Oral Nutritional Supplement with ß-hydroxy-ß-methylbutyrate (HMB) Improves Nutrition, Physical Performance and Ameliorates Intramuscular Adiposity in Pre-Frail Older Adults: A Randomized Controlled Trial.

OBJECTIVES: Supplementation of high protein oral nutrition shakes supplemented with ß-hydroxy-ß-methylbutyrate (HP-HMB) has been shown to improve muscle mass, muscle strength, and physical performance in older adults, but the roles of HP-HMB supplementation on the intramuscular adiposity remained unknown. This 12-week randomized controlled trial evaluated the changes of muscle mass, muscle strength, physical performance and intramuscular adiposity among community-dwelling pre-frail older persons. METHODS: This was an open-label, parallel group, randomized controlled trail that enrolled 70 community-dwelling pre-frail older persons without active or uncontrolled conditions, disability or dementia. The intervention group was provided with two services of HP HMB (Ensure® Plus Advance containing 3g HMB) per day for 12 weeks, and the control group was provided with professional nutritional counselling for sufficient protein intake. All participants received functional assessments, laboratory tests and magnetic resonance imaging (MRI) of the dominant leg before and after study. Intramuscular adipose tissue (IMAT) and the mid-thigh cross-sectional area (CSA) of muscle were obtained by MRI, and the IMAT-to-CSA ratio was calculated to evaluate intramuscular adiposity. RESULTS: Overall, 62 participants (mean age: 71.1±3.8 years, 69.4% female) completed the study (HP-HMB group: 29, control group: 33) and comparisons of baseline characteristics between groups were not statistically different. For the primary outcome, HP-HMB group showed significant improvements in the CSA of mid-thigh muscle (mean increase of CSA: 149.1±272.3 for HMB group vs -22.9±309.1 mm2 for control group, P=0.045). The improvement of MNA-SF was borderline (0.28±0.75 vs. -0.15±0.94, P=0.064), but serum levels of Vit D were significantly increased in the HMB group (3.83±8.18 vs. -1.30±4.81 ng/mL, P=0.002). Moreover, the body weight and BMI were significantly increased in the HMB group (1.10±1.18 vs. 0.24±1.13 kg, P=0.005; 0.56±0.68 vs. 0.22±0.47 kg/m2, P=0.019). In particular, the IMAT-to-CSA ratio was reduced in the HMB group (-0.38±1.21 vs. -0.02±2.56 %, P=0.06). Using the generalized estimating equation, we found that SPPB score in chair rise test was significantly improved (ß=0.71, 95% C.I.0.09-1.33, P=0.026). CONCLUSIONS: The 12-week supplementation with high protein oral nutrition shake supplemented with 3g HMB per day significantly increased muscle mass, as well as nutritional status and physical performance, and ameliorated the intramuscular adiposity of pre-frail older persons. Further study is needed to explore the long-term benefits of HP-HMB supplementation on muscle and metabolic health for older adults.

Illuminating gravitational waves: A concordant picture of photons from a neutron star merger.

Merging neutron stars offer an excellent laboratory for simultaneously studying strong-field gravity and matter in extreme environments. We establish the physical association of an electromagnetic counterpart (EM170817) with gravitational waves (GW170817) detected from merging neutron stars. By synthesizing a panchromatic data set, we demonstrate that merging neutron stars are a long-sought production site forging heavy elements by r-process nucleosynthesis. The weak gamma rays seen in EM170817 are dissimilar to classical short gamma-ray bursts with ultrarelativistic jets. Instead, we suggest that breakout of a wide-angle, mildly relativistic cocoon engulfing the jet explains the low-luminosity gamma rays, the high-luminosity ultraviolet-optical-infrared, and the delayed radio and x-ray emission. We posit that all neutron star mergers may lead to a wide-angle cocoon breakout, sometimes accompanied by a successful jet and sometimes by a choked jet.

Small bowel obstruction due to incarcerated sciatic hernia: ultrasound diagnosis.

A 71-year-old woman presented with vomiting, abdominal pain and vague right gluteal discomfort. Abdominal ultrasound showed ascites and dilated small bowel loops with peristaltic movement, while transgluteal ultrasound revealed entrapped ascites beneath gluteal muscles and an oedematous, immobile bowel loop trapped between the sacrum and iliac bone with barely visible colour Doppler flow suggestive of an incarcerated sciatic hernia. CT demonstrated similar findings and subsequent surgery confirmed the diagnosis. To our knowledge, this is the first report of a pre-operative diagnosis of incarcerated sciatic hernia on ultrasound.

Quantification of macrovesicular and microvesicular hepatic steatosis in rats using 3.0-T ¹H-magnetic resonance spectroscopy.

BACKGROUND AND OBJECTIVE: Hepatic steatosis (HE), which is common among the general population, is present in donor organs, potentially affecting their graft survival as well as the recovery of the donor. Our goal was to develop an experimentally and clinically reliable, noninvasive method to quantify macrovesicular and microvesicular hepatic steatosis using 3-T (1)H-magnetic resonance spectroscopy (MRS). MATERIALS AND METHODS: Macrovesicular and microvescular steatosis were induced in rats using methylcholine deficiency and choline deficiency diets. A MayoBC10 coil was used for radiofrequency transmission and signal recept. Measurements of hepatic fat content were performed using (1)H spectroscopy on a 3.0-T whole-body GE Signa system. The ratio of the areas under the curve of fat (0.8-1.3 ppm) and water (4.7 ppm) was used to determine hepatic fat content, which was compared with the degree of histopathologic and biochemical steatosis. RESULTS: Twenty rats were divided into two groups based on the percentage of microvesicular liver steatosis. Group A (n = 13) was the lower percentage group (microvesicular < 10%) while group B (n = 7), the higher group (microvesicular ≥ 10%). The mean total fatty change in the liver was 58.4% ± 47.2% and 67.6% ± 39.1% in groups A and B, respectively. A highly significant linear correlation between (1)H-MRS and total fatty change was observed in group A (r = .986, P < .001) while there was a relatively poor correlation in group B (r = .764, P = .05). The power to predict fatty change in the liver in groups A and B was significantly different (P = .004). CONCLUSIONS: The degree of hepatic steatosis with a small amount of microvesicular steatosis (<10%) can be precisely predicted using 3-T (1)H-MRS.

Delayed spontaneous hepatogastric fistula formation following transcatheter arterial embolisation and radiotherapy for hepatocellular carcinoma.

A 58-year-old male patient with an unresectable 10 cm liver lesion that was a histologically proven hepatocellular carcinoma (HCC) underwent transcatheter hepatic artery embolisation (TAE). 4 months later, the patient was referred for salvage radiotherapy owing to local recurrence. The HCC became an encapsulated tumour with central necrosis after radiotherapy. The patient enjoyed a normal lifestyle for 9 years, with local control achieved by radiotherapy, until a hepatogastric fistula developed. Although the hepatogastric fistula resolved with surgical drainage, the patient later died from septic shock. Hepatogastric fistula is a rare but serious complication after TAE and radiotherapy for HCC. Development of fever, abdominal pain and jaundice after an initial symptom-free interval should arouse suspicion of hepatogastric fistula formation from an encapsulated necrotic HCC or a ruptured liver abscess. Because the mortality is high, aspiration of a suspected necrotic lesion should be performed as soon as possible. Patients with risk factors, including liver cirrhosis and large lesions close to the adjacent gastrointestinal tract, are especially vulnerable. Gas formation within a necrotic liver tumour requires immediate drainage.