Treatment of Chronic Insomnia in Adults.

Insomnia affects 30% of the U.S. population, with 5% to 15% meeting criteria for chronic insomnia. It can negatively impact quality of life, decrease productivity, increase fatigue and drowsiness, and put patients at higher risk of developing other health problems. Initial treatment focuses on nonpharmacologic therapies such as cognitive behavior therapy, which improves negative thought patterns and behaviors through sleep restriction, stimulus control, and relaxation techniques. Other nonpharmacologic treatments include exercise, mindfulness, and acupuncture. If these approaches are ineffective, pharmacologic agents may be considered. Medications such as benzodiazepines and Z-drugs are often prescribed for insomnia but should be avoided, if possible, due to short- and long-term risks associated with their use. Melatonin receptor agonists are safer and well tolerated but have limited effectiveness. Dual orexin receptor antagonists are effective in patients who have sleep maintenance insomnia or difficulty with sleep onset. Evidence for the use of antihistamines to treat insomnia is generally lacking, but doxylamine is effective for up to four weeks.

Temporomandibular Disorders: Rapid Evidence Review.

Temporomandibular disorders affect between 5% and 12% of the population and present with symptoms such as headache, bruxism, pain at the temporomandibular joint, jaw popping or clicking, neck pain, tinnitus, dizziness, decreased hearing, and hyperacuity to sound. Common signs on physical examination include tenderness of the pterygoid muscles, temporomandibular joints, and temporalis muscles, and malocclusion of the jaw and crepitus. The diagnosis is based on history and physical examination; however, use of computed tomography or magnetic resonance imaging is recommended if the diagnosis is in doubt. Nonpharmacologic therapy includes patient education (e.g., good sleep hygiene, soft food diet), cognitive behavior therapy, and physical therapy. Pharmacologic therapy includes nonsteroidal anti-inflammatory drugs, cyclobenzaprine, tricyclic antidepressants, and gabapentin. Injections of the temporomandibular joints with sodium hyaluronate, platelet-rich plasma, and dextrose prolotherapy may be considered, but the evidence of benefit is weak. A referral to oral and maxillofacial surgery is indicated for refractory cases.

Specialized oral nutritional supplement (ONS) improves handgrip strength in hospitalized, malnourished older patients with cardiovascular and pulmonary disease: A randomized clinical trial.

BACKGROUND & AIMS: Oral Nutritional Supplements (ONS) are used to treat malnutrition and improve clinical outcomes in malnourished patients. Poor handgrip strength (HGS) is associated with an increased risk of mortality, disability and other adverse health consequences. This analysis examined the effect of a specialized ONS on HGS and its relationship to nutritional status in hospitalized, older adults with malnutrition who were participants in the NOURISH trial. METHODS: We enrolled older (≥65years), malnourished (Subjective Global Assessment [SGA] class B/C) adults hospitalized for cardiovascular and pulmonary events: congestive heart failure, acute myocardial infarction, pneumonia and/or chronic obstructive pulmonary disease exacerbation in a double-blind, randomized, placebo-controlled trial (NOURISH study). During hospitalization and until 90 days after discharge, participants received standard-of-care plus a high protein and beta-hydroxy-beta-methylbutyrate containing ONS (S-ONS; n = 328) or a placebo supplement (n = 324), aimed at 2 servings/day. HGS was evaluated by dynamometer at baseline, hospital discharge, day (d) 30, d60, and d90 post-discharge. RESULTS: Post hoc, repeated measures analysis of data at discharge, d30, d60, and d90 showed significantly higher HGS in the S-ONS vs. the placebo group in the evaluable group (Least Squares Means ± Standard Error: (23.25 ± 0.25 vs. 22.63 ± 0.25, p = 0.043). At d90, there was a significant positive association between HGS and nutritional status (SGA) improvements in the entire cohort: 49% of participants with increased HGS from discharge had improved nutritional status versus 31% with unchanged or decreased HGS (p = 0.003). HGS and the scores on the Katz index of independence in activities of daily living (ADL) were positively associated at all visits including all ITT subjects (Pearson's r range: 0.24 to 0.34, all p < 0.0001). CONCLUSIONS: S-ONS provided during hospitalization and up to 90 days post-discharge improves HGS in malnourished older adults following cardiovascular and pulmonary events and may contribute to improvement in patients' overall recovery. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.gov NCT01626742.

Reduced mortality risk in malnourished hospitalized older adult patients with COPD treated with a specialized oral nutritional supplement: Sub-group analysis of the NOURISH study.

BACKGROUND: Hospitalized, malnourished older adults with chronic obstructive pulmonary disease (COPD) have an elevated risk of readmission and mortality. OBJECTIVE: Post-hoc, sub-group analysis from the NOURISH study cohort examined the effect of a high-protein oral nutritional supplement (ONS) containing HMB (HP-HMB) in malnourished, hospitalized older adults with COPD and to identify predictors of outcomes. METHODS: The NOURISH study (n = 652) was a multicenter, randomized, placebo-controlled, double-blind trial. The COPD subgroup (n = 214) included hospitalized, malnourished (based on Subjective Global Assessment), older adults (≥65 y), with admission diagnosis of COPD who received either standard-of-care plus HP-HMB (n = 109) or standard-of-care and a placebo supplement (n = 105) prescribed 2 servings/day from within 3 days of hospital admission (baseline) and up to 90 days after discharge. The primary study outcome was a composite endpoint of incidence of death or non-elective readmission up to 90-day post-discharge, while secondary endpoints included changes in hand-grip strength, body weight, and nutritional biomarkers over time. Categorical outcomes were analyzed using Cochran-Mantel-Haenszel tests, longitudinal data by repeated measures analysis of covariance; and changes from baseline by analysis of covariance. p-values ≤ 0.05 were considered statistically significant. Multivariate logistic regression was used to model predictors of the primary outcome and components. RESULTS: In patients with COPD, 30, 60, and 90-day hospital readmission rate did not differ, but in contrast, 30, 60, and 90-day mortality risk was approximately 71% lower with HP-HMB supplementation relative to placebo (1.83%, 2.75%, 2.75% vs. 6.67%, 9.52% and 10.48%, p = 0.0395, 0.0193, 0.0113, resp.). In patients with COPD, compared to placebo, intake of HP-HMB resulted in a significant increase in handgrip strength (+1.56 kg vs. -0.34 kg, p = 0.0413) from discharge to day 30; increased body weight from baseline to hospital discharge (0.66 kg vs. -0.01 kg, p < 0.05) and, improvements in blood nutritional biomarker concentrations. The multivariate logistic regression predictors of the death, readmission or composite endpoints in these COPD patients showed that participants who were severely malnourished (p = 0.0191) and had a Glasgow prognostic score (GPS) Score of 1 or 2 had statistically significant odds of readmission or death (p = 0.0227). CONCLUSIONS: Among malnourished, hospitalized patients with COPD, supplementation with HP-HMB was associated with a markedly decreased mortality risk, and improved handgrip strength, body weight, and nutritional biomarkers within a 90-day period after hospital discharge. This post-hoc, subgroup analysis highlights the importance of early identification of nutritional risk and administration of high-protein ONS in older, malnourished patients with COPD after hospital admission and continuing after hospital discharge.

Readmission and mortality in malnourished, older, hospitalized adults treated with a specialized oral nutritional supplement: A randomized clinical trial.

BACKGROUND: Hospitalized, malnourished older adults have a high risk of readmission and mortality. OBJECTIVE: Evaluation of a high-protein oral nutritional supplement (HP-HMB) containing beta-hydroxy-beta-methylbutyrate on postdischarge outcomes of nonelective readmission and mortality in malnourished, hospitalized older adults. DESIGN: Multicenter, randomized, placebo-controlled, double-blind trial. SETTING: Inpatient and posthospital discharge. PATIENTS: Older (≥65 years), malnourished (Subjective Global Assessment [SGA] class B or C) adults hospitalized for congestive heart failure, acute myocardial infarction, pneumonia, or chronic obstructive pulmonary disease. INTERVENTIONS: Standard-of-care plus HP-HMB (n = 328) or a placebo supplement (n = 324), 2 servings/day. MEASUREMENTS: Primary composite endpoint was 90-day postdischarge incidence of death or nonelective readmission. Other endpoints included 30- and 60-day postdischarge incidence of death or readmission, length of stay (LOS), SGA class, body weight, and activities of daily living (ADL). RESULTS: The primary composite endpoint was similar between HP-HMB (26.8%) and placebo (31.1%). No between-group differences were observed for 90-day readmission rate, but 90-day mortality was significantly lower with HP-HMB relative to placebo (4.8% vs. 9.7%; relative risk 0.49, 95% confidence interval [CI], 0.27 to 0.90; p = 0.018). The number-needed-to-treat to prevent 1 death was 20.3 (95% CI: 10.9, 121.4). Compared with placebo, HP-HMB resulted in improved odds of better nutritional status (SGA class, OR, 2.04, 95% CI: 1.28, 3.25, p = 0.009) at day 90, and an increase in body weight at day 30 (p = 0.035). LOS and ADL were similar between treatments. LIMITATIONS: Limited generalizability; patients represent a selected hospitalized population. CONCLUSIONS: Although no effects were observed for the primary composite endpoint, compared with placebo HP-HMB decreased mortality and improved indices of nutritional status during the 90-day observation period. CLINICAL TRIAL REGISTRATION: www.ClinicalTrials.govNCT01626742.

Tea and coffee consumption and MRSA nasal carriage.

PURPOSE: Hot tea and coffee have been found to have antimicrobial properties. The purpose of this study was to determine whether the consumption of tea, coffee, or both is associated with less frequent nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). METHODS: We performed a secondary analysis of data from the 2003-2004 National Health and Nutrition Examination Survey to investigate the relationship between the consumption of coffee, hot tea, cold tea, and soft drinks, and MRSA nasal carriage among the noninstitutionalized population of the United States. RESULTS: An estimated 2.5 million persons (1.4% of the population) were MRSA nasal carriers. In an adjusted logistic regression analysis controlling for age, race, sex, poverty-income ratio, current health status, hospitalization in the past 12 months, and use of antibiotics in the past month, individuals who reported consuming hot tea were one-half as likely to have MRSA nasal carriage relative to individuals who drank no hot tea (odds ratio = 0.47; 95% confidence interval, 0.31-0.71). Similarly, individuals who reported consuming coffee had about a one-half reduction in the risk of MRSA nasal carriage relative to individuals who drank no coffee (odds ratio = 0.47; 95% confidence interval, 0.24-0.93). CONCLUSIONS: Consumption of hot tea or coffee is associated with a lower likelihood of MRSA nasal carriage. Our findings raise the possibility of a promising new method to decrease MRSA nasal carriage that is safe, inexpensive, and easily accessible.

Vitamin D and methicillin-resistant Staphylococcus aureus nasal carriage.

Studies have found that vitamin D plays an important role in mediating immune function via a number of pathways, including enhancing the release of antimicrobial peptides in the skin. Given these findings, we hypothesize that low serum vitamin D levels may increase the risk of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA). A secondary data analysis of the National Health and Nutrition Examination Survey 2001-2004 was performed to investigate the association between serum vitamin D levels and MRSA nasal carriage for the non-institutionalized population of the USA. An estimated 2.7 million persons (1.2% of the population) are MRSA nasal carriers. An estimated 63.3 million persons (28.4% of the population) are vitamin D deficient (serum vitamin D <20 ng/ml). In an adjusted logistic regression analysis controlling for age, race, gender, poverty income ratio, current health status, hospitalization in the past 12 months, and antibiotic use in the past month, individuals with vitamin D deficiency had a statistically significant increased risk of MRSA carriage of 2.04 (95% CI 1.09-3.84). Vitamin D deficiency is associated with an increased risk of MRSA nasal carriage. Further trials may be warranted to determine whether vitamin D supplementation decreases the risk of MRSA colonization.

The association between onion consumption and bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older.

OBJECTIVE: The aim of this study was to determine whether frequent onion consumption is associated with increased bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older. METHODS: An analysis of the National Health and Nutrition Examination Survey 2003-2004 was performed. Perimenopausal and postmenopausal non-Hispanic white female participants (unweighted N = 507; weighted N = 35.7 million) were divided into those who consumed onions less than once a month, twice a month to twice a week, three to six times a week, and once a day or more based on self-reported dietary history. All study participants underwent total body dual-energy x-ray absorptiometry. RESULTS: After controlling for age, body mass index, daily calcium intake, serum vitamin D, serum parathyroid hormone, estrogen use, smoking status, and exercise status, bone density increased as the frequency of onion consumption increased. Individuals who consumed onions once a day or more had an overall bone density that was 5% greater than individuals who consumed onions once a month or less (P < 0.03). CONCLUSIONS: Onion consumption seems to have a beneficial effect on bone density in perimenopausal and postmenopausal non-Hispanic white women 50 years and older. Furthermore, older women who consume onions most frequently may decrease their risk of hip fracture by more than 20% versus those who never consume onions.