Effect of a 12-week home-based exercise training program on aerobic capacity, muscle mass, liver and spleen stiffness, and quality of life in cirrhotic patients: a randomized controlled clinical trial.

BACKGROUND: Physical inactivity and sarcopenia are two important predictors associated with increased morbidity and mortality in patients with cirrhosis. At present, the benefit of a home-based exercise training program is not well established in cirrhotic patients. The main objective of this study was to evaluate the effect of a 12-week home-based exercise training program on aerobic capacity in cirrhotic patients. METHODS: This is a randomized controlled study. Patients with compensated cirrhosis were randomized by a block of 4 with concealed allocation to the home-based exercise training (n = 20) or control (n = 20). Both groups received protein supplementation (9 g/day) for 12 weeks. The home-based exercise training program included several aerobic/isotonic moderate-intensity continuous training exercises for 40 min per session, at least four times a week, with a total duration of 12 weeks. The heart rate was continuously monitored using a Garmin® watch. In the control group, patients received exercise instruction without active encouragement and continuous monitoring. The primary outcome was a change in the 6-min walk test from baseline. Secondary outcomes were the difference in thigh muscle thickness, liver stiffness, spleen stiffness, and quality of life. RESULTS: A total of 40 patients were enrolled prospectively. The mean age was 56.3 ± 7.8 years, with a male predominance of 65%. The mean body mass index was 25.23 ± 3.0 kg/m2, and all were Child-Pugh A. Chronic hepatitis B or C was the primary cause of cirrhosis. The baseline values were a 6-min walk test of 475 ± 70 m, liver stiffness of 15.3 ± 9.3 kPa, spleen stiffness of 29.8 ± 21.7 kPa, and thigh muscle thickness (average compression index) of 0.64 ± 0.2 cm/m2. All baseline characteristics between the two groups were not different except the mean muscle mass which was significantly higher in the home-based exercise training group (p = 0.03, 95% CI 0.01 to 0.17). At the end of the study, no significant difference in the 6-min walk test was observed (p = 0.36, 95% CI -15.5 to 41.7). Liver stiffness measurement significantly improved in both groups, but no significant difference between groups was demonstrated (p = 0.77, 95% CI -1.3 to 1.8). Thigh muscle thickness was not different between groups. The fatigue domain of the quality of life index was significantly improved in the home-based exercise training group compared with the control group (p = 0.05, 95% CI 0.00 to 0.67). No adverse events occurred in a home-based exercise training program. CONCLUSIONS: A 12-week moderate-intensity home-based exercise training program in compensated cirrhotic patients significantly improved the fatigue domain of the quality of life index without an increase in adverse events. However, no benefit in terms of aerobic capacity, thigh muscle mass, liver stiffness, and spleen stiffness was demonstrated. TRIAL REGISTRATION: Thai Clinical Trials Registry number TCTR20190926002, 26/09/2019 (Retrospectively registered).

A high-protein peptide-based enteral formula improves diarrhea in tube-fed patients: A prospective multicenter study.

BACKGROUND: Diarrhea is a common problem in tube-fed patients. The relevant guidelines suggest using a peptide-based enteral formula in patients with diarrhea; however, sufficient evidence to support this recommendation is currently lacking. AIM: This study aimed to evaluate the effects of a high-protein peptide-based formula on gastrointestinal intolerance, mainly focusing on diarrhea symptoms in patients who were intolerant to polymeric formula feeding. METHODS: This prospective, single-arm, open-label, multicenter study was conducted from March 2021 to March 2022 at two tertiary-care hospitals. Patients who presented with diarrhea during tube feeding with polymeric formula were assigned to receive a high-protein peptide-based formula for ≤7 days. Stool weight and frequency were monitored at baseline, on day 3, and on day 7 (or end of the study) as the primary outcomes. RESULTS: Twenty-eight tube-fed patients with diarrhea were recruited. After switching their feeding formula from polymeric to peptide based, significant improvements in stool frequency and stool weight were observed on day 3 and day 7 compared with the baseline (median [IQR] stool frequency: 5 (2), 2.5 (3.5), and 3 (3) times/day, respectively, p <0.001; median stool weight: 500 (370), 170 (285), and 275 (385) gram/day, respectively, p = 0.015). Stool consistency was assessed using the Bristol Stool Score and showed significant improvement with time. No serious adverse events were reported. CONCLUSION: A high-protein peptide-based enteral formula was effective in reducing stool weight and frequency in patients who experienced diarrhea during tube feeding with a polymeric formula.Trial registration: TCTR20210302006.

Physician awareness, preparedness, and opinions toward consumer-initiated genetic testing in Thailand: Views from a changing landscape.

Consumer-initiated genetic tests have captured public interest in recent years, including in low-to-middle-income countries (LMICs) such as Thailand. Due to limited resources and personnel, physicians will most likely bear the burden of increasing service needs from the public as consumer-initiated genetic tests become popularized. The primary objective of this study was to describe (a) awareness, (b) preparedness to provide counseling about the consumer-initiated genetic test, and (c) opinions on the usefulness of consumer-initiated genetic tests among physicians at an academic hospital in Bangkok, Thailand. The secondary objective was to describe factors that were associated with the awareness, preparedness, and opinion of the participants. Paper questionnaires were sent out to participants which included internal medicine residents, fellows, and faculty staff members. The questionnaires assessed awareness, preparedness to discuss consumer-initiated genetic test results, and opinion on the usefulness of consumer-initiated genetic tests and included both closed- and open-ended questions. Responses were anonymous. Among 308 participants, there were 223 (72.4%) residents, 14 (4.5%) fellows, and 71 (23.1%) staff members. Only 15% of participants were aware of consumer-initiated genetic tests, mostly from the internet, and only 7% were prepared to provide counseling regarding consumer-initiated genetic tests. However, 60% agreed that consumer-initiated genetic tests may be clinically useful. Many participants, including trainees, expressed concerns about the interpretation of consumer-initiated genetic test results, application into clinical practice, appropriate counseling, and patient referral to geneticists. Multivariate logistic regression revealed that years of work experience was independently associated with awareness of consumer-initiated genetic tests, while male gender and less work experience were independently associated with favorable opinion toward the usefulness of consumer-initiated genetic tests. Our results pointed to an urgent need for genetic counselors in Thailand. Also, physicians, particularly trainees, need appropriate training to prepare them for a rapidly evolving environment where consumer-initiated genetic tests become commonplace.

Effects of meal replacement therapy on metabolic outcomes in Thai patients with type 2 diabetes: A randomized controlled trial.

BACKGROUND: A meal replacement (MR) with a low glycemic index (GI) is possibly beneficial for glycemic control. However, the effects of MR on diabetes mellitus have not been studied among Thai patients with type 2 diabetes (T2DM). AIM: To compare metabolic outcomes between T2DM patients receiving the new MR formula (ONCE PRO) and normal controlled diets. METHODS: A multicenter, open-labeled, randomized controlled trial was conducted. Eligible patients received either ONCE PRO for one meal daily with controlled diets or only controlled diets for 3 months. The differences in metabolic profile between the baseline and end point of each group and between groups were measured. RESULTS: 110 participants were enrolled; the mean difference and standard deviation in hemoglobin A1C (HbA1c) (%) from baseline were -0.21 ± 0.78 (p = 0.060) and -0.27 ± 0.60 (p = 0.001) in the MR and control groups, respectively; however, there was no significant difference between groups (p = 0.637). Patients consuming a MR instead of breakfast had a significant decrease in HbA1c (p = 0.040). Body weight (BW) and body mass index (BMI) were significantly reduced in both groups. There were no significant change in waist circumference, fasting plasma glucose, total cholesterol and triglycerides. Low-density lipoprotein cholesterol (LDL-C) was significantly decreased in the MR group compared with the control group (p = 0.049). CONCLUSIONS: Short-term conventional diet control and the low-GI MR product were associated with a decreased BW and BMI. Changes in the other metabolic outcomes, HbA1c, total cholesterol and triglycerides, were comparable despite ONCE PRO as the MR having a better effect on LDL-C lowering.

FAT-FREE MASS, METABOLICALLY HEALTHY OBESITY, AND TYPE 2 DIABETES IN SEVERELY OBESE ASIAN ADULTS.

OBJECTIVE: To determine whether fat free mass (FFM) is independently associated with the metabolically healthy obesity (MHO) phenotype, the metabolic syndrome (MS), and type 2 diabetes (T2D) in obese Asian adults. METHODS: Obese patients (body mass index [BMI] ≥25 kg/m2) seeking weight management at an academic medical center from 2007 to 2016 were included. FFM was measured by bioelectrical impedance. RESULTS: Of the 552 patients (67.0% female, median age 40.5 years, median BMI 38.3 kg/m2), MHO was present in 19%, MS in 55.4%, and T2D in 32.6%. In multivariate models, higher fat-free mass index (FFMI) was independently associated with the metabolically abnormal obesity (MAO) phenotype, (odds ratio [OR] 1.22, 95% confidence interval [CI] 1.09-1.37), and increased risk of MS (OR 1.12, 95% CI 1.03-1.22) in women but not in men. Older age was independently associated with the MAO phenotype (OR 1.06, 95% CI 1.04-1.09 in women; OR 1.06, 95% CI 1.02-1.09 in men), MS (OR 1.05, 95% CI 1.03-1.06 in women; OR 1.05, 95% CI 1.02-1.07 in men), and T2D (OR 1.07, 95% CI 1.05-1.09 in women; OR 1.06, 95% CI 1.04-1.09 in men). Waist-hip ratio was independently associated with the MAO phenotype in men (OR 1.08, 95% CI 1.01-1.15), while waist circumference was associated with T2D in women (OR 1.03, 95% CI 1.01-1.05). CONCLUSION: Older age, central fat distribution, and-in contrast to previous findings-an increase in FFMI among women were independent predictors of adverse metabolic health in this cohort of middle-aged obese Asian adults. Further studies are required to elucidate underlying mechanisms and therapeutic implications of these findings. ABBREVIATIONS: BIA = bioelectrical impedance analysis BMI = body mass index CI = confidence interval DXA = dual-energy X-ray absorptiometry FFM = fat-free mass FFMI = fat-free mass index FM = fat mass HbA1c = glycated hemoglobin A1c MAO = metabolically abnormal obesity MHO = metabolically healthy obesity MS = metabolic syndrome OR = odds ratio T2D = type 2 diabetes WC = waist circumference WHR = waist-hip-ratio.

Deconstructing the roles of glucocorticoids in adipose tissue biology and the development of central obesity.

Central obesity is associated with insulin resistance and dyslipidemia. Thus, the mechanisms that control fat distribution and its impact on systemic metabolism have importance for understanding the risk for diabetes and cardiovascular disease. Hypercortisolemia at the systemic (Cushing's syndrome) or local levels (due to adipose-specific overproduction via 11ß-hydroxysteroid dehydrogenase 1) results in the preferential expansion of central, especially visceral fat depots. At the same time, peripheral subcutaneous depots can become depleted. The biochemical and molecular mechanisms underlying the depot-specific actions of glucocorticoids (GCs) on adipose tissue function remain poorly understood. GCs exert pleiotropic effects on adipocyte metabolic, endocrine and immune functions, and dampen adipose tissue inflammation. GCs also regulate multiple steps in the process of adipogenesis. Acting synergistically with insulin, GCs increase the expression of numerous genes involved in fat deposition. Variable effects of GC on lipolysis are reported, and GC can improve or impair insulin action depending on the experimental conditions. Thus, the net effect of GC on fat storage appears to depend on the physiologic context. The preferential effects of GC on visceral adipose tissue have been linked to higher cortisol production and glucocorticoid receptor expression, but the molecular details of the depot-dependent actions of GCs are only beginning to be understood. In addition, increasing evidence underlines the importance of circadian variations in GCs in relationship to the timing of meals for determining their anabolic actions on the adipocyte. In summary, although the molecular mechanisms remain to be fully elucidated, there is increasing evidence that GCs have multiple, depot-dependent effects on adipocyte gene expression and metabolism that promote central fat deposition. This article is part of a Special Issue entitled: Modulation of Adipose Tissue in Health and Disease.

Type 2 diabetes in children and adolescents on atypical antipsychotics.

Youth receiving treatment with antipsychotics are particularly susceptible to weight gain, type 2 diabetes (T2D), and associated metabolic disorders, which is directly associated with excess morbidity and mortality in this vulnerable population. The risk of T2D is 2- to 3-fold that of the general population, starts early in the course of treatment, and reflects the effects of weight gain in conjunction with direct effects of antipsychotics on the hypothalamus, pancreatic beta cells, and insulin-sensitive peripheral tissues. Close monitoring with early intervention through lifestyle intervention, switching away from antipsychotics with deleterious metabolic effects, and adjunctive treatment with metformin are modalities available to mitigate weight gain and improve cardiometabolic health in these patients. Despite rapidly advancing knowledge in the field, patient's access to metabolic screening and quality care remains limited. Efforts must be made to broaden reach of early cardiometabolic intervention among these patients in order to avert serious cardiovascular disease burden in the future.

The effectiveness of holistic diabetic management between Siriraj Continuity of Care clinic and medical out-patient department.

BACKGROUND: Diabetes mellitus is one of the most common diseases in the Thai population, and it is well known that diabetic complications could be prevented with appropriate management. Despite published guidelines, most Thai patients with diabetes do not achieve treatment goals. Siriraj Continuity of Care clinic (CC clinic) was recently established in order to provide training for medical students and internal medicine residents. It is possible that the training component in the CC clinic may contribute to better overall outcomes in type 2 diabetes mellitus (type 2 DM) patients when compared with usual care at the medical out-patient department (OPD). OBJECTIVE: To compare the effectiveness of diabetic management in type 2 diabetes mellitus patients who attended the CC clinic and the medical OPD. MATERIAL AND METHOD: Retrospective chart review was performed in type 2 diabetes mellitus patients who were treated at either clinic at Siriraj Hospital in 2007-2011. Baseline demographics, treatment strategies and outcomes, and participation in an appropriate health maintenance program were assessed in both groups. RESULTS: Seven hundred and fifty seven medical records were reviewed, including 383 patients in the CC clinic group and 374 in the OPD group. Mean HbA1c was significantly lower in the CC clinic group compared with the OPD group (7.3 +/- 0.9% and 7.8 +/- 1.3%, respectively, < 0.001). The number of patients who achieved goal HbA1c of less than 7% in CC clinic group was 123 (32.1%) compared with 91 (24.3%) in the OPD group (p = 0.039). More patients were screened for diabetic complications in the CC clinic group compared with the OPD group, including screening for diabetic neuropathy (57.4% vs. 2.1%, p < 0.001), diabetic retinopathy (56.7% vs. 36.6%, p < 0.001), and diabetic nephropathy (80.9% vs. 36.9%, p < 0.001). Patients in the CC clinic group had a higher rate of age-appropriate cancer screening than those in the OPD group (54.2% vs. 13.3%, p < 0.001 for breast cancer; 24.0% vs. 0.9%, p < 0.001 for cervical cancer; and 23.0% vs. 7.4%, p < 0.001 for colon cancer). Moreover, significantly more patients in the CC clinic group received recommended immunization (influenza, diphtheria tetanus and pneumococcal vaccine) compared with the control group (p < or = 0.001). CONCLUSION: Diabetic patients treated at the CC clinic had better clinical outcomes and healthcare maintenance compared with those who received usual care at the medical OPD. Continuity of care and integrated training component may have contributed to the improved outcomes.

The association between sarcopenia, defined by a simplified screening tool, and long-term outcomes.

BACKGROUND: Sarcopenia and frailty are frequently observed in older adult patients and linked to unfavorable postoperative outcomes. Identifying low muscle mass and function is primary for diagnosing sarcopenia. The simpler screening, which excludes muscle mass measurement, exhibited strong predictive capabilities in identifying sarcopenia. This research explored the association between sarcopenia, as defined by the C3 formula, and long-term outcomes in older adult cancer patients who underwent surgery. METHODS: Surgical cancer patients aged 60 and older were enrolled. Sarcopenia was identified using the C3 formula, assessing muscle strength through handgrip strength, physical performance via a 6-m walk test, and nutrition status via the Mini Nutritional Assessment-Short Form. Long-term outcomes were evaluated with the Barthel Index for activities of daily living (B-ADL) at 3 months, as well as 1-year mortality rates. RESULTS: The study enrolled 251 patients, with 130 classified as sarcopenic according to the C3 formula. Compared with nonsarcopenic patients, patients with sarcopenia exhibited a higher frequency of moderate to severe disability (B-ADL ≤70) 3 months postdischarge (19.5% vs 5.2%; P = 0.001) and elevated 1-year mortality rates (29.5% vs 14.9%; P = 0.006). No significant differences were observed in infection rates, hospital stay duration, or in-hospital mortality. Distant organ metastasis (HR = 3.99; 95% CI = 2.25-7.07) and sarcopenia defined by the C3 formula (HR = 1.78; 95% CI = 1.01-3.15) were identified as independent risk factors for 1-year mortality. CONCLUSION: The simplified sarcopenia screening tool was associated with increased rates of moderate to severe disability 3 months postdischarge and higher 1-year mortality rates compared with nonsarcopenic patients.

Effectiveness of a cognitive behavioral therapy-integrated, hospital-based program for prediabetes: a matched cohort study.

Intensive lifestyle interventions are effective in preventing T2DM, but evidence is lacking for high cardiometabolic individuals in hospital settings. We evaluated a hospital-based, diabetes prevention program integrating cognitive behavioral therapy (CBT) for individuals with prediabetes. This matched cohort assessed individuals with prediabetes receiving the prevention program, which were matched 1:1 with those receiving standard care. The year-long program included five in-person sessions and several online sessions covering prediabetes self-management, dietary and behavioral interventions. Kaplan-Meier and Cox regression models estimated the 60-month T2DM incidence rate. Of 192 patients, 190 joined the prevention program, while 190 out of 10,260 individuals were in the standard-care group. Both groups had similar baseline characteristics (mean age 58.9 ± 10.2 years, FPG 102.3 ± 8.2 mg/dL, HbA1c 5.9 ± 0.3%, BMI 26.2 kg/m2, metabolic syndrome 75%, and ASCVD 6.3%). After 12 months, the intervention group only showed significant decreases in FPG, HbA1c, and triglyceride levels and weight. At 60 months, the T2DM incidence rate was 1.7 (95% CI 0.9-2.8) in the intervention group and 3.5 (2.4-4.9) in the standard-care group. After adjusting for variables, the intervention group had a 0.46 times lower risk of developing diabetes. Therefore, healthcare providers should actively promote CBT-integrated, hospital-based diabetes prevention programs to halve diabetes progression.

Alteration of BDNF, SPARC, FGF-21, and GDF-15 circulating levels after 1 year of anti-obesity treatments and their association with 1-year weight loss.

PURPOSE: Emerging evidence revealed that brain-derived neurotrophic factor (BDNF), secreted protein acidic and rich in cysteine (SPARC), fibroblast growth factor 21(FGF-21) and growth differentiation factor 15 (GDF-15) are involved in energy metabolism and body weight regulation. Our study aimed at examining their association with BMI, their alterations after anti-obesity treatments, and their association with 1-year weight loss. METHODS: A prospective observational study of 171 participants with overweight and obesity and 46 lean controls was established. All participants received lifestyle educational intervention (LEI) with or without anti-obesity treatments (LEI + bariatric/metabolic surgery, n = 41; LEI + topiramate, n = 46; LEI + liraglutide, n = 31; LEI + orlistat, n = 12; and LEI alone, n = 41). Anthropometric and metabolic parameters, insulin sensitivity, C-reactive protein (CRP), fasting plasma levels of BDNF, SPARC, GDF-15, and FGF-21 were measured at baseline and 1 year. RESULTS: Multiple linear regression showed that fasting levels of SPARC, FGF-21, and GDF-15 were significantly associated with baseline BMI after adjustment for age and sex. At 1 year, the average weight loss was 4.8% in the entire cohort with a significant improvement in glycemia, insulin sensitivity, and CRP. Multiple linear regression adjusted for age, sex, baseline BMI, type of treatment, and presence of T2DM revealed that the decrease in log10FGF-21 and log10GDF-15 at 1 year from baseline was significantly associated with a greater percentage of weight loss at 1 year. CONCLUSIONS: This study highlights the association of SPARC, FGF-21, and GDF-15 levels with BMI. Decreased circulating levels of GDF-15 and FGF-21 were associated with greater weight loss at 1 year, regardless of the types of anti-obesity modalities.

Performance of a simplified nutrition screening tool for outpatient radiotherapy cancer patients.

Public hospitals in Thailand recently adopted a new nutrition screening tool to satisfy documentation requirements for reimbursements through the diagnosis-related group system. However, data on the performance of this instrument remains limited. This study was designed to assess the validity and cutoff points of the Society of Parenteral and Enteral Nutrition of Thailand (SPENT) nutrition screening tool against the patient-generated subjective global assessment (PG-SGA) and malnutrition diagnostic criteria proposed by the global leadership initiative on malnutrition (GLIM) in cancer patients receiving outpatient radiation therapy. A cross-sectional study of 350 patients was conducted from August 2018 to September 2020. All patients were screened for malnutrition using the SPENT nutrition screening tool. The instrument's sensitivity, specificity, positive predictive value, negative predictive value, and agreement were calculated using either the PG-SGA or GLIM malnutrition diagnosis as benchmarks. The cutoff that gave the highest sensitivity and specificity of the SPENT nutrition screening tool was selected. The mean age standard deviation of the 350 cancer patients was 59.9 (13.9) years, and 191 (54.6%) were men. Head and neck cancers were the most common type (35.7%). Against PG-SGA and GLIM malnutrition diagnosis, the SPENT nutrition screening tool demonstrated good sensitivity (85.3% and 82.8%), specificity (84.1% and 59.4%), positive predictive value (90.5% and 64.0%), negative predictive value (76.3% and 79.9%), with moderate strength of agreement (Cohen kappa 0.678, P < .001 and 0.414, P < .001). Using only the first 2 out of 4 questions revealed an acceptable sensitivity and specificity. The SPENT nutrition screening tool is an accurate, sensitive, and specific tool for malnutrition screening in cancer patients receiving outpatient radiotherapy.

Effects of a novel rice-based diabetes-specific formula on postprandial glucose and gastrointestinal hormones: a double-blinded multi-arm randomized crossover trial.

Introduction: We developed a novel rice-based medical food for diabetes (MFDM) powder formula, using locally available ingredients in Thailand, which can potentially improve patient access to diabetes-specific formula (DSF) by reducing cost and improving availability. Purpose: The goals of our studies were to 1) measure the glycemic index (GI) and glycemic load (GL) of the MFDM powder formula in healthy individuals, and 2) assess postprandial glucose, insulin, satiety, hunger, and gastrointestinal (GI) hormone responses in adults with prediabetes or early type 2 diabetes after consuming MFDM in comparison with a commercially available standard formula (SF) and a DSF. Methods: In Study 1, glycemic responses were assessed using the area under the curve (AUC), which was used to calculate GI and GL. Study 2 was a double-blinded multi-arm randomized crossover trial enrolling participants with either prediabetes or type 2 diabetes of ≤6 years. At each study visit, participants consumed either MFDM, SF, or DSF which contained 25 g of carbohydrates. Hunger and satiety were assessed using a visual analog scale (VAS). Glucose, insulin, and GI hormones were assessed using AUC. Results: All participants tolerated the MFDM well with no adverse events. In Study 1, the measured GI was 39 ± 6 (low GI) and GL was 11 ± 2 (medium GL). In Study 2, glucose and insulin responses were significantly lower after MFDM compared with SF (p-value<0.01 for both), however, those responses were similar between MFDM and DSF. MFDM suppressed hunger, promoted satiety, stimulated active GLP-1, GIP, and PYY, and suppressed active ghrelin although these changes were similar to SF and DSF. Conclusions: MFDM had a low GI and a low-to-medium GL. In people with prediabetes or early type 2 diabetes, MFDM elicited reduced glucose and insulin responses when compared with SF. Rice-based MFDM may be an option for patients who are at risk for postprandial hyperglycemia. Clinical Trial Registration: https://www.thaiclinicaltrials.org/show/TCTR20210731001, identifier TCTR20210731001; https://www.thaiclinicaltrials.org/show/TCTR20210730007, identifier TCTR20210730007.

Diagnosis and outcomes of cachexia in Asia: Working Consensus Report from the Asian Working Group for Cachexia.

Chronic diseases often lead to metabolic disorders, causing anabolic resistance and increased energy consumption, which result in cachexia. Cachexia, in turn, can lead to major clinical consequences such as impaired quality of life, shortened life expectancy, and increased healthcare expenditure. Existing international diagnostic criteria for cachexia employ thresholds derived from Western populations, which may not apply to Asians due to differing body compositions. To address this issue, the Asian Working Group for Cachexia (AWGC) was initiated. The AWGC comprises experts in cachexia research and clinical practice from various Asian countries and aims to develop a consensus on diagnostic criteria and significant clinical outcomes for cachexia in Asia. The AWGC, composed of experts in cachexia research and clinical practice from several Asian countries, undertook three-round Delphi surveys and five meetings to reach a consensus. Discussions were held on etiological diseases, essential diagnostic items for cachexia, including subjective and objective symptoms and biomarkers, and significant clinical outcomes. The consensus highlighted the importance of multiple diagnostic factors for cachexia, including chronic diseases, either or both weight loss or low body mass index, and at least one of the following: anorexia, decreased grip strength (<28 kg in men and <18 kg in women), or elevated C-reactive protein levels (>5 mg/L [0.5 mg/dL]). The AWGC proposed a significant weight change of 2% or more over a 3-6 month period and suggested a tentative cut-off value of 21 kg/m2 for low body mass index in diagnosing cachexia. Critical clinical outcomes were determined to be mortality, quality of life as assessed by tools such as EQ-5D or the Functional Assessment of Anorexia/Cachexia Therapy, and functional status as measured by the Clinical Frailty Scale or Barthel Index, with significant emphasis on patient-reported outcomes. The AWGC consensus offers a comprehensive definition and user-friendly diagnostic criteria for cachexia, tailored specifically for Asian populations. This consensus is set to stimulate future research and enhance the multidisciplinary approach to managing cachexia. With plans to develop further guidelines for the optimal treatment, prevention, and care of cachexia in Asians, the AWGC criteria are expected to drive research across chronic co-morbidities and cancer in Asia, leading to future refinement of diagnostic criteria.

Vitamin D supplementation: guidelines and evidence for subclinical deficiency.

PURPOSE OF REVIEW: To summarize recommendations from the 2011 US Institute of Medicine report (on vitamin D) and the new guideline from the US Endocrine Society with emphasis on treating and preventing vitamin D deficiency, including patients with inflammatory bowel disease and prior gastric bypass. RECENT FINDINGS: The US Institute of Medicine Recommended Dietary Allowance of vitamin D is 400 IU per day for children younger than 1 year of age, 600 IU per day for children at least 1 year of age and adults up to 70 years, and 800 IU per day for older adults. The US Institute of Medicine concluded that serum 25-hydroxyvitamin D [25(OH)D] of 20 ng/ml or more will cover the requirements of 97.5% of the population. The US Endocrine Society's Clinical Practice Guideline suggested that 400-1000 IU per day may be needed for children aged less than 1 year, 600-1000 IU per day for children aged 1 year or more, and 1500-2000 IU per day for adults aged 19 years or more to maintain 25(OH)D above the optimal level of 30 ng/ml. Patients with inflammatory bowel disease even in a quiescent state and those with gastric bypass malabsorb vitamin D and need more vitamin D to sustain their vitamin D status. SUMMARY: Difference in the recommendations from the US Institute of Medicine and the US Endocrine Society's Practice Guideline reflects different goals and views on current evidence. Significant gaps remain in the literature, and studies of vitamin D treatment assessing changes in outcomes at different 25(OH)D levels are needed.

The effect of ultraviolet radiation from a novel portable fluorescent lamp on serum 25-hydroxyvitamin D3 levels in healthy adults with Fitzpatrick skin types II and III.

BACKGROUND/PURPOSE: Ultraviolet (UV) B irradiation may provide a safe and effective method to treat vitamin D deficiency. The objective of this study was to assess the effectiveness of a novel Sperti D/UV-Fluorescent lamp in converting 7-dehydrocholesterol (7-DHC) to previtamin D(3) in vitro and in raising serum 25-hydroxyvitamin D(3) [25(OH)D(3) ] in healthy adults. METHODS: The lamp was assessed in vitro using a 7-DHC solution and a human skin sample. In a prospective cohort study, five healthy adults with skin types II and III were exposed to a 0.75 minimal erythemal dose of UV radiation over ≈ 9% of body surface area three times a week for 4 weeks. The main outcomes were percentage of conversion from 7-DHC to previtamin D(3) in vitro and changes in serum 25(OH)D(3) after irradiation in vivo. RESULTS: A dose response between UV irradiation time and conversion of 7-DHC to previtamin D(3) was seen in the 7-DHC solution and surgically obtained human skin. The subjects had a significant increase in mean 25(OH)D(3) from 18.4 ± 8.2 to 27.3 ± 7.6 ng/ml (P < 0.001) after 4 weeks of irradiation. No adverse events occurred. CONCLUSION: The Sperti D/UV-Fluorescent lamp is effective in converting 7-DHC to previtamin D(3) in vitro and in raising serum 25(OH)D(3) in healthy adults.

Low Fat-Free Mass Index Measured by Bioelectrical Impedance Analysis Correlates With Hematologic Adverse Events in Early-Stage Breast Cancer Patients Receiving Chemotherapy: A Prospective Observational Cohort Study.

Background: Low muscle mass is associated with worse cancer treatment outcomes. Although dual-energy X-ray absorptiometry or computerized tomography-based analysis have both been widely studied in this clinical setting, studies in the use of bioelectrical impedance analysis (BIA) remain limited. The aim of this prospective study was to investigate for association between body composition estimated by BIA and hematologic adverse events in early-stage breast cancer patients receiving chemotherapy. Methods: A total of 144 female patients were enrolled. Before the first cycle of chemotherapy, body weight and fat-free mass were measured by a BIA device and then those values were converted into body mass index and fat-free mass index. Association between fat-free mass index and composite adverse events (CAEs), including grade 4 neutropenia, febrile neutropenia, or relative dose intensity <85%, was explored. Results: CAEs occurred in 85 patients (59%), and point biserial correlation showed an inverse correlation between the fat-free mass index and CAE. No included patients were sarcopenic (fat-free mass index <11.4 kg/m2). Receiver operating characteristic curve analysis revealed <14.85 kg/m2 as the cutoff value indicating a low fat-free mass index. Using this cutoff, 85 patients were classified as having a low fat-free mass index, and 62 of those patients (72.9%) had CAE (relative risk: 1.86, P < .001). After adjusting for other factors, a low fat-free mass index was found to be independently associated with a high CAE (adjusted odds ratio: 4.562, 95% CI: 2.162-9.627, P < .001). Conclusion: Low fat-free mass index is an independent predictor of increased risk of hematologic adverse events in early-stage breast cancer patients receiving chemotherapy. Estimation of fat-free mass index by BIA may identify at-risk patients so that interventions can be considered to improve treatment outcomes.

A report on the first case of vancomycin-intermediate Staphylococcus aureus (VISA) in Hawai'i.

The state of Hawai'i has the highest prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection in the United States. Since vancomycin is the most frequently-prescribed antibiotic for healthcare-associated MRSA infection, there is concern for development of vancomycin resistance. We report on a 61 year-old woman with history of previous successful treatments of MRSA bacteremia with vancomycin. She was later hospitalized for catheter-related MRSA bacteremia that persisted despite vancomycin treatment. The vancomycin minimal inhibitory concentration (MIC) was initially 1-2 µg/ml, suggesting susceptibility, but changed to 4 µg/ml. At this level, the organism was classified as a vancomycin-intermediate Staphylococcus aureus (VISA). Therapy was changed from vancomycin to daptomycin, and the patient's blood cultures were sterilized. High suspicion of VISA should be raised in MRSA-infected patients who fail or have a history of vancomycin therapy so that additional susceptibility testing and appropriate antibiotic therapy can be promptly commenced to reduce the morbidity associated with VISA infection.

A simpler screening tool for sarcopenia in surgical patients.

BACKGROUND: Sarcopenia is defined as decreased skeletal muscle mass and muscle functions (strength and physical performance). Muscle mass is measured by specific methods, such as bioelectrical impedance analysis and dual-energy X-ray absorptiometry. However, the devices used for these methods are costly and are usually not portable. A simple tool to screen for sarcopenia without measuring muscle mass might be practical, especially in developing countries. The aim of this study was to design a simple screening tool and to validate its performance in screening for sarcopenia in older adult cancer patients scheduled for elective surgery. METHODS: Cancer surgical patients aged >60 years were enrolled. Their nutritional statuses were evaluated using the Mini Nutrition Assessment-Short Form. Sarcopenia was assessed using Asian Working Group for Sarcopenia (AWGS) criteria. Appendicular skeletal muscle mass was measured by bioelectrical impedance analysis. Four screening formulas with differing combinations of factors (muscle strength, physical performance, and nutritional status) were assessed. The validities of the formulas, compared with the AWGS definition, are presented as sensitivity, specificity, accuracy, and area under a receiver operating characteristic curve. RESULTS: Of 251 enrolled surgical patients, 84 (34%) were diagnosed with sarcopenia. Malnutrition (odds ratio [OR]: 2.89, 95% CI: 1.40-5.93); underweight status (OR: 2.80, 95% CI: 1.06-7.43); and age increments of 5 years (OR: 1.78, 95% CI: 1.41-2.24) were independent predictors of preoperative sarcopenia. The combination of low muscle strength and/or abnormal physical performance, plus malnutrition/risk of malnutrition had the highest sensitivity, specificity, and accuracy (81.0%, 78.4%, and 79.3%, respectively). This screening formula estimated the probability of sarcopenia with a positive predictive value of 65.4% and a negative predictive value of 89.1%. CONCLUSION: Sarcopenia screening can be performed using a simple tool. The combination of low muscle strength and/or abnormal physical performance, plus malnutrition/risk of malnutrition, has the highest screening performance.

Association between dietary patterns and disease recurrence in Thai colorectal cancer patients.

Beside established anti-cancer treatment, dietary modification is one of the most promising approaches for reducing the probability of colorectal cancer (CRC) recurrence. Many Western studies showed a relationship between shortened survival and increased amounts of Western diet (meat and processed meat). Given that Thai food is dissimilar to Western diet, we aimed to explore the association between dietary patterns and disease recurrence among Thai CRC patients.Early-stage CRC patients who were disease-free at the end of a 2-year period or patients with disease recurrence within 2 years were enrolled. Patients were administered a food frequency questionnaire to evaluate their dietary lifestyle. Quantitative comparison within individual food groups among patients who were disease-free and among those with recurrence was performed. Proportion of patients with recurrence and disease-free survival was compared between patients who had consumed the lowest and highest tertile of each dietary pattern.A total of 225 CRC patients were enrolled (151 disease-free and 74 recurrence). There were no significant differences in demographic or tumor parameters between patients with or without disease recurrence. From the questionnaire, 45 food items were assigned to 1 of 12 food groups according to similarity in nutritional profile. Patients who consumed high amounts of pickled fish or chili-paste had significantly lower recurrence rates compared to patients who had never eaten those foods (P < .01). From the factor analysis, meat/wheat, vegetarian, and fast-food/processed fruit patterns were identified as the major dietary patterns. There was no significant association between intakes of individual dietary patterns and CRC recurrence.Among CRC patients with Thai dietary lifestyles there was no association between meat/wheat, fast-food/processed fruit, or vegetarian dietary patterns and CRC recurrence. Greater consumption of some unique Thai foods, such as chili-paste or pickled fish, may relate to better outcomes for CRC patients.