The ability of the Global Leadership Initiative on Malnutrition (GLIM) to diagnose protein-energy malnutrition in patients requiring vascular surgery: a validation study.

Identifying nutritional deficits and implementing appropriate interventions in patients requiring vascular surgery is challenging due to the paucity of appropriate screening and assessment tools in this group. This retrospective study aimed to determine the validity of the Global Leadership Initiative on Malnutrition (GLIM) in identifying protein-energy malnutrition (PEM) in inpatients admitted to a vascular surgery unit, using the PG-SGA as the comparator. Diagnostic accuracy and consistency were determined between the GLIM and the Patient-Generated Subjective Global Assessment (PG-SGA) global rating. The GLIM determination was made retrospectively using the relevant parameters collected at baseline in the original study. Two hundred and twenty-four (70·1 % male) participants were included. The prevalence of PEM was 28·6 % on GLIM and 17 % via the PG-SGA. Compared with the PG-SGA, the GLIM achieved sensitivity of 73·7 % and specificity of 80·6 %; however positive predictive value was 43·7 % indicating that the GLIM over-diagnosed malnutrition compared with the PG-SGA. Kappa reached 0·427 indicating moderate diagnostic consistency. Due to the absence of an ideal instrument and the complexity of malnutrition often seen in this group which extends beyond PEM to significant micronutrient deficiencies, further work is required to determine the most appropriate instrument in this patient group, and how micronutrient status can also be included in the overall assessment given the critical role of micronutrients in this group.

A scoping review of the use of visual tools and adapted easy-read approaches in Quality-of-Life instruments for adults.

PURPOSE: Self-Reporting using traditional text-based Quality-of-Life (QoL) instruments can be difficult for people living with sensory impairments, communication challenges or changes to their cognitive capacity. Adapted communication techniques, such as Easy-Read techniques, or use of pictures could remove barriers to participation for a wide range of people. This review aimed to identify published studies reporting adapted communication approaches for measuring QoL, the methodology used in their development and validation among adult populations. METHODS: A scoping review of the literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews checklist was undertaken. RESULTS: The initial search strategy identified 13,275 articles for screening, with 264 articles identified for full text review. Of these 243 articles were excluded resulting in 21 studies for inclusion. The majority focused on the development of an instrument (12 studies) or a combination of development with some aspect of validation or psychometric testing (7 studies). Nineteen different instruments were identified by the review, thirteen were developed from previously developed generic or condition-specific quality of life instruments, predominantly aphasia (7 studies) and disability (4 studies). Most modified instruments included adaptations to both the original questions, as well as the response categories. CONCLUSIONS: Studies identified in this scoping review demonstrate that several methods have been successfully applied e.g. with people living with aphasia post-stroke and people living with a disability, which potentially could be adapted for application with more diverse populations. A cohesive and interdisciplinary approach to the development and validation of communication accessible versions of QOL instruments, is needed to support widespread application, thereby reducing reliance on proxy assessors and promoting self-assessment of QOL across multiple consumer groups and sectors.

Low muscle mass determined by psoas muscle area does not correlate with dual-energy x-ray absorptiometry or total lumbar muscle mass scores: A prospective cohort study of patients undergoing vascular surgery.

Background/Objective: Low muscle mass and sarcopenia have been explored as risk factors for poor outcomes following vascular surgery. The findings have been variable. The use of a diverse range of techniques to identify low muscle mass is a confounder in establishing the true relationship between low muscle mass, sarcopenia and outcomes. Our aim was to establish if different scoring methods identified the same patients as sarcopenic. We also explored which method best predicted outcomes. Method: 70 patients undergoing vascular surgery were prospectively assessed for sarcopenia using dual-energy x-ray absorptiometry (DEXA) scan, grip strength and gait speed. These patients underwent abdominal CT imaging as routine care. The muscle mass of each patient was determined using DEXA and by both psoas muscle and total skeletal muscle area on CT, normalised for patient height (PMI and CT-SMI, respectively). Low muscle mass was defined by published age- and sex-specific cut-offs. Grip strength data was combined with muscle mass to define sarcopenic patients. One- and 3-year mortality and time to readmission was recorded. Conclusion and Results: 10-22% of patients had low muscle mass and 4-10% of patients were sarcopenic, depending on the method employed. PMI did not correlate with DEXA or CT-SMI for low muscle mass, but CT-SMI correlated with DEXA (p = 0.0007). For sarcopenia, CT-SMI and DEXA scoring correlated (p = 0.002); PMI correlated with CT-SMI (p = 0.0006) but not DEXA. Low muscle mass by PMI predicted 1-year mortality (p = 0.02, X2 = 5.34, Effect size = 1.04) but the applicability of this finding is limited by the diverse pathologies explored. No other method predicted 1- or 3-year mortality or readmissions in this heterogenous cohort. The psoas area did not correlate with muscle mass defined by DEXA or total lumbar skeletal muscle area. Low psoas muscle index may be an independent marker of poor outcome, unrelated to generalised sarcopenia, and this warrants investigation in specific pathologies. A lower total number of patients were sarcopenic than had been expected, emphasising the need to use population-based pre-defined cut-offs.

Effect of student-led health interventions on patient outcomes for those with cardiovascular disease or cardiovascular disease risk factors: a systematic review.

BACKGROUND: As the need for health care services rise, alternative service delivery models such as student-led health interventions become attractive alternatives to alleviate the burden on healthcare. Predominantly, student-led health interventions were free clinics servicing socially disadvantaged communities in the USA. A 2015 systematic review identified that students value these student-run clinics and reported skill and knowledge attainment from participating. Previous research has reported on patient satisfaction outcomes, but less frequently about the clinical outcomes patients accrue from these student-delivered services. As cardiovascular disease is the leading cause of death worldwide, this review aimed to explore the effectiveness of student-led health interventions through examining their impact on objective clinical outcomes, using the case of patients at risk of, or with, cardiovascular disease. METHODS: A systematic literature search was conducted in eight electronic databases to identify student-led health interventions conducted on adults with a cardiovascular disease risk factor or established cardiovascular disease, and a clinical outcome of interest. Through double-blinded screening and data extraction, sixteen studies were identified for synthesis. RESULTS: The majority of student-led health interventions for patients at risk of cardiovascular disease demonstrated a positive impact on patient health. Statistically significant changes amongst patients at risk of cardiovascular disease appeared to be associated with student-led individualised intervention or group-based interventions amongst patients with diabetes or those who are overweight or obese. The evidence was of moderate quality, as included studies lacked a control group for comparison and detail to enable the intervention to be replicated. CONCLUSIONS: Future research applying a student-led health intervention through a randomised control trial, with rigorous reporting of both student and patient interventions and outcomes, are required to further understand the effectiveness of this alternative service delivery model.

Does a neutropenic diet reduce adverse outcomes in patients undergoing chemotherapy?

OBJECTIVE: This study aimed to compare clinical outcomes of chemotherapy patients who received either a neutropenic diet (ND) or liberalised diet (LD) and to investigate associations between ND and infectious outcomes. METHODS: A retrospective case note audit of patients admitted to Flinders Medical Centre from 2013 to 2017 was conducted. Patients were eligible if they were aged 18 years and above, received chemotherapy and were neutropenic during admission. Demographic and clinical data were collected from medical records. Primary outcomes were occurrence of infections and fever. Secondary outcomes include hospital length of stay and infection-related mortality. RESULTS: Seventy-nine patients received ND while 75 patients received LD. The ND group had more patients with acute myeloid leukaemia (p < .001) and receiving high-toxicity chemotherapy (p = .005). Incidence of febrile neutropenia (p = .016), bacteraemia (p = .044) and number of febrile days (p = .033) was higher in the ND group. ND was not independently associated with occurrence of febrile neutropenia or infections. Subsample analysis of 20 pairs of patients matched on age, sex and cancer diagnosis found no significant differences in clinical outcomes between groups. CONCLUSION: ND was not associated with the prevention of adverse outcomes in chemotherapy patients.

An evaluation of the validity of nutrition screening and assessment tools in patients admitted to a vascular surgery unit.

Vascular surgery patients are nutritionally vulnerable. Various malnutrition screening and assessment tools are available; however, none has been developed or validated in vascular patients. The present study aimed to: (1) investigate the validity of four commonly administered malnutrition screening tools (Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST), Nutrition Risk Screen-2002 (NRS-2002) and the Mini-Nutritional Assessment - Short Form (MNA-SF) and an assessment tool (the Patient-Generated Subjective Global Assessment (PG-SGA)) compared against a comprehensive dietitian's assessment and (2) evaluate the ability of the instruments to predict outcomes. Vascular inpatients were screened using the four malnutrition screening tools and assessed using the PG-SGA. Each was assessed by a dietitian incorporating nutritional biochemistry, anthropometry and changes in dietary intake. Diagnostic accuracy, consistency and predictive ability were determined. A total of 322 (69·3 % male) patients participated, with 75 % having at least one parameter indicating nutritional deficits. No instrument achieved the a priori levels for sensitivity (14·9-52·5 %). Neither tool predicted EuroQoL 5-dimension 5-level score. All tools except the MNA-SF were associated with length of stay (LOS); however, the direction varied with increased risk of malnutrition on the MUST and NRS-2002 being associated with shorter LOS (P=0·029 and 0·045) and the reverse with the MST and PG-SGA (P=0·005 and <0·001). The NRS-2002 was associated with increased risk of complications (P=0·039). The MST, NRS-2002 and PG-SGA were predictive of discharge to an institution (P=0·004, 0·005 and 0·003). The tools studied were unable to identify the high prevalence of undernutrition; hence, vascular disease-specific screening and/or assessment tools are warranted.

Nutritional status of patients admitted to a metropolitan tertiary care vascular surgery unit.

BACKGROUND AND OBJECTIVES: Undernutrition in vascular surgery patients has a significant impact on clinical outcomes. This observational study aimed to investigate the nutritional status of a heterogeneous sample of vascular surgery inpatients and to determine the prevalence of nutritional risk, malnutrition (including nutrient deficiencies) and sarcopenia. METHODS AND STUDY DESIGN: All participants were screened for risk of malnutrition using the Malnutrition Universal Screening Tool (MUST) and assessed using the Patient-Generated Subjective Global Assessment (PG-SGA). Micronutrient status was examined via plasma/serum samples. The presence of sarcopenia was explored using an accepted algorithm incorporating gait speed, muscle mass (DEXA) and grip strength. RESULTS: 322 participants (69% male, mean age 67.6±14.1y) consented to the study. 12.5% were identified as at risk of malnutrition by the MUST while 15.8% were deemed malnourished by the PG-SGA. Only 5% were diagnosed as sarcopenic. Prevalence of malnutrition was much higher when micronutrients were examined with 79% showing low vitamin C, 56% low vitamin D and over 40% having low zinc, vitamin B-12 and folate. A smaller proportion were also low in selenium (19%). CONCLUSIONS: Patients with vascular disease are a nutritionally vulnerable group. The MUST and PG-SGA did not identify the full extent of nutritional deficiencies. Further investigation is warranted to assess tool validity in this group. A number of micronutrients are crucial in these patients and hence a more comprehensive assessment that encompasses a wider range of parameters, including micronutrient status appears warranted.

Eating occasions and the contribution of foods to sodium and potassium intakes in adults.

OBJECTIVE: To examine dietary Na and K intake at eating occasions in Australian adults and identify the contribution of major food sources to Na and K at different eating occasions. DESIGN: Secondary analysis of 24 h recall diet data from the Australian Health Survey (2011-2013). SETTING: Nationally representative survey in Australia. SUBJECTS: Male and female Australians aged 18-84 years (n 7818). RESULTS: Dinner contributed the greatest proportion to total daily Na intake (33 %) and K intake (35 %). Na density was highest at lunch (380 mg/MJ) and K density highest at between-meal time eating occasions (401 mg/MJ). Between-meal time eating occasions provided 20 % of daily Na intake and 26 % of daily K intake. The major food group sources of Na were different at meal times (breads and mixed dishes) compared with between-meal times (cakes, muffins, scones, cake-type desserts). The top food group sources of K at meal times were potatoes and unprocessed meat products and dishes. CONCLUSIONS: Foods which contributed to Na and K intake differed according to eating occasion. Major food sources of Na were bread and processed foods. Major food sources of K were potatoes and meat products and dishes. Public health messages that emphasise meal-based advice and diet patterns high in vegetables, fruits and unprocessed foods may also aid reduction in dietary Na intake and increase in dietary K intake.

Does the presence of cardiovascular disease risk factors or established disease influence the dietary intake of affected adults and their children residing in the same household? A secondary analysis of the Australian Health Survey (2011-2013).

BACKGROUND: Diet is an important contributor to risk of cardiovascular disease (CVD) and integral in management and delaying progression. Little is known however about whether increased CVD risk or established CVD has any influence on dietary intakes of Australian adults or children residing in the same household. This study aimed to determine whether the presence of CVD or CVD risk factors influences dietary intake of Australian adults and if the presence of an adult with increased CVD risk influences the dietary intake of a child living in the same household. METHODS: Data were sourced from the 2011-2013 Australian Health Survey for: (1) adults ≥18 years with risk factors or established CVD and (2) children 2-17 years residing in the same household as adults with CVD risk factors or established CVD. Selected nutrient intakes (total fat, saturated fat plus trans fat, alpha-linolenic acid, total long chain omega 3 fatty acids, fibre and sodium) collected by repeated 24 h recalls were compared to national dietary recommendations and to the intakes of all other adults and children surveyed. Standard errors of the estimates were calculated using the replicate weights method, and an alpha value of <0.05 considered statistically significant. RESULTS: Six thousand two hundred sixty five of 9435 adults surveyed were identified as having CVD risk factors or established disease and of these 1609 had a child in the same household that also contributed data in this survey. No differences were observed in adjusted mean dietary intakes between those without risk factors or established CVD and those with, except for total energy and sodium which were significantly lower in the adults with CVD risk factors and/or established disease. However sodium intakes across both groups were higher than recommended targets. There were no differences for selected nutrients between children residing with affected adults and other children surveyed. CONCLUSIONS: While intakes of Australian adults with CVD risk factors or established disease were favourable for sodium, compared to unaffected adults, there is still scope for improvement as many Australian adults, despite CVD risk, are unable to achieve targets for selected nutrients. Effective dietary behaviour change strategies and resources are urgently needed.

Dietary intake of working women with children does not appear to be influenced by hours of employment: A secondary analysis of the Australian Health Survey (2011-2013).

UNLABELLED: Women with children often fulfil multiple roles of running a household, raising a family and working outside the home. Good nutrition during this time is important to optimise their performance and prevent lifestyle diseases. Women also act as nutritional gatekeepers for their family. The dual burden of paid employment and unpaid family work may be associated with time scarcity in mothers which can impact food preparation and therefore nutritional adequacy. The aim of this study was to examine the diet of women who lived with children by comparison of hours worked. METHODS: This was a secondary analysis of the Australian National Nutrition and Physical Activity Survey 2011-12. Subjects were women aged 18-65 years who resided with ≥1 child (<18 years). Women were grouped according to hours of employment: not working; working <25 h a week; and working ≥25 hours a week. Data from two 24-h dietary recalls were used to compare differences between groups in nutrient intake and proportion of energy from discretionary foods. Covariates included were age, education, smoker status, Socio-Economic Indexes for Areas (SEIFA), number of persons in household, week or weekend day of the survey and the sequence of recalls. RESULTS: Analyses included 1869 women. Dietary intakes varied minimally between groups with intakes of fibre, vitamin C, and calcium lowest in the group not working. Overall diet quality was poor with >30% of energy coming from discretionary foods in all groups. CONCLUSIONS: Usual hours of employment per week have a minimal effect on diet quality in women with children. It is likely that different factors specific to each group contribute to the poor dietary intakes and should be further investigated.

In Patients Admitted to a Home Rehabilitation Service, Can a Physical Examination of Muscle, Fat, and Fluid Status be Completed Remotely Via Videocall? A Validation Study.

BACKGROUND: Teleconsultation via videocall by a dietitian may allow remote diagnosis of malnutrition amongst patients undertaking home rehabilitation; however, whether or not a physical examination can be performed accurately remotely has not yet been determined. OBJECTIVE: This study aimed to compare agreement between an in-person and videocall by a dietitian for overall physical assessment in patients admitted to a home rehabilitation service. DESIGN: This was a cross-sectional diagnostic accuracy study. PARTICIPANTS AND SETTING: This study involved 71 adults admitted to the home rehabilitation program at Flinders Medical Centre in Adelaide, South Australia, Australia, between September 2019 to November 2019 and August 2020 to November 2020. MAIN OUTCOME MEASURES: Validity of the videocall by a dietitian to undertake a physical assessment was determined using an in-person physical assessment completed by a trained dietitian in the participant's own home. A dietitian blinded to the in-person assessment completed the physical examination via a videocall to determine the presence and degree of deficit at each anatomical site and make an overall physical assessment. STATISTICAL ANALYSES PERFORMED: Percentage agreement, weighted kappa, sensitivity, and specificity were determined to assess agreement between videocall and in-person assessments undertaken by a dietitian. RESULTS: The overall videocall physical examination by a dietitian rating achieved a percentage agreement of 69.0% against the in-person assessment by a dietitian, with a weighted kappa agreement of 0.658 (95% CI 0.530 to 0.786), sensitivity of 87.5%, and specificity of 81.1%. CONCLUSIONS: The substantial weighted kappa, good sensitivity, and specificity supports the use of the physical assessment in contributing to diagnosing malnutrition via videocall in home rehabilitation settings. Services that are without a local dietetic workforce should consider using dietitians to undertake videocalls for the physical examination component of nutrition assessment to facilitate timely nutrition assessment and optimal nutrition interventions, as well as support review of nutrition interventions.

The effect of omega-3 polyunsaturated fatty acid intake on blood levels of omega-3s in people with chronic atherosclerotic disease: a systematic review.

CONTEXT: Atherosclerosis is a systemic pro-inflammatory and pro-oxidative disease, accounting for approximately a third of deaths globally. It has been proposed that omega-3s, through their antioxidant and anti-inflammatory properties, mitigate atherosclerotic disease progression. However, due to the systemic pro-inflammatory and pro-oxidative state of atherosclerosis, it is proposed that patients with atherosclerotic disease may have higher omega-3 requirements than the average requirement, due to increased nutrient utilization in anti-inflammatory and anti-oxidant processes. OBJECTIVE: The aim of this review was to determine what dose and duration of omega-3 supplementation is required to reach a therapeutic blood level of omega-3s (eicosapentaenoic acid ≥150 µg/mL or omega-3 index ≥8%) in people with chronic atherosclerotic disease. DATA SOURCES: This systematic review comprehensively searched MEDLINE, Emcare, Scopus, and CINAHL using key search terms for atherosclerotic disease, omega-3, supplementation, and blood levels of omega-3s. DATA EXTRACTION: Two reviewers independently screened 529 randomized controlled trials (RCTs) supplementing omega-3s in patients with chronic atherosclerotic disease. DATA ANALYSIS: In total, 25 journal articles from 17 original RCTs were included and assessed quantitatively. Supplementation at 1.8 g to 3.4 g per day for a 3-month-6-month duration, and at 4.4 g and above for as little as 1 month-6 months were identified as the most effective dosage ranges for increasing blood levels of omega-3s to therapeutic levels in people with atherosclerotic disease. CONCLUSIONS: Consideration should be given to routine omega-3 supplementation and to increasing the omega-3 dietary recommendations and upper limits of daily intake to improve clinical outcomes and reduce the risk of cardiac mortality in this population.

In Patients Admitted to a Home Rehabilitation Service, Is Remote Completion of the Patient-Generated Subjective Global Assessment Physical Examination Using Still Images Captured by Allied Health Assistants a Valid Alternative to an In-Person Physical Examination?

BACKGROUND: There is increasing provision of telehealth services, including nutrition services. However, remote nutrition assessments are challenging due to difficulties in conducting physical assessments remotely, a crucial component of assessing nutritional status. OBJECTIVE: The aim of this study was to evaluate whether remote completion of the Patient-Generated Subjective Global Assessment physical examination using still images captured by allied health assistants (AHAs) is a valid alternative to an in-person physical examination in patients admitted to a home rehabilitation service. DESIGN: This study was cross-sectional in design. PARTICIPANTS/SETTING: This study involved 104 adults admitted to the home rehabilitation service at Southern Adelaide Local Health Network, Adelaide, Australia, over 2 sampling periods in 2019 and 2020 who were receiving home visits by an AHA and were engaged in rehabilitation activities. MAIN OUTCOME MEASURES: Validity of the still image-based physical assessment was determined using still images collected by an AHA and an in-person physical assessment completed by a dietitian from each participant. A dietitian blinded to the in-person results later assessed the de-identified still images to determine the presence and extent of deficit at each anatomical site and overall physical examination component of the Patient-Generated Subjective Global Assessment. STATISTICAL ANALYSES PERFORMED: Percentage agreement, weighted κ, sensitivity, and specificity between the still image based and in-person physical examinations were determined to assess agreement between the 2 methods of assessment. RESULTS: The still image based physical examination achieved a percentage agreement of 75% against the in-person examination, with a weighted κ of 0.662 (95% confidence interval 0.516-0.808) and a sensitivity-specificity pair of 76.6% and 89.1%. CONCLUSIONS: Physical examination using still images collected by AHAs achieved percentage agreement, κ, and sensitivity and specificity compared with an in-person physical examination that is consistent with or superior to commonly adopted nutrition screening and assessment tools. There is potential for implementation of this method to facilitate remote nutritional assessments by dietitians; however, further work is needed to ensure dietitians are able to assess still images reliably.

BMI: a simple, rapid and clinically meaningful index of under-nutrition in the oldest old?

BMI is commonly used as a sole indicator for the assessment of nutritional status. While it is a good predictor of morbidity and mortality among young and middle-aged adults, its predictive ability among the oldest old remains unclear. The objective of the present study was to investigate the relationship between BMI and risk of falls, fractures and all-cause mortality among older Australians in residential aged care facilities. One thousand eight hundred and forty-six residents of fifty-two nursing homes and thirty hostels in northern Sydney, Australia, participated in the present study. Baseline weight and height were measured and BMI (kg/m2) calculated. For 2 years following the baseline measurements, incidence and date of all falls and fractures were recorded by research nurses who visited the facilities regularly and date of death was documented based on the participants' records at each facility. Cox proportional hazards regression models were calculated to determine the relationship between baseline BMI and time to fall, fracture or death, within 2 years following the baseline measures taken to be the censoring date. After adjustments were made for age, sex and level of care, low BMI (,22 kg/m2) increased the risk of fracture by 38% (hazard ratio = 1.38, 95% CI 1.11, 1.73) and all-cause mortality by 52% (hazard ratio = 1.52, 95% CI 1.30, 1.79). The magnitude of this effect was only slightly reduced when adjustments were further made to incorporate cognition, number of medications, falls and fracture in the subsequent 2-year period. In conclusion, BMI has predictive ability in the area of fracture and all-cause mortality for residents of aged care facilities. It is a simple and rapid indicator of nutritional status rendering it a useful nutrition screen and goal for nutrition intervention.

Feasibility of population screening tests to establish a healthy ageing trajectory.

OBJECTIVES: There are no agreed comprehensive tests for age-related changes to physical, emotional, mental and social functioning. Research into declining function focuses on those 75 years and older and little is known about age-related changes in younger people. The aims of this project were (1) to ascertain a comprehensive test battery that could underpin community-based health screening programmes for people aged 40-75 years and pilot both (2) community-based recruitment and (3) the utility, acceptability, response burden and logistics. METHODS: A total of 11 databases were searched using a broad range of relevant terms. An identified comprehensive, recent, high-quality systematic review of screening instruments for detection of early functional decline for community-dwelling older people identified many relevant tools; however, not all body systems were addressed. Therefore, lower hierarchy papers identified in the rapid review were included and expert panel consultation was conducted before the final test battery was agreed. Broad networks were developed in one Australian city to aid pilot recruitment of community-dwellers 40-75 years. Recruitment and testing processes were validated using feasibility testing with 12 volunteers. RESULTS: The test battery captured (1) online self-reports of demographics, health status, sleep quality, distress, diet, physical activity, oral health, frailty and continence; and (2) objective tests of anthropometry; mobility; lung function; dexterity; flexibility, strength and stability; hearing; balance; cognition and memory; foot sensation; and reaction time. Recruitment and testing processes were found to be feasible. CONCLUSION: This screening approach may provide new knowledge on healthy ageing in younger people.

Evaluating Photographs as a Replacement for the In-Person Physical Examination of the Scored Patient-Generated Subjective Global Assessment in Elderly Hospital Patients.

BACKGROUND: Undernourished patients discharged from the hospital require follow-up; however, attendance at return visits is low. Teleconsultations may allow remote follow-up of undernourished patients; however, no valid method to remotely perform physical examination, a critical component of assessing nutritional status, exists. OBJECTIVE: This study aims to compare agreement between photographs taken by trained dietitians and in-person physical examinations conducted by trained dietitians to rate the overall physical examination section of the scored Patient Generated Subjective Global Assessment (PG-SGA). DESIGN: Nested cross-sectional study. PARTICIPANTS/SETTING: Adults aged ≥60 years, admitted to the general medicine unit at Flinders Medical Centre between March 2015 and March 2016, were eligible. All components of the PG-SGA and photographs of muscle and fat sites were collected from 192 participants either in the hospital or at their place of residence after discharge. MAIN OUTCOME MEASURES: Validity of photograph-based physical examination was determined by collecting photographic and PG-SGA data from each participant at one encounter by trained dietitians. A dietitian blinded to data collection later assessed de-identified photographs on a computer. STATISTICAL ANALYSES PERFORMED: Percentage agreement, weighted kappa agreement, sensitivity, and specificity between the photographs and in-person physical examinations were calculated. All data collected were included in the analysis. RESULTS: Overall, the photograph-based physical examination rating achieved a percentage agreement of 75.8% against the in-person assessment, with a weighted kappa agreement of 0.526 (95% CI: 0.416, 0.637; P<0.05) and a sensitivity-specificity pair of 66.9% (95% CI: 57.8%, 75.0%) and 92.4% (95% CI: 82.5%, 97.2%). CONCLUSIONS: Photograph-based physical examination by trained dietitians achieved a nearly acceptable percentage agreement, moderate weighted kappa, and fair sensitivity-specificity pair. Methodological refinement before field testing with other personnel may improve the agreement and accuracy of photograph-based physical examination.

Effect of Flavonoids on Oxidative Stress and Inflammation in Adults at Risk of Cardiovascular Disease: A Systematic Review.

Oxidative stress (OS) and inflammatory processes initiate the first stage of cardiovascular disease (CVD). Flavonoid consumption has been related to significantly improved flow-mediated dilation and blood pressure. Antioxidant and anti-inflammatory mechanisms are thought to be involved. The effect of flavonoids on markers of oxidative stress and inflammation, in at risk individuals is yet to be reviewed. Systematic literature searches were conducted in MEDLINE, Cochrane Library, CINAHL and SCOPUS databases. Randomised controlled trials in a Western country providing a food-based flavonoid intervention to participants with one or two modifiable risk factors for CVD measuring a marker of OS and/or inflammation, were included. Reference lists were hand-searched. The Cochrane Collaboration Risk of Bias Tool was used to assess study quality. The search strategy retrieved 1248 articles. Nineteen articles meeting the inclusion criteria were reviewed. Eight studies were considered at low risk of bias. Cocoa flavonoids provided to Type 2 diabetics and olive oil flavonoids to mildly-hypertensive women reduced OS and inflammation. Other food sources had weaker effects. No consistent effect on OS and inflammation across patients with varied CVD risk factors was observed. Study heterogeneity posed a challenge for inter-study comparisons. Rigorously designed studies will assist in determining the effectiveness of flavonoid interventions for reducing OS and inflammation in patients at risk of CVD.

Do dietary patterns in older age influence the development of cancer and cardiovascular disease: A longitudinal study of ageing.

BACKGROUND: The association between diet and cancer, and diet and cardiovascular disease (CVD) is well established in younger adults, however limited evidence exists to demonstrate that these associations persist for older adults, particularly in the context of dietary patterns. AIMS: To investigate whether the dominant dietary patterns identified in a cohort of older adults are predictive of cancer or CVD development. METHODS: This study was a secondary analysis of data from the Australian Longitudinal Study of Ageing (ALSA). The ALSA is a multi-dimensional population based study of human ageing which commenced in 1992 with 2087 participants aged 65 years or more. Data from a 170-item food frequency questionnaire administered at baseline in 1992 to 1034 older adults free from cancer and CVD was explored using factor analysis to identify dominant dietary patterns, being those patterns which comprise foods commonly consumed by the sample. Pooled logistic regression from data available at baseline, 2 and 8 years of follow-up was used to determine whether any associations existed between dietary patterns and development of or death from cancer or CVD. RESULTS: Five dominant dietary patterns were identified and labelled 'discretionary choices and breads and cereals', 'vegetable and fruit', 'white meat and milk products', 'breads and cereals, sweet bakery goods and milk products' and 'red meat and protein alternatives'. None of the dominant dietary patterns demonstrated a significant overall trend for the development of or death from cancer or CVD with the exception of the 'red meat and protein alternatives' pattern where an increased risk of cancer development or death was observed with adjustment for age, gender, smoking, overweight and obesity and total number of comorbidities (tertile 2: OR 1.46, 95% CI 1.03-2.07; tertile 3: OR 1.28, 95% CI 0.87-1.90). CONCLUSIONS: These results suggest that the development of or death from cancer and CVD may be independent of most dietary patterns in those who are free of either condition at age 70 years or older. Importantly, there was an association observed between the 'red meat and protein alternatives' pattern and cancer development and death. If these findings are confirmed then dietary guidelines for older adults may require further revision.

A systematic review to evaluate the effectiveness of carnitine supplementation in improving walking performance among individuals with intermittent claudication.

OBJECTIVE: To evaluate the evidence for the use of carnitine supplementation in improving walking performance among individuals with intermittent claudication. DESIGN: Systematic review. METHODS: An electronic search of the literature was performed using MEDLINE (PubMed), Scopus, Cochrane Central Register of Controlled Trials and The Cochrane Library from inception through to November 2012. Search terms included peripheral arterial disease, intermittent claudication and carnitine. Reference lists of review articles and primary studies were also examined. Full reports of published experimental studies including randomized controlled trials and pre-test/post-test trials were selected for inclusion. A quality assessment was undertaken according to the Jadad scale. RESULTS: A total of 40 articles were retrieved, of which 23 did not meet the inclusion criteria. The 17 included articles reported on a total of 18 experimental studies of carnitine supplementation (5 pre-test/post-test; 8 parallel RCT; 5 cross-over RCT) for improving walking performance in adults with intermittent claudication. For pre-test/post-test studies, 300-2000 mg propionyl-L-carnitine (PLC) was administered orally or intravenously for a maximum of 90 days (7-42 participants) with statistically significant improvements of between 74 m and 157 m in pain free walking distance and between 71 m and 135 m in maximal walking distance across 3 out of 5 studies. Similarly, PLC (600 mg-3000 mg) was administered orally in 7 out of 8 parallel RCTs (22-485 participants), the longest duration being 12 months. All but one of the smallest trials demonstrated statistically significant improvements in walking performance between 31 and 54 m greater than placebo for pain free walking distance and between 9 and 86 m greater than placebo for maximal walking distance. A double-blind parallel RCT of cilostazol plus 2000 mg oral L-carnitine or placebo for 180 days (145 participants) did not demonstrate any significant improvement in walking performance. Of 5 cross-over RCTs (8-20 participants), 4 demonstrated significant improvements in walking performance following administration of 300-6000 mg L-carnitine or PLC. Compared to placebo, pain free walking distance and maximal walking distance improved by 23-132 m and 104 m respectively following carnitine intervention. CONCLUSIONS: Most trials demonstrated a small or modest improvement in walking performance with administration of PLC or L-carnitine. These findings were largely independent of level or quality of evidence, while there was some evidence that intravenous administration was more effective than oral administration and those with severe claudication may achieve greater benefits than those with moderate claudication. Routine carnitine supplementation in the form of PLC may therefore be a useful adjunct therapy for management of intermittent claudication. Further research is warranted to determine the optimal form, duration, dose and safety of carnitine supplementation across the spectrum of peripheral arterial disease severity and its effect with concurrent supervised exercise programs and best medical therapy. These studies should be supplemented with cost effectiveness studies to ensure that the return on the investment is acceptable.

A 3-year follow-up study of inpatients with lower limb ulcers: evidence of an obesity paradox?

OBJECTIVES: To determine whether body composition is related to long-term outcomes amongst vascular inpatients with lower limb ulcers. DESIGN: Prospective study with 3 years follow-up. MATERIALS AND METHODS: Body mass index (BMI), fat, and fat-free mass were measured and associations with readmission to hospital (number, cause, length of stay) and all-cause mortality were explored. RESULTS: Thirty patients (22 men, 8 women) participated in the study. Ten patients (33%) had a BMI ≥ 30 kg/m(2). 18/20 (90%) patients with a BMI < 30 kg/m(2) and 9/10 (90%) patients with a BMI ≥ 30 kg/m(2) were admitted to hospital in the 3 years of follow-up. Patients with a BMI < 30 kg/m(2) were admitted more frequently, earlier and for longer compared to those with BMI ≥ 30 kg/m(2) but these did not reach statistical significance. The 3 year mortality rate for patients with BMI ≥ 30 kg/m(2) was 20% (n = 2/10) compared to 70% (n = 14/20) with a BMI < 30 kg/m(2), P = 0.019. CONCLUSION: This preliminary study suggests that higher BMI may have a protective effect against mortality in vascular patients with lower limb ulcers. These findings contradict the universal acceptance that obesity leads to poor health outcomes. Further work is required to confirm these findings and explore some of the potential mechanisms for this effect.