Maternal and pregnancy predictive risk factors for having a compensated maternal injury claim: a Swedish nationwide cohort study.

To describe trends and identify maternal and pregnancy predictive risk factors for having a compensated claim for a maternal injury during delivery, as a proxy for having received suboptimal care. This nationwide retrospective cohort study included 1 754 869 births in Sweden between 2000 and 2016, including 4488 maternal injury claims filed with The National Swedish Patient Insurance Company (Löf), of which 1637 were compensated. Descriptive statistics on maternal and pregnancy characteristics, trends in filed/compensated claims over time, and distribution of compensated claims by clinical classification are presented. Characteristics associated with suboptimal care were identified using multivariable logistic regression, with mutual adjustment in the final model. Compensated claims were sorted into 14 clinical classifications (ICD-10 codes for main condition, injury, and causality). Overall, there was a two-fold increase in filed claims from 2000 to 2016, peaking in 2014. The rate of compensated claims only increased marginally, and 36.5% of filed claims were deemed avoidable. Perineal and pelvic floor injuries, as well as medical and diagnostic errors, were responsible for the majority of compensated claims. Women with a previous caesarean section, post term delivery, chronic or gestational disease, > 13 antenatal visits, or a multiple pregnancy had increased risk of having a compensated claim for a maternal injury during delivery. Understanding the risk factors for having a compensated maternal injury claim may guide health workers and maternity wards in improving the quality and organisation of care to reduce the risk of childbirth related injuries.

Safety, regulatory and environmental issues related to breeding and international trade of edible insects in Africa.

Insect breeding or farming for food and feed is an emerging enterprise that can address the ever-growing demand for protein and curb high unemployment rates in Africa and beyond. However, for the sector to prosper, its value chain needs to be regulated to ensure sustainability and safety for consumers and the environment. Although a few African countries, such as Kenya, Uganda and Rwanda, have promulgated standards on the use of insects as food and feed, greater efforts are needed in other countries, and relevant policies governing the sector need to be formulated. All over the globe, attention to the regulation of the edible insect sector is increasing, and more investment in the industry is foreseen. Safety issues such as identifying which species should be reared, substrate quality and traceability imposed by importing countries will be critical for expansion of the sector. This paper analyses safety, regulatory and environmental issues related to breeding and international trade of edible insects in Africa and provides case studies and recommendations for sustainable use of insects for food and feed.

Les élevages et les fermes d'insectes destinés à l'alimentation humaine et animale sont de nouvelles entreprises qui pourraient répondre à la hausse continue de la demande en protéines tout en réduisant les taux élevés du chômage en Afrique et ailleurs. Néanmoins, pour que ce secteur puisse prospérer, sa chaîne de création de valeur doit être réglementée afin de garantir sa durabilité et son innocuité pour les consommateurs et l'environnement. Si un petit nombre de pays africains dont le Kenya, l'Ouganda et le Rwanda ont élaboré des normes applicables à l'utilisation des insectes pour l'alimentation humaine et animale, dans d'autres pays les efforts doivent se poursuivre et des politiques appropriées doivent être mises en place pour régir ce secteur. Partout dans le monde, la réglementation du secteur des insectes comestibles fait désormais l'objet d'une attention considérable et des investissements accrus dans la filière sont attendus. Les questions de sécurité telles que l'identification des insectes à élever, la qualité du substrat et la traçabilité exigée par les pays importateurs seront cruciales pour le développement du secteur. Les auteurs analysent les questions de sécurité et les enjeux réglementaires et environnementaux liés à l'élevage et au commerce international d'insectes comestibles en Afrique et présentent des études de cas et des recommandations pour une utilisation durable des insectes destinés à l'alimentation humaine et animale.

La cría o producción de insectos con fines de alimentación humana o animal es una actividad incipiente que puede ayudar a responder a la siempre creciente demanda de proteínas y a contener las elevadas tasas de desempleo de África y otras regiones. Para que el sector prospere, no obstante, es preciso reglamentar su cadena de valor a fin de asegurar su sostenibilidad y su inocuidad para el consumidor y el medio ambiente. Aunque unos pocos países africanos, como Kenia, Uganda o Ruanda, tienen promulgadas normas sobre el uso de insectos para la alimentación humana o la producción de piensos, aún hay que redoblar esfuerzos en otros países y formular políticas que ordenen el sector. En todo el planeta se presta hoy una atención sin precedentes a la regulación del sector de los insectos comestibles, un sector que previsiblemente va a recibir cada vez más inversiones. Las cuestiones ligadas a la inocuidad, como la identidad de los insectos que se van a producir, la calidad del substrato o la rastreabilidad impuesta por los países importadores, serán fundamentales para el desarrollo del sector. Los autores analizan las cuestiones reglamentarias, ambientales y de inocuidad que se plantean en relación con la cría y el comercio internacional de insectos comestibles en África, presentan ejemplos concretos y formulan recomendaciones para un uso sostenible de los insectos con fines de alimentación humana o animal.

Adherence to dietary guidelines is associated with better physical and mental quality of life: results from a cross-sectional survey among 728 Dutch MS patients.

BACKGROUND: A healthy diet has been associated with less symptoms or progression of disease in multiple sclerosis (MS). However, whether specific diets are needed, or general healthy diet recommendations are sufficient is unknown. OBJECTIVE: To investigate the association between diet quality, use of diets, and quality of life (QoL) in men and women with MS. METHODS: Diet quality was measured with the Dutch Healthy Diet-index, which measures adherence to the Dutch Guidelines for a Healthy Diet. QoL was assessed with the MSQoL-54 questionnaire. A total of 728 people were included (623 women, 105 men). Multiple linear regression, stratified for gender, was used to analyse the data. RESULTS: In women with MS, an association was found between diet quality and both physical and mental QoL after adjusting for several confounders (Physical Health Composite Score (ß=0.410; P=0.001); Mental Health Composite Score (ß=0.462; P=0.002)). Similar results were less pronounced in men. Subjects following a specific diet had higher diet quality and QoL than subjects not following a diet. CONCLUSION: Adherence to the Dutch dietary guidelines is associated with better physical and mental QoL, especially in women. Following an MS-specific diet may help to adhere to these guidelines.

Polycystic ovary syndrome and risk of stillbirth: a nationwide register-based study.

OBJECTIVE: To investigate whether polycystic ovary syndrome (PCOS) is associated with increased risk of stillbirth and whether any such association is linked to PCOS with a severe hyperandrogenic profile. DESIGN: Nationwide register-based cohort study. SETTING: Sweden. POPULATION: The cohort consisted of women giving birth to singleton infants in 1997-2015. All women with a diagnosis of PCOS in the period 1997-2017 and a randomly selected reference group of women without PCOS diagnosis were included. PCOS with a severe hyperandrogenic profile was defined as a PCOS diagnosis with at least two dispensations of prescribed anti-androgens during 2005-2017. METHODS: The risk of stillbirth in women with PCOS was estimated through multiple logistic regression, using women without PCOS as a reference. Risks were expressed as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs), adjusted for maternal age, parity, body mass index, type-1 diabetes, educational level and country of birth. MAIN OUTCOME MEASURES: Stillbirth, at ≥22 weeks of gestation in 2008-2015 and at ≥28 weeks of gestation in 1997-2007. RESULTS: Compared with women without PCOS (n = 241 750), women with PCOS (n = 41 851) had a 50% increased risk of stillbirth (aOR 1.50, 95% CI 1.28-1.77). The incidence of stillbirth in women with PCOS was particularly increased at term. Women with PCOS and a severe hyperandrogenic profile (n = 13 713) did not have a stronger association with stillbirth than women with PCOS who did not have such a profile. CONCLUSIONS: PCOS is associated with stillbirth and should be considered as a possible risk factor in antenatal care. Further research is warranted to investigate possible causal mechanisms. TWEETABLE ABSTRACT: Women with PCOS have increased risk of stillbirth, and the incidence is particularly increased at term.

Intermittent fasting contributes to aligned circadian rhythms through interactions with the gut microbiome.

The timing of food consumption is considered to be an important modulator of circadian rhythms, regulating a wide range of physiological processes which are vital to human health. The exact mechanisms underlying this relationship are not fully understood, but likely involve alterations in the structure and functioning of the gut microbiome. Therefore, this narrative review aims to clarify these mechanisms by focusing on intermittent fasting as a dietary strategy of food timing. A literature search identified 4 clinical and 18 preclinical studies that examined either (1) the impact of intermittent fasting on the gut microbiome, or (2) whether circadian rhythms of the host are subject to changes in the bacterial populations in the gut. Results reveal that intermittent fasting directly influences the gut microbiome by amplifying diurnal fluctuations in bacterial abundance and metabolic activity. This in turn leads to fluctuations in the levels of microbial components (lipopolysaccharide) and metabolites (short-chain fatty acids, bile acids, and tryptophan derivates) that act as signalling molecules to the peripheral and central clocks of the host. Binding of these substrates to pattern-recognition receptors on the surface of intestinal epithelial cells in an oscillating manner leads to fluctuations in the expression of circadian genes and their transcription factors involved in various metabolic processes. Intermittent fasting thus contributes to circadian rhythmicity in the host and could hold promising implications for the treatment and prevention of diseases associated with disordered circadian rhythms, such as obesity and metabolic syndrome. Future intervention studies are needed to find more evidence on this relationship in humans, as well as to clarify the optimal fasting regimen for balanced circadian rhythms.

Criterion validity of assessment methods to estimate body composition in children with cerebral palsy: A systematic review.

BACKGROUND: Poor nutritional status is a problem in a high number of children with cerebral palsy (CP) and impairs their well-being. Therefore, periodic assessment of nutritional status and especially body composition is essential. However, we lack consensus on the best method to assess body composition in clinical practice. OBJECTIVE: We aimed to systematically review the available evidence on the criterion validity of equation-based skinfold measurement and bioelectrical impedance analysis (BIA) to estimate body composition in children with CP. METHODS: In a systematic review (MEDLINE, Cochrane Library and EMBASE), we identified studies that reported on the agreement between the estimation of body composition by equations of skinfold thickness or impedance values of BIA with a gold standard (isotope techniques or dual-energy-X-ray-absorptiometry [DXA]) in children with CP. We included only studies that provided correlations or agreement between estimations of body compartments (e.g., percentage body fat [%BF] or fat mass). Limits of agreement of 2.5%BF points were considered acceptable. Study quality was assessed by using the Quality Assessment of Diagnostic Accuracy Studies 2. RESULTS: We included reports of 9 studies describing 3 skinfold equations and 4 equations to estimate body composition with BIA. Neither skinfold equations nor BIA could be reliably used to assess body composition in an individual child with CP at one point in time. On a population level, the Gurka skinfold equation was valid in ambulant children with CP, and the Kushner and Fjeld BIA equations were valid in a heterogeneous group of children with CP. Conclusions The future role of skinfold equations and BIA to assess and monitor body composition in an individual child with CP needs to be further investigated.

Antenatal care service delivery and factors affecting effective tetanus vaccine coverage in low- and middle-income countries: Results of the Maternal Immunisation and Antenatal Care Situational analysis (MIACSA) project.

OBJECTIVES: To map the integration of existing maternal tetanus immunization programmes within antenatal care (ANC) services for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with high performance maternal vaccine service delivery. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits was undertaken between 2016 and 2018. Associations of different service delivery process components with protection at birth (PAB) and with country groups were established. PAB was defined as the proportion of neonates protected at birth against neonatal tetanus. Regression analysis and structural equation modelling was used to assess associations of different variables with maternal tetanus immunization coverage. Latent class analysis (LCA), was used to group country performance for maternal immunization, and to address the problem of multicollinearity. SETTING: LMICs. RESULTS: The majority of LMICs had a policy on recommended number of ANC visits, however most were yet to implement the WHO guidelines recommending eight ANC contacts. Countries that recommended > 4 ANC contacts were more likely to have high PAB > 90%. Passive disease surveillance was the most common form of disease surveillance performed but the maternal and neonatal morbidity and mortality indicators recorded differed between countries. The presence of user fees for antenatal care and maternal immunization was significantly associated with lower PAB (<90%). CONCLUSIONS: Recommendations include implementing the current WHO ANC guideline to facilitate increased opportunities for vaccination during each pregnancy. Improved utilisation of ANC services by increasing the demand side by increasing the quality of services, reducing any associated costs and supporting user fee exemptions, or the supply side can also enhance utilisation of ANC services which are positioned as an ideal platform for delivery of maternal vaccines.

Vaccine implementation factors affecting maternal tetanus immunization in low- and middle-income countries: Results of the Maternal Immunization and Antenatal Care Situational Analysis (MIACSA) project.

OBJECTIVES: To examine the characteristics of existing maternal tetanus immunization programmes for pregnant women in low- and middle-income countries (LMICs) and to identify and understand the challenges, barriers and facilitators associated with maternal vaccine service delivery that may impact the introduction and implementation of new maternal vaccines in the future. DESIGN: A mixed methods, cross sectional study with four data collection phases including a desk review, online survey, telephone and face-to-face interviews and in country visits. SETTING: LMICs. RESULTS: The majority of countries (84/95; 88%) had a maternal tetanus immunization policy. Countries with high protection at birth (PAB) were more likely to report tetanus toxoid-containing vaccine (TTCV) coverage targets > 90%. Less than half the countries included in this study had a TTCV coverage target of > 90%. Procurement and distribution of TTCV was nearly always the responsibility of the Expanded Programme on Immunization (EPI), however planning and management of maternal immunization was often shared between EPI and Maternal, Newborn and Child Health (MNCH) programmes. Receipt of TTCV at the same time as the antenatal care visit correlated with high PAB. Most countries (81/95; 85%) had an immunization safety surveillance system in place although only 11% could differentiate an adverse event following immunization (AEFI) in pregnant and non-pregnant women. CONCLUSIONS: Recommendations arising from the MIACSA project to strengthen existing services currently delivering maternal tetanus immunization in LMICs include establishing and maintaining vaccination targets, clearly defining responsibilities and fostering collaborations between EPI and MNCH, investing in strengthening the health workforce, improving the design and use of existing record keeping for immunization, adjusting current AEFI reporting to differentiate pregnant women and endeavoring to integrate the provision of TTCV within ANC services where appropriate.

Non-fasting bioelectrical impedance analysis in cystic fibrosis: Implications for clinical practice and research.

BACKGROUND: Nutritional status affects pulmonary function in cystic fibrosis (CF) patients and can be monitored by using bioelectrical impedance analysis (BIA). BIA measurements are commonly performed in the fasting state, which is burdensome for patients. We investigated whether fasting is necessary for clinical practice and research. METHODS: Fat free mass (FFM) and fat mass (FM) were determined in adult CF patients (n = 84) by whole body single frequency BIA (Bodystat 500) in a fasting and non-fasting state. Fasting and non-fasting BIA outcomes were compared with Bland-Altman plots. Pulmonary function was expressed as Forced Expiratory Volume at 1 s percentage predicted (FEV1%pred). Comparability of the associations between fasting and non-fasting body composition measurements with FEV1%pred was assessed by multiple linear regression. RESULTS: Fasting FFM, its index (FFMI), and phase angle were significantly lower than non-fasting estimates (-0.23 kg, p = 0.006, -0.07 kg/m2, p = 0.002, -0.10°, p = 0.000, respectively). Fasting FM and its index (FMI) were significantly higher than non-fasting estimates (0.22 kg, p = 0.008) 0.32%, p = 0.005, and 0.07 kg/m2, (p = 0.005). Differences between fasting and non-fasting FFM and FM were <1 kg in 86% of the patients. FFMI percentile estimates remained similar in 83% of the patients when measured after nutritional intake. Fasting and non-fasting FFMI showed similar associations with FEV1%pred (ß: 4.3%, 95% CL: 0.98, 7.70 and ß: 4.6%, 95% CI: 1.22, 8.00, respectively). CONCLUSION: Differences between fasting and non-fasting FFM and FM were not clinically relevant, and associations with pulmonary function remained similar. Therefore, BIA measurements can be performed in a non-fasting state.

Nutritional care: The 'poor child' of clinical care in children with cerebral palsy.

There is a considerable risk of malnutrition for children with Cerebral Palsy (CP) due to insufficient nutritional intake. The most important causes of insufficient intake are feeding problems which are highly prevalent in children with CP (depending on definition, age and heterogeneity of the researched population). Considering these facts, nutritional status should have the full attention of healthcare professionals but this is not yet the case. Evidence from research in clinical practice suggests that: 1) there is no consensus regarding who should perform the measurement and how often, 2) no standardised nutritional assessment is implemented, and 3) there is suboptimal communication and management about feeding and nutritional status in most healthcare networks. To overcome these problems, validated and practical tools for the screening and assessment of nutritional status should be a topic of research and subsequently made available and implemented in clinical practice. Because body composition is an objective indicator of available energy stores, research should focus on optimising measurement methods to determine body composition using anthropometric measures or bioelectrical impedance analysis (BIA). Furthermore, there is a definite need among health care providers for explicit and clear agreements on organisation and communication about nutritional care for children with CP.

Intestinal Permeability Measured by Urinary Sucrose Excretion Correlates with Serum Zonulin and Faecal Calprotectin Concentrations in UC Patients in Remission.

BACKGROUND AND AIMS: Ulcerative colitis (UC) is associated with an increased intestinal permeability, possibly through a dysbiosis of intestinal bacteria. We investigated which markers are most relevant to assess intestinal permeability in UC patients and whether probiotics had an effect on these markers. METHODS: In this twelve-week placebo-controlled randomized double-blind study, twenty-five subjects with UC in remission received either placebo or a multispecies probiotics. Samples of blood, urine, and faeces were taken at baseline, week 6, and week 12 to assess intestinal permeability and inflammation. Diaries and Bristol stool scale were kept to record stool frequency and consistency. Quality of life was scored from 32-224 with the inflammatory bowel disease questionnaire (IBD-Q). RESULTS: This group of UC patients, in clinical remission, did not show increased intestinal permeability at baseline of this study. During the study, no significant group or time effects were found for intestinal permeability measured by the 5-sugar absorption test, serum zonulin, and faecal zonulin. Likewise, the inflammatory markers C-reactive protein (CRP), calprotectin, and the cytokines IFNγ, TNFα, IL-6, and IL-10 were not significantly affected. Stool frequency and consistency were not significantly affected either. The IBD-Q score, 194 for the probiotics group and 195 for the placebo group, remained unaffected. Correlations were tested between all outcomes; urinary sucrose excretion was significantly correlated with serum zonulin (r = 0.62) and faecal calprotectin (r = 0.55). Faecal zonulin was not significantly correlated with any of the other markers. CONCLUSION: Serum zonulin may be a more relevant biomarker of intestinal permeability than faecal zonulin, due to its correlation with other biomarkers of intestinal permeability. UC patients in remission did not show an effect of the probiotic treatment or a change in gut permeability. This should not discourage further studies because effects might be present during active disease or shortly after a flare up.

What Approaches are Most Effective at Addressing Micronutrient Deficiency in Children 0-5 Years? A Review of Systematic Reviews.

Introduction Even though micronutrient deficiency is still a major public health problem, it is still unclear which interventions are most effective in improving micronutrient status. This review therefore aims to summarize the evidence published in systematic reviews on intervention strategies that aim at improving micronutrient status in children under the age of five. Methods We searched the literature and included systematic reviews that reported on micronutrient status as a primary outcome for children of 0-5 years old, had a focus on low or middle income countries. Subsequently, papers were reviewed and selected by two authors. Results We included 4235 reviews in this systematic review. We found that (single or multiple) micronutrient deficiencies in pre-school children improved after providing (single or multiple) micronutrients. However home fortification did not always lead to significant increase in serum vitamin A, serum ferritin, hemoglobin or zinc. Commercial fortification did improve iron status. Cord clamping reduced the risk of anemia in infants up to 6 months and, in helminth endemic areas, anthelminthic treatment increased serum ferritin levels, hemoglobin and improved height for age z-scores. Anti-malaria treatment improved ferritin levels. Discussion Based on our results the clearest recommendations are: delayed cord clamping is an effective intervention for reducing anemia in early life. In helminth endemic areas iron status can be improved by anthelminthic treatment. Anti-malaria treatment can improve ferritin. In deficient populations, single iron, vitamin A and multimicronutrient supplementation can improve iron, vitamin A and multimicronutrient status respectively. While the impact of home-fortification on multimicronutrient status remains questionable, commercial iron fortification may improve iron status.

Prenatal exposures and birth indices, and subsequent risk of polycystic ovary syndrome: a national registry-based cohort study.

OBJECTIVE: To study the associations between prenatal exposures and risk of developing polycystic ovary syndrome (PCOS). DESIGN: National registry-based cohort study. SETTING: Sweden. POPULATION: Girls born in Sweden during the years 1982-1995 (n = 681 123). METHODS: The girls were followed until the year 2010 for a diagnosis of PCOS. We estimated the associations between maternal body mass index (BMI), smoking, and size at birth with the risk of developing a PCOS diagnosis. Risks were calculated by adjusted hazard ratio (aHR) and 95% confidence intervals (95% CIs). MAIN OUTCOME MEASURES: A diagnosis of PCOS at 15 years of age or later. RESULTS: During the follow-up period 3738 girls were diagnosed with PCOS (0.54%). Girls with mothers who were overweight or obese had 1.5-2.0 times higher risk of PCOS (aHR 1.52, 95% CI 1.36-1.70; aHR 1.97, 95% CI 1.61-2.41, respectively), compared with girls born to mothers of normal weight. The risk of PCOS was increased if the mother smoked during pregnancy (1-9 cigarettes/day, aHR 1.31, 95% CI 1.18-1.47; ≥10 cigarettes/day, aHR 1.44, 95% CI 1.27-1.64). Being born small for gestational age (SGA) was associated with a later diagnosis of PCOS in crude estimates, but the association was not significant after adjusting for maternal factors. CONCLUSIONS: Maternal smoking and increased BMI appear to increase the risk of PCOS in offspring. The association between SGA and the development of PCOS appears to be mediated by maternal factors. TWEETABLE ABSTRACT: Smoking during pregnancy and high maternal BMI are associated with PCOS diagnosis in the offspring.

Micronutrient status of populations and preventive nutrition interventions in South East Asia.

Objectives Since the 1990s, programs for the control of micronutrient deficiencies became a public health priority for many governments, including the countries partnering the project "Sustainable Micronutrient Interventions to Control Deficiencies and Improve Nutritional Status and General Health in Asia" (SMILING): Cambodia, Indonesia, Laos-PDR, Thailand and Vietnam. The aim of this study was to map which micronutrient deficiencies have been addressed and which interventions were in place in the SMILING countries. Methods The mapping covered the period up to 2012. Updated information from relevant surveys after 2012 is included in this paper after the completion of the SMILING project. The mapping of micronutrient status was limited to either national or at least large-scale surveys. Information on nutrition interventions obtained through a systematic mapping of national programs combined with a snowball collection from various sources. Results Among the five SMILING countries, Thailand differed historically by an early implementation of a nationwide community-based nutrition program, contributing to reductions in undernutrition and micronutrient deficiencies. For Cambodia, Indonesia, Laos PDR, and Vietnam, some national programs addressing micronutrients have been implemented following adjusted international recommendations. National surveys on micronutrient status were scattered and inconsistent across the countries in design and frequency. Conclusion for practice In conclusion, some micronutrient deficiencies were addressed in national interventions but the evidence of effects was generally lacking because of limited nationally representative data collected. Improvement of intervention programs to efficiently reduce or eliminate micronutrient deficiencies requires more systematic monitoring and evaluation of effects of interventions in order to identify best practices.

Implementing the WHO Safe Childbirth Checklist: lessons from a global collaboration.

The WHO Safe Childbirth Checklist (SCC) was developed to ensure the delivery of essential maternal and perinatal care practices around the time of childbirth. A research collaboration was subsequently established to explore factors that influence use of the Checklist in a range of settings around the world. This analysis article presents an overview of the WHO SCC Collaboration and the lessons garnered from implementing the Checklist across a diverse range of settings. Project leads from each collaboration site were asked to distribute two surveys. The first was given to end users, and the second to implementation teams to describe their respective experiences using the Checklist. A total of 134 end users and 38 implementation teams responded to the surveys, from 19 countries across all levels of income. End users were willing to adopt the SCC and found it easy to use. Training and the provision of supervision while using the Checklist, alongside leadership engagement and local ownership, were important factors which helped facilitate initial implementation and successful uptake of the Checklist. Teams identified several challenges, but more importantly successfully implemented the WHO SCC. A critical step in all settings was the adaptation of the Checklist to reflect local context and national protocols and standards. These findings were invaluable in developing the final version of the WHO SCC and its associated implementation guide. Our experience will provide useful insights for any institution wishing to implement the Checklist.

The effects of a multispecies probiotic on migraine and markers of intestinal permeability-results of a randomized placebo-controlled study.

BACKGROUND/OBJECTIVES: Migraine, associated with several gastrointestinal disorders, may result from increased intestinal permeability, allowing endotoxins to enter the bloodstream. We tested whether probiotics could reduce migraine through an effect on intestinal permeability and inflammation. SUBJECTS/METHODS: In total, 63 patients were randomly allocated to the probiotic (n=31) or the placebo group (n=32). Participants ingested a multispecies probiotic (5x109 colony-forming units) or placebo daily for 12 weeks. Migraine was assessed with the Migraine Disability Assessment Scale (MIDAS), the Headache Disability Inventory (HDI) and headache diaries. At baseline and 12 weeks, intestinal permeability was measured with the urinary lactulose/mannitol test and fecal and serum zonulin; inflammation was measured from interleukin (IL) -6, IL-10, tumor necrosis factor-α and C-reactive protein in serum. RESULTS: The MIDAS migraine intensity score significantly decreased in both groups (P<0.001) and the HDI score significantly decreased in the probiotic group (P=0.032) and borderline in the placebo group (P=0.053). In the probiotics group, patients had a median of 6 migraine days in the first month, 4 in the second month (P=0.002) and 5 in the last month, which was not significantly different from the 5, 4, and 4 days in the placebo group. A ⩾2day reduction in migraine days was seen in 12/31 patients in the probiotics group versus 7/29 in the placebo group (ns). Probiotic use did not significantly affect medication use, intestinal permeability or inflammation compared to placebo. CONCLUSIONS: In this study, we could not confirm significant benefit from a multispecies probiotic compared to a placebo on the outcome parameters of migraine and intestinal integrity.

Protein Enrichment of Familiar Foods as an Innovative Strategy to Increase Protein Intake in Institutionalized Elderly.

OBJECTIVE: To increase the protein intake of older adults, protein enrichment of familiar foods and drinks might be an effective and attractive alternative for oral nutritional supplements (ONS). We performed a pilot study to test whether these products could help institutionalized elderly to reach a protein intake of 1.2 gram per kg body weight per day (g/kg/d). DESIGN: Intervention study with one treatment group (no control group). Dietary assessment was done before and at the end of a 10-day intervention. SETTING: Two care facilities in Gelderland, the Netherlands: a residential care home and a rehabilitation center. PARTICIPANTS: 22 elderly subjects (13 women, 9 men; mean age 83.0±9.4 years). INTERVENTION: We used a variety of newly developed protein enriched regular foods and drinks, including bread, soups, fruit juices, and instant mashed potatoes. MEASUREMENTS: Dietary intake was assessed on two consecutive days before and at the end of the intervention, using food records filled out by research assistants. Energy and macronutrient intake was calculated using the 2013 Dutch food composition database. Changes in protein intake were evaluated using paired t-tests. RESULTS: Protein intake increased by 11.8 g/d (P=0.003); from 0.96 to 1.14 g/kg/d (P=0.002). This increase is comparable to protein provided by one standard portion of ONS. The intake of energy and other macronutrients did not change significantly. At the end of the intervention more elderly reached a protein intake level of 1.2 g/kg/d than before (9 vs 4). Protein intake significantly increased during breakfast (+3.7 g) and during the evening (+2.2 g). CONCLUSION: Including familiar protein enriched foods and drinks in the menu helped to meet protein recommendations in institutionalized elderly.