Dose-dependent effects of randomized intraduodenal whey-protein loads on glucose, gut hormone, and amino acid concentrations in healthy older and younger men

Protein-rich supplements are used widely for the prevention and management of malnutrition in older people. We have reported that healthy older, compared to younger, adults have less suppression of energy intake by whey-protein-effects on appetite-related hormones are unknown. The objective was to determine the effects of intraduodenally administered whey-protein on glucose, gut hormone, and amino acid concentrations, and their relation to subsequent ad libitum energy intake at a buffet meal, in healthy older and younger men. Hydrolyzed whey-protein (30 kcal, 90 kcal, and 180 kcal) and a saline control (~0 kcal) were infused intraduodenally for 60 min in 10 younger (19-29 years, 73 ± 2 kg, 22 ± 1 kg/m²) and 10 older (68-81 years, 79 ± 2 kg, 26 ± 1 kg/m²) healthy men in a randomized, double-blind fashion. Plasma insulin, glucagon, gastric inhibitory peptide (GIP), glucagon-like peptide-1 (GLP-1), peptide tyrosine-tyrosine (PYY), and amino acid concentrations, but not blood glucose, increased, while ghrelin decreased during the whey-protein infusions. Plasma GIP concentrations were greater in older than younger men. Energy intake correlated positively with plasma ghrelin and negatively with insulin, glucagon, GIP, GLP-1, PYY, and amino acids concentrations (p < 0.05). In conclusion, intraduodenal whey-protein infusions resulted in increased GIP and comparable ghrelin, insulin, glucagon, GIP, GLP-1, PYY, and amino acid responses in healthy older and younger men, which correlated to subsequent energy intake.Caroline Giezenaar, Natalie D Luscombe-Marsh, Amy T Hutchison, Scott Standfield, Christine Feinle-Bisset, Michael Horowitz, Ian Chapman and Stijn Soene

Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Achieving good-quality consent: review of literature, case law and guidance

Background Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self‐determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent‐based discussions with competent patients undergoing elective procedures. Methods Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer‐reviewed literature and case law, was considered in the formulation of this review. Results A framework for obtaining consent is presented that is informed by the key tenets of shared decision‐making (SDM), a model that advocates the contribution of both the clinician and patient to the decision‐making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process. Conclusion This SDM‐centric framework provides structure, detail and suggestions for achieving meaningful consent

The efficiency of increasing the capacity of physiotherapy screening clinics or traditional medical services to address unmet demand in orthopaedic outpatients: a practical application of discrete event simulation with dynamic queuing

Background: Hospital outpatient orthopaedic services traditionally rely on medical specialists to assess all new patients to determine appropriate care. This has resulted in significant delays in service provision. In response, Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services (OPSC) have been introduced to assess and co-ordinate care for semi- and non-urgent patients. Objectives: To compare the efficiency of delivering increased semi- and non-urgent orthopaedic outpatient services through: (1) additional OPSC services; (2) additional traditional orthopaedic medical services with added surgical resources (TOMS\ua0+\ua0Surg); or (3) additional TOMS without added surgical resources (TOMS\ua0−\ua0Surg). Methods: A cost-utility analysis using discrete event simulation (DES) with dynamic queuing (DQ) was used to predict the cost effectiveness, throughput, queuing times, and resource utilisation, associated with introducing additional OPSC or TOMS\ua0±\ua0Surg versus usual care. Results: The introduction of additional OPSC or TOMS (±surgery) would be considered cost effective in Australia. However, OPSC was the most cost-effective option. Increasing the capacity of current OPSC services is an efficient way to improve patient throughput and waiting times without exceeding current surgical resources. An OPSC capacity increase of ~100 patients per month appears cost effective (A$8546 per quality-adjusted life-year) and results in a high level of OPSC utilisation (98\ua0%). Conclusion: Increasing OPSC capacity to manage semi- and non-urgent patients would be cost effective, improve throughput, and reduce waiting times without exceeding current surgical resources. Unlike Markov cohort modelling, microsimulation, or DES without DQ, employing DES-DQ in situations where capacity constraints predominate provides valuable additional information beyond cost effectiveness to guide resource allocation decisions

Evaluation of rapid training in ultrasound guided tourniquet application skills

Tourniquet application has been widely accepted to improve survival for major limb trauma. Colour duplex ultrasound (US) can be used as a non-invasive method of confirming cessation of arterial flow. Participants with no or limited experience of ultrasound were taught to apply the Combat Application Tourniquet with ultrasound guidance. Following this, participants were tested in effective tourniquet application: Blind and with ultrasound guidance. US guidance improved abolition of limb perfusion from 22 to 93 per cent in upper limb; from 25 to 100 per cent in lower limb (p=0.0027 and <0.0001). No significant difference was found in application time for the lower limb; less time was taken for application with US guidance in the upper limb 8.1 (7.1, 8.6) vs 4.5 s (4.0, 5.3; median (IQR)), p=0.002. Tourniquet ultrasound skills are rapidly acquired by novice operators. Accuracy improves with ultrasound guidance, this may have a role in improving survival