A randomised controlled trial of twelve months protein supplementation on muscle mass and strength in elderly women

Background. Aging is associated with progressive loss of muscle (sarcopenia), which can lead to reduced muscle strength and an increased risk of falls. Sarcopenia exists in otherwise healthy elderly people and its aetiology is not fully understood. Many epidemiological studies have shown that high protein intake is associated with preserving muscle mass and strength in the elderly. To date there have been few randomized trials of sufficient duration and power to examine the effects of dietary protein supplement on muscle mass and strength in the elderly. The objective of this study was to examine the effectiveness of whey protein supplementation on preventing sarcopenia in elderly women.Methods. A population based, one-year randomized, double blind and placebo controlled trial of protein supplementation was conducted on 219 community-dwelling ambulant women aged 70 to 80 years. Participants in the protein supplement group (n=109) consumed a drink daily which contained 30 g of protein. The control group (n=110) consumed a drink with the same energy (kilojoules) but only contained 2 g of protein. Assessments were taken at baseline and one year. Body composition was assessed by anthropometry and whole body dual-energy x-ray absorptiometry. Peripheral quantitative computer tomography was used to assess calf muscle crosssectional area. Hand grip, ankle dorsiflexion, knee and hip strengths were assessed using an isokinetic dynamometer. Mobility was assessed by the ‘Timed Up and Go’ test. Standing balance was assessed by the Romberg test. Dietary intake was assessed by a 3-day weighed food record. Compliance with the dietary intervention was assessed by 24-hour urinary nitrogen and by counting the returned empty supplement containers. Serum insulin-like growth factor one (IGF-1) was also measured.Results. One-hundred and ninety-five participants aged 74±3 years completed the one year trial. There were no significant differences in baseline characteristics between the protein supplemented group (n=100) and control group (n=95). Compared to their baseline values, both groups significantly increased whole body lean mass (protein group: +1.6%, p<0.05; control group: +2.3%, p<0.05), appendicular lean mass (protein group: +1.3%, p<0.05; control group: +1.8%, p<0.05), body weight (protein group: +0.8%, p<0.05; control group: +1.5%, p<0.05) and knee strength (protein group: +31%, p< 0.05; control group: +36%, p<0.05) after one year. The total fat mass increased from baseline only in the control group (protein group: +0.7%, p=0.19; control group: +1.5%, p<0.05). There were however no significant differences between the two drink groups in any of the above mentioned parameters. Over one year serum IGF-1 increased significantly in the protein group but decreased in the control group (protein group: +7.6%, p = 0.006; control group: -1.0%, p = 0.005), and the changes were significantly different between two drink groups (p = 0.006). The protein supplement also showed a protective effect on preserving balance function at one year. The prevalence of ‘poor standing balance’ and ‘fall rates’ were significantly increased in the control group at one year.Conclusion. Muscle mass and strength increased equally in both drink groups. Although fat mass only increased in the control group at one year there was no statistically significant difference in the changes in fat mass between the two groups due to the wide variance in response. Protein supplementation resulted in an increased serum IGF-1 level at one year compared with the control group. These data are consistent with the concept that in this age group increased energy intake regardless of the macronutrient composition of the supplements improves muscle mass and function. It is possible that achieving this through increased protein rather than carbohydrate may prevent the increase in fat mass noted with the carbohydrate supplement for the control drink perhaps by an effect of the protein to increase serum IGF-1. The metabolic significance of this remains to be explored

A randomised trial deploying a simulation to investigate the impact of hospital discharge letters on patient care in general practice

Objective To determine how the timing and length of hospital discharge letters impact on the number of ongoing patient problems identified by general practitioners (GPs). Trial design GPs were randomised into four groups. Each viewed a video monologue of an actor-patient as he might present to his GP following a hospital admission with 10 problems. GPs were provided with a medical record as well as a long or short discharge letter, which was available when the video was viewed or 1 week later. GPs indicated if they would prescribe, refer or order tests for the patient's problems. Methods Setting Primary care. Participants Practising Australian GPs. Intervention A short or long hospital discharge letter enumerating patient problems. Outcome measure Number of ongoing patient problems out of 10 identified for management by the GPs. Randomisation 1:1 randomisation. Blinding (masking) Single-blind. Results Numbers randomised 59 GPs. Recruitment GPs were recruited from a network of 102 GPs across Australia. Numbers analysed 59 GPs. Outcome GPs who received the long letter immediately were more satisfied with this information (p&lt;0.001). Those who received the letter immediately identified significantly more health problems (p=0.001). GPs who received a short, delayed discharge letter were less satisfied than those who received a longer delayed letter (p=0.03); however, both groups who received the delayed letter identified a similar number of health problems. GPs who were older, who practised in an inner regional area or who offered more patient sessions per week identified fewer health problems (p values &lt;0.01, &lt;0.05 and &lt;0.05, respectively). Harms Nil. Conclusions Receiving information during patient consultation, as well as GP characteristics, influences the number of patient problems addressed. Trial registration number ACTRN12614000403639

Management of behavioural change in patients presenting with a diagnosis of dementia: a video vignette study with Australian general practitioners

Objective: To test the impact of feedback on the proposed management of standardised patients presenting with behavioural change with a diagnosis of dementia in Australian primary care. Materials and methods: A video vignette study was performed with Australian general practitioners (GPs) in 2013. Participants viewed six pairs of matched videos depicting people presenting changed behaviour in the context of a dementia diagnosis in two phases. In both phases GPs indicated their diagnosis and management. After phase 1, GPs were offered feedback on management strategies for the patients depicted. Analyses focused on identification of change in management between the two phases of the study. Factors impacting on the intention to coordinate care for such patients were tested in a questionnaire based on the Theory of Planned Behaviour. Results: Forty-five GPs completed the study. There was significant improvement in the proposed management of three of the six scenarios after the intervention. Older GPs were more likely to refer appropriately (OR=1.11 (1.01 to 1.23), p=0.04.). Overall referral to support agencies was more likely after the intervention (OR=2.52 (1.53 to 4.14), p<0.001). Older GPs were less likely to intend to coordinate care for such patients (OR=0.89 (0.81 to 0.98) p=0.02). Participants who felt confident about their ability to coordinate care were more likely to do so (OR=3.79 (1.08 to 13.32) p=0.04).Conclusions: The intervention described in this study promoted multidisciplinary management of patients with behavioural problems with a diagnosis of dementia. Increasing practitioner confidence in their ability to coordinate care may increase the proportion of GPs who will respond to patients and carers in this context. Older GPs may benefit in particular

An investigation of factors that influence general practitioners’ referral of computed tomography scans in patients with headache

Aim: In assessing patients with headaches, general practitioners (GPs) play animportant role in determining which patients require computed tomography (CT)scans. The purpose of this study was to identify factors that influence GPs’ decisionsto refer CT scans for patients with headaches. Materials and methods: Aself-administered survey was presented to GPs in Western Australia. One hundredand twenty-eight vignettes describing patients who may have required CT referralfor headache were constructed encompassing six clinical variables. Nine vignettes,selected at random, were presented to each respondent. Respondents were askedif they would refer the patient for diagnostic imaging tests, if so, which imagingmodalities would they request, how urgently and the perceived benefits of therequested imaging modality. Multinomial logistic regression was used for the multivariateanalysis. Results: We received 105 completed questionnaires (21%). GPswere more likely to refer patients with headaches for diagnostic imaging and CTscans in the following clinical scenarios: patients with a history of colorectal cancerand epilepsy; and patients feeling unwell for the past 6 weeks and headachebeing exacerbated with valsalva manoeuvrers. Private health insurance and otherrespondent demographics such as GPs experience and site of care increased imagingreferral. Conclusion: GP’s referral decisions of diagnostic imaging and CTexaminations for patients with headaches are dependent on clinical scenarios andthe likelihood of a significant pathology. Further research is required to identifythe significant clinical findings with regard to the CT referrals and ensure that CTscans are not requested in patients who are unlikely to benefit

Protein effects on bone and muscle in elderly women

Fractures continue to constitute a major public health problem of aging despite recent evidence that the age-specific rate may be falling.1 The facts that before dying at a median age of approximately 83 years, 50% of women would have sustained a fracture with its consequent morbidity, and health care costs give some idea of the magnitude of the problem. As with other common health problems such as atherosclerotic cardiovascular disease, a combination of the whole of the population public health approach with pharmaceutical intervention for those at highest risk is recommended. In this regard, increased calcium supplementation to counteract reduced intestinal calcium absorption and increased renal excretion due to the loss of the effect of estrogen on these two mechanisms2 is now widely accepted as is vitamin D supplementation due to a reduction in skin exposure to sunlight. Interestingly this latter factor, which in the absence of adequate sunlight can be replaced in the diet, has also been shown to play a significant role in falls prevention which together with osteoporosis constitute the pathological basis for fracture

Piloting and validating an innovation to triage patients presenting with cough to community pharmacies in Western Australia

Aim: To develop a tool to assist community pharmacists to triage patients presenting with cough and to validate this against an established cough-specific quality of life (QoL) measure. Methods: A decision-support tool, the Pharmacy Cough Assessment Tool (PCAT) was developed with reference to published guidelines and a team of clinical experts. The PCAT was validated against the Leicester Cough Questionnaire (LCQ). It was then administered at four community pharmacies in Perth, Western Australia to assess the scope to recruit and follow up participants, and to estimate the proportion of participants who would be advised to consult a general practitioner (GP). The reported outcomes of the consultations with doctors were also recorded. Results: Ninety-nine subjects were recruited over 12 weeks. Thirty-seven participants were advised to consult a GP for further assessment with reference to the PCAT; seven attended their doctor. The LCQ scores of those referred to their GP were significantly lower, indicating a poorer quality of life (adjusted mean and range 13.16 [11.87, 14.46]; non-referred 15.82 [14.47, 17.18]; P < 0.001). Scores of this magnitude have previously been shown to identify patients with chronic respiratory conditions. A smaller group of participants also had a poor quality of life based on LCQ scores but were not referred to their GP. Of the seven participants who made an appointment with their GP, most were prescribed treatment or referred for investigation. There was no significant difference in LCQ score based on gender, or decision to consult a GP. Conclusions: The PCAT identifies patients with cough who might benefit from medical advice and may feasibly be used as an initial screening tool in the community pharmacy setting

Response to Comments by Vuksan V. et al., Nutrients 2017, 9, 398, Regarding an Article by Solah V.A. et al., Nutrients 2017, 9, 149

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