucasian men and women. Servings of meat items were calculated based on the US Department of Agriculture recommendations and their contributions to intakes of total meat, red meat, vitamin B12, iron and zinc were determined. RESULTS: Of all types of meat, poultry contributed the most to meat consumption, followed by red meat and fish among all ethnicities, except for Latino (born in Mexico and Central/South America) men who consumed more beef. Lean beef was the most commonly consumed red meat for all ethnic-sex groups (9.3-14.3%), except for Native Hawaiian and Japanese American men, and Japanese American women whose top contributor was stew/curry with beef/lamb and stir-fried beef/pork with vegetables, respectively. The contribution of meat was most substantial for zinc (11.1-29.3%) and vitamin B12 (19.7-40%) and, to a lesser extent, for iron (4.3-14.2%). CONCLUSIONS: This is the first large multiethnic cohort study to describe meat sources and their contributions to selected nutrients among ethnic minorities in the USA. These findings may be used to develop ethnic-specific recommendations for meat consumption aiming to improve dietary quality among these groups.

The changing face of orthostatic and neurocardiogenic syncope with age.

AIM: Reports of the outcomes of syncope assessment across a broad spectrum of ages in a single population are scarce. It is our objective to chart the varying prevalence of orthostatic and neurocardiogenic syncope (NCS) as a patient ages. METHODS: This was a retrospective study. All consecutive patients referred to a tertiary referral syncope unit over a decade were included. Patients were referred with recurrent falls or orthostatic intolerance. Tilt tests and carotid sinus massage (CSM) were performed in accordance with best practice guidelines. RESULTS: A total of 3002 patients were included (1451 short tilt, 127 active stand, 1042 CSM and 382 prolonged tilt). Ages ranged from 11 to 91 years with a median (IQR) of 75 (62-81) years. There were 1914 females; 1088 males. Orthostatic hypotension (OH) was the most commonly observed abnormality (test positivity of 60.3%). Those with OH had a median (IQR) age of 78 (71-83) years. Symptomatic patients were significantly younger than asymptomatic (P = 0.03). NCS demonstrated a bimodal age distribution. Of 194 patients with carotid sinus hypersensitivity, the median age (IQR) was 77 (68-82) years. Those with vasovagal syncope (n = 80) had a median (IQR) age of 30 (19-44) years. There were 57 patients with isolated postural orthostatic tachycardia syndrome. Of the total patients, 75% were female. They had a median (IQR) age of 23 (17-29) years. CONCLUSION: We have confirmed, in a single population, a changing pattern in the aetiology of syncope as a person ages. The burden of disease is greatest in the elderly.

Assessment of dietary adequacy in a remote Inuvialuit population.

BACKGROUND: Traditional foods are rich sources of essential nutrients, but Inuvialuit in the Northwest Territories (NWT), Canada, have been undergoing a nutrition transition, characterised by an increased consumption of non-nutrient-dense foods. The present study aimed to characterise energy, nutrient and food intakes amongst adult Inuvialuit. METHODS: The study collected up to three 24-h dietary recalls on nonconsecutive days for each participant in spring/summer of 2008 in one remote community in the NWT. Recall data were analysed for energy and nutrient intake, dietary adequacy, most commonly reported foods, and food contributors to energy and nutrients. RESULTS: Participants included 14 men and 50 women (response rate 79%). Median daily energy intake was 9.4 (interquartile range=5.7) MJ for men and 8.3 (3.6) MJ for women. The majority of adult Inuvialuit did not meet the recommendation for vitamins A [median intake=344.7 (246.3) µg-RAE in men, 248.9 (213.8) µg-RAE in women], B(6) [0.9 (0.8) mg in men, 1.0 (0.5) mg in women] and E [2.4 (2.1) mg in men, 1.8 (1.0) mg in women], dietary fibre [7.7 (5.7) g in men, 8.7 (4.4) g in women], calcium [779.6 (842.0) mg in men, 610.4 (431.5) mg in women] and total folate [222.6 (57.7) µg in men, 264.6 (127.5) µg in women]. Vitamin D intake was below the recommendation for most women [median intake=100.0 (119.2) IU]. Traditional foods contributed substantially to protein and iron intake. Juices were the main contributors to energy, carbohydrate and calcium. CONCLUSIONS: The present study revealed an inadequate consumption of essential nutrients in an Inuvialuit population. If these nutrient deficiencies continue, this population will face an increased burden of chronic diseases and malnutrition.

Socioeconomic indicators and frequency of traditional food, junk food, and fruit and vegetable consumption amongst Inuit adults in the Canadian Arctic.

BACKGROUND: Increasing consumption of non-nutrient-dense foods (NNDF), decreasing consumption of traditional foods (TF) and low consumption of fruit and vegetables (FV) may contribute to increasing chronic disease rates amongst Inuit. The present study aimed to assess the daily frequency and socioeconomic and demographic factors influencing consumption of TF, FV and NNDF amongst Inuit adults in Nunavut, Canada. METHODS: Using a cross-sectional study design and random household sampling in three communities in Nunavut, a food frequency questionnaire developed for the population was used to assess frequency of NNDF, TF and FV consumption amongst Inuit adults. Socioeconomic status (SES) was assessed by education level, ownership of items in working condition, and whether or not people in the household were employed or on income support. Mean frequencies of daily consumption were compared across gender and age groups, and associations with socioeconomic indicators were analysed using logistic regression. RESULTS: Two hundred and eleven participants (36 men, 175 women; mean (standard deviation) ages 42.1 (15.0) and 42.2 (13.2) years, respectively; response rate 69-93%) completed the study. Mean frequencies of consumption for NNDF, TF and FV were 6.3, 1.9 and 1.6 times per day, respectively. On average, participants ≤50 years consumed NNDF (P=0.003) and FV (P=0.01) more frequently and TF (P=0.01) less frequently than participants >50 years. Education was positively associated with FV consumption and negatively associated with TF consumption. Households on income support were more likely to consume TF and NNDF. CONCLUSIONS: These results support the hypothesis that the nutrition transition taking place amongst Inuit in Nunavut results in elevated consumption of NNDF compared with TF and FV.

Food patterns and socioeconomic indicators of food consumption amongst Inuvialuit in the Canadian Arctic.

BACKGROUND: Inuvialuit in the Canadian Arctic have been experiencing a nutrition transition resulting in a decrease in nutrient-dense food consumption, which may, in part, explain this population's increasing chronic disease rates. Because the available literature is limited, the present study aimed to document the extent of this transition by examining current dietary patterns and socioeconomic factors affecting food group consumption. METHODS: This cross-sectional study was conducted in three Inuvialuit communities in the Northwest Territories between 2007 and 2008. A validated food frequency questionnaire determined intake frequency of fruit and vegetables (FV), traditional foods (TF) and non-nutrient-dense foods (NNDF). Socioeconomic status (SES) was assessed by questions on education, ownership of items in working condition used to create a Material Style of Life (MSL) scale and residents in household employed/on income support. Daily intake frequencies were compared by gender and age group using Wilcoxon rank sum test. SES association with food group intake was determined using logistic regression. RESULTS: The response rate was 65-85%. One hundred and seventy-five participants were female and 55 were male, aged 19-84 years [mean (SD) 44 (14)]. Mean frequencies of FV and TF consumption were 1.6 (1.5) and 1.6 (1.7) times per day, respectively. NNDF were reported 9.2 (3.0) times per day. The highest MSL score (>12) was significantly associated with higher fruit (≥0.7 times per day) and higher TF intake (≥1.1 times per day) compared with the lowest score (≤7). An intermediate MSL score (8-12) was related to higher vegetable consumption (≥0.4 times per day). CONCLUSIONS: NNDF were consumed approximately seven times more frequently than TF in the present study, indicating that the dietary transition is well underway amongst Inuvialuit. Participants with higher SES were more likely to consume nutrient-dense foods, suggesting possible cost barriers.

The nutrition transition in Barbados: trends in macronutrient supply from 1961 to 2003.

Barbados has been experiencing increasing rates of obesity and chronic non-communicable diseases characteristic of a country in nutrition transition. However, few studies have been carried out on how precisely the diet has changed in recent decades. Our aim was to analyse the FAO food balance sheets for Barbados from 1961 to 2003 in order to characterise the changes that have taken place in the macronutrient supply of the country during that period. Annual food balance sheets were downloaded from the FAOSTAT database, and per capita supply for twelve commodity groupings was analysed for energy and macronutrient levels using WISP dietary analysis software (Tinuviel Software, Llanfechell, Anglesey, UK). The food supply in 2003 provided over 2500 kJ (about 600 kcal) more energy per capita per d than it did in 1961. Energy from carbohydrate as a percentage of total energy has fallen from 70% in 1961 to 57% in 2003 and is now at the lower end of WHO recommendations. Energy from fat as a percentage of total energy increased from 19% to 28% and now lies at the upper end of WHO recommendations. Sugars, at over 17% of dietary energy, are well above the upper limit set by the WHO. Despite having methodological limitations associated with the use of food balance statistics, our data suggest that these imbalances need to be addressed as a matter of priority in order to try to reverse the incidence of nutrition-related chronic diseases that are projected to cause increasing disability and premature death in the country in the coming years.

Sitting and standing blood pressure measurements are not accurate for the diagnosis of orthostatic hypotension.

INTRODUCTION: Orthostatic hypotension (OH) is associated with troublesome symptoms and increased mortality. It is treatable and deserving of accurate diagnosis. This can be time consuming. The current reference standard for its diagnosis is head-up tilt (HUT) testing with continuous beat-to-beat plethysmography. Our objective was to assess the accuracy of sit-stand testing with semi-automatic sphygmomanometry for the diagnosis of OH. DESIGN: Retrospective test of diagnostic accuracy. METHODS: This was a retrospective study performed using a database maintained by a busy syncope unit. HUT testing was performed using an automated tilt table with Finometer monitoring. A 3 min 70 degrees HUT was performed following 5 min supine. Sitting blood pressure (BP) was measured following 3 min rest. Standing BP was measured within 30 s of assuming the upright posture. The results of sit-stand testing were compared with HUT testing as a reference standard. Both tests happened within 5 min of each other and patients underwent no intervention between tests. RESULTS: From a total of 1452 consecutive HUTs, we identified 730 with pre-test measures of sitting and standing BP. The mean age of this group was 70.57 years (SD = 15.1), 62% were female. The sensitivity of sit-stand testing was calculated as 15.5%, specificity as 89.9%, positive predictive value as 61.7%, negative predictive value as 50.2% and the likelihood ratio as 1.6. The area under the Receiver Operator Curve was 0.564. CONCLUSION: We have demonstrated that sit-stand testing for OH has very low diagnostic accuracy. We recommend that the more time-consuming reference standard method of diagnosis be used if the condition is suspected.

Orthostatic hypotension: a new classification system.

AIMS: Orthostatic hypotension (OH) is a common condition, which is defined as a reduction in systolic blood pressure of >or=20 mmHg or diastolic blood pressure of >or=10 mmHg within 3 min of orthostatic stress. Utilizing total peripheral resistance (TPR) and cardiac output (CO) measurements during tilt-table testing (Modelflow method), we classified OH into three categories, namely arteriolar, venular, and mixed. The principle defect in arteriolar OH is impaired vasoconstriction after orthostatic stress, reflected by absence of the compensatory increase in TPR. In venular OH, the predominant defect is excessive reduction in venous return, reflected by a large drop in CO after orthostatic stress with marked tachycardia. Mixed OH is due to a combination of both these mechanisms. METHODS AND RESULTS: We analysed haemodynamic parameters of 110 patients with OH and categorized them as arteriolar, venular, or mixed. Significant differences between the groups were found for the magnitude and time to reach nadir of the systolic blood pressure drop post-head-up tilt. The mixed OH category had the largest systolic blood pressure reduction (42.5, 31.9, 53.3 mmHg, P < 0.001) and the longest nadir time (18.6, 20, 30.7 s, P = 0.002). CONCLUSION: This is a practical classification tool and when validated physiologically, this system could be useful in directing treatment of OH.

Case report: factitious hypoglycemia in diabetic patients.

Factitious hypoglycemia (FH) in a diabetic patient represents a difficult diagnostic and costly management problem. An adolescent diabetic with FH is reported. A literature search revealed 10 adolescent and 45 adult diabetic patients with FH. Tests currently available for diagnosis are evaluated. The role of psychiatric therapy in relation to overall management and prognosis is stressed.

Alcohol and the heart. How it helps, how it harms.

Does regular consumption of alcohol protect against coronary artery disease but not against sudden death? In this article, Dr Sheehy examines several theories that have been proposed to explain the cardioprotective effect of ethanol and also reviews the factors related to sudden death in alcoholics.

Diabetic gustatory sweating.

Gustatory sweating is an unusual entity that may occur as an idiosyncratic reaction to certain foods, as a localized reaction to trauma or infection, or as the result of diabetic neuropathy. This report deals with a severe case of diabetic gustatory sweating, discusses the various types of gustatory sweating, and reviews the English literature dealing with the diabetic form.