The impact of malnutrition and decreased food intake on length of stay, readmission, and mortality in acute care patients

Rationale: The Australasian Nutrition Care Day Survey (ANCDS) evaluated if malnutrition and decreased food intake are independent risk factors for negative outcomes in hospitalised patients. Methods: A multicentre (56 hospitals) cross-sectional survey was conducted in two phases. Phase 1 evaluated nutritional status (defined by Subjective Global Assessment) and 24-hour food intake recorded as 0, 25, 50, 75, and 100% intake. Phase 2 data, which included length of stay (LOS), readmissions and mortality, were collected 90 days post-Phase 1. Logistic regression was used to control for confounders: age, gender, disease type and severity (using Patient Clinical Complexity Level scores). Results: Of 3122 participants (53% males, mean age: 65±18 years) 32% were malnourished and 23% consumed�25% of the offered food. Median LOS for malnourished (MN) patients was higher than well-nourished (WN) patients (15 vs. 10 days, p<0.0001). Median LOS for patients consuming �25% of the food was higher than those consuming �50% (13 vs. 11 days, p<0.0001). MN patients had higher readmission rates (36% vs. 30%, p = 0.001). The odds ratios of 90-day in-hospital mortality were 1.8 times greater for MN patients (CI: 1.03 3.22, p = 0.04) and 2.7 times greater for those consuming �25% of the offered food (CI: 1.54 4.68, p = 0.001). Conclusion: The ANCDS demonstrates that malnutrition and/or decreased food intake are associated with longer LOS and readmissions. The survey also establishes that malnutrition and decreased food intake are independent risk factors for in-hospital mortality in acute care patients; and highlights the need for appropriate nutritional screening and support during hospitalisation. Disclosure of Interest: None Declared.

Extracorporeal lessons from sheep

Background: Extracorporeal circulation (ECC), the diversion of blood flow through a circuit located outside of the body, has been one of the major advances in modern medicine. Cardio-pulmonary bypass (CPB), renal dialysis, apheresis and extracorporeal membrane oxygenation (ECMO) are all different forms of ECC. Despite its major benefits, when blood comes into contact with foreign material, both the coagulation and inflammation cascades are activated simultaneously. Short periods of exposure to ECC e.g. CPB (�2 h duration), are known to be associated with haemolysis, coagulopathies, bleeding and inflammation which demand blood product support. Therefore, it is not unexpected that these complications would be exaggerated with prolonged periods of ECC such as in ECMO (days to weeks duration). The variability and complexities of the underlying pathologies of patients requiring ECC makes it difficult to study the cause and effect of these complications. To overcome this problem we developed an ovine (sheep) model of ECC. Method: Healthy female sheep (1–3 y.o.) weighing 40–50 kg were fasted overnight, anaesthetised, intubated and ventilated [1]. Half the group received smoke induced acute lung injury (S-ALI group) (n = 8) and the other half did not (healthy group) (n = 8). Sheep were subsequently cannulated (Medtronic Inc, Minneapolis, MN, USA) and veno-venous ECMO commenced using PLS ECMO circuit and Quadrox D oxygenator (Maquet Cardiopulmonary AG, Hechinger Straße, Germany). There was continuous physiological monitoring and blood was collected at specified time intervals for full blood counts, platelet function analysis (by Multiplate®), routine coagulation and assessment of clot formation and lysis (by ROTEM®). Preliminary results Full blood counts and routine coagulation results from normal healthy sheep were comparable to those of normal human adults. Within 15 min of initiating of ECMO, PT, PTT and EXTEM clot formation time increased, whilst EXTEM maximum clot firmness decreased in both cohorts. Discussion & Conclusions: Preliminary results of sheep from both 2 h ECMO cohorts showed that the anatomy, haematology and coagulation parameters of an adult sheep are comparable to that a human adult. Experiments are currently underway with healthy (n = 8) and S-ALI (n = 8) sheep on ECMO for 24 h. In addition to characterising how ECMO alters haematology and coagulation parameters, we hope that it will also define which blood components will be most effective to correct bleeding or clotting complications during ECMO support.

ECMO : the clinician’s view

Background: Extra corporeal membrane oxygenation (ECMO) is a complex rescue therapy used to provide cardiac and/or respiratory support for critically ill patients who have failed maximal conventional medical management. ECMO is based on a modified cardiopulmonary bypass (CPB) circuit, and can provide cardiopulmonary support for up-to several months. It can be used in a veno venous configuration for isolated respiratory failure, (VV-ECMO), or in a veno arterial configuration (VA-ECMO) where support is necessary for cardiac +/- respiratory failure. The ECMO circuit consists of five main components: large bore cannulae (access cannulae) for drainage of the venous system, and return cannulae to either the venous (in VV-ECMO) or arterial (in VA ECMO) system. An oxygenator, with a vast surface area of hollow filaments, allows addition of oxygen and removal of carbon dioxide; a centrifugal blood pump allows propulsion of blood through the circuit at upto 10 L/minute; a control module and a thermoregulatory unit, which allows for exact temperature control of the extra corporeal blood. Methods: The first successful use of ECMO for ARDS in adults occurred in 1972, and its use has become more commonplace over the last 30 years, supported by the improvement in design and biocompatibility of the equipment, which has reduced the morbidity associated with this modality. Whilst the use of ECMO in neonatal population has been supported by numerous studies, the evidence upon which ECMO was integrated into adult practice was substantially less robust. Results: Recent data, including the CESAR study (Conventional Ventilatory Support versus Extra corporeal membrane oxygenation for Severe Respiratory failure) has added a degree of evidence to the role of ECMO in such a patient population. The CESAR study analysed 180 patients, and confirmed that ECMO was associated with an improved rate of survival. More recently, ECMO has been utilized in numerous situations within the critical care area, including support in high-risk percutaneous interventions in cardiac catheter lab; the operating room, emergency department, as well in specialized inter-hospital retrieval services. The increased understanding of the risk:benefit profile of ECMO, along with a reduction in morbidity associated with its use will doubtless lead to a substantial rise in the utilisation of this modality. As with all extra-corporeal circuits, ECMO opposes the basic premises of the mammalian inflammation and coagulation cascade where blood comes into foreign circulation, both these cascades are activated. Anti-coagulation is readily dealt with through use of agents such as heparin, but the inflammatory excess, whilst less macroscopically obvious, continues un-abated. Platelet consumption and neutrophil activation occur rapidly, and the clinician is faced with balancing the need of anticoagulation for the circuit, against haemostasis in an acutely bleeding patient. Alterations in pharmacokinetics may result in inadequate levels of disease modifying therapeutics, such as antibiotics, hence paradoxically delaying recovery from conditions such as pneumonia. Key elements of nutrition and the innate immune system maysimilarly be affected. Summary: This presentation will discuss the basic features of ECMO to the nonspecialist, and review the clinical conundrum faced by the team treating these most complex cases.

Nutritional support and functional capacity in chronic obstructive pulmonary disease: A systematic review and meta-analysis

Currently there is confusion about the value of using nutritional support to treat malnutrition and improve functional outcomes in chronic obstructive pulmonary disease (COPD). This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to clarify the effectiveness of nutritional support in improving functional outcomes in COPD. A systematic review identified 12 RCTs (n = 448) in stable COPD patients investigating the effects of nutritional support [dietary advice (1 RCT), oral nutritional supplements (ONS; 10 RCTs), enteral tube feeding (1 RCT)] versus control on functional outcomes. Meta-analysis of the changes induced by intervention found that whilst respiratory function (FEV(1,) lung capacity, blood gases) was unresponsive to nutritional support, both inspiratory and expiratory muscle strength (PI max +3.86 SE 1.89 cm H(2) O, P = 0.041; PE max +11.85 SE 5.54 cm H(2) O, P = 0.032) and handgrip strength (+1.35 SE 0.69 kg, P = 0.05) were significantly improved, and associated with weight gains of ≥ 2 kg. Nutritional support produced significant improvements in quality of life in some trials, although meta-analysis was not possible. It also led to improved exercise performance and enhancement of exercise rehabilitation programmes. This systematic review and meta-analysis demonstrates that nutritional support in COPD results in significant improvements in a number of clinically relevant functional outcomes, complementing a previous review showing improvements in nutritional intake and weight.

Introducing solids and water to Australian infants

Background: Recommendations for the introduction of solids and fluids to an infant’s diet have changed over the past decade. Since these changes, there has been minimal research to determine patterns in the introduction of foods and fluids to infants. Methods: This retrospective cohort study surveyed mothers who birthed in Queensland, Australia, from February 1 to May 31, 2010, around 4 months postpartum. Frequencies of foods and fluids given to infants at 4, 8, 13, and 17 weeks were described. Logistic regression determined associations between infant feeding practices, the introduction of other foods and fluids at 17 weeks, and sociodemographic characteristics. Results: Response rate was 35.8%. At 17 weeks, 68% of infants were breastfed and 33% exclusively breastfed. Solids and water had been introduced in 8.6% and 35.0% of infants, respectively. The introduction of solids by 17 weeks was associated with younger maternal age and the infant being given water and infant formula at 4 weeks. The infant being given water at 17 weeks was associated with younger maternal age, the infant being given infant formula at 4 weeks, level of education, relative socioeconomic disadvantage, parity, and birth facility. Conclusion: Over the past decade, there has been a significant reduction in the proportion of infants in Australia who have been given solids by 17 weeks. Sociodemographic characteristics and formula feeding practices at 4 weeks were associated with the introduction of solids and water by 17 weeks. Further research should examine these barriers to improve compliance with current infant feeding recommendations.

Tenofovir-associated proteinuria

Proteinuria was observed in 27% of 153 patients taking tenofovir for more than 1 year. Concomitant protease inhibitor therapy and cumulative tenofovir exposure were independently associated with proteinuria in this cohort. Proteinuria was reversible in 11 of 12 patients who ceased tenofovir because of proteinuria without altering other medications. Clinicians should be aware that tenofovir can cause reversible proteinuria in patients with HIV.

Genome-wide search for markers associated with bovine spongiform encephalopathy

A genome-wide search for markers associated with BSE incidence was performed by using Transmission-Disequilibrium Tests (TDTs). Significant segregation distortion, i.e., unequal transmission probabilities of alleles within a locus, was found for three marker loci on Chromosomes (Chrs) 5, 10, and 20. Although TDTs are robust to false associations owing to hidden population substructures, it cannot distinguish segregation distortion caused by a true association between a marker and bovine spongiform encephalopathy (BSE) from a population-wide distortion. An interaction test and a segregation distortion analysis in half-sib controls were used to disentangle these two alternative hypotheses. None of the markers showed any significant interaction between allele transmission rates and disease status, and only the marker on Chr 10 showed a significant segregation distortion in control individuals. Nevertheless, the control group may have been a mixture of resistant and susceptible but unchallenged individuals. When new genotypes were generated in the vicinity of these three markers, evidence for an association with BSE was confirmed for the locus on Chr 5.

An exploratory study of associations between Australian-Indian mothers’ use of controlling feeding practices, concerns and perceptions of children’s weight and children’s picky eating

Aim This cross-sectional study explores associations between migrant Indian mothers’ use of controlling feeding practices (pressure to eat, restriction and monitoring) and their concerns and perceptions regarding their children’s weight and picky eating behaviour. Methods Two hundred and thirty mothers with children aged 1-5 years, residing in Australia for 1-8 years, participated by completing a self-reported questionnaire. Results Perceptions and concerns regarding children’s weight were not associated with any of the controlling feeding practices. A positive association was noted between pressure feeding and perceptions of pickiness after adjusting for covariates: children’s age, gender and weight-for-age Z-score. Girls, older children, and children with higher weight-for-age z scores were pressure fed to a greater extent. Conclusions This study supports the generalisation of findings from Caucasian literature that pressure feeding and perceptions of pickiness are positively related.

Making more sustainable urban environments by responding to neurodiversity in later life

The ageing population is increasing worldwide, as are a range of chronic diseases, conditions, and physical and cognitive disabilities associated with later life. The older population is also neurologically diverse, with unique and specific challenges around mobility and engagement with the urban environment. Older people tend to interact less with cities and neighbourhoods, putting them at risk of further illnesses and co-morbidities associated with being less physically and socially active. Empirical evidence has shown that reduced access to healthcare services, health-related resources and social interaction opportunities is associated with increases in morbidity and premature mortality. While it is crucial to respond to the needs of this ageing population, there is insufficient evidence for interventions regarding their experiences of public space from the vantage point of neurodiversity. This paper provides a conceptual and methodological framework to investigate relationships between the sensory and cognitive abilities of older people, and their use and negotiation of the urban environment. The paper will refer to a case example of the city of Logan, an urban area in Queensland, Australia, where current urban development provides opportunities for the design of spaces that take experiences of neurodiversity into account. The framework will inform the development of principles for urban design for increasingly neurologically diverse populations.

Legal Profession Act 2004 (NSW) : costs agreement between law practice and client - whether binding on non-associated third party payer

The decision in the New South Wales Supreme Court in Boyce v McIntyre [2008] NSWSC 1218 involved determination of a number of issues relating to an assessment of costs under the Legal Profession Act 2004 (NSW). The issue of broad significance was whether a non-associated third party payer must pay the fixed fee that was agreed between the law practice and the client. The court found that the client agreement did not form the basis of assessing costs for the non-associated third party payer.

The relationship between anti-mullerian hormone in women receiving fertility assessments and age at menopause in subfertile women : evidence from large population studies

Context: Anti-Müllerian hormone (AMH) concentration reflects ovarian aging and is argued to be a useful predictor of age at menopause (AMP). It is hypothesized that AMH falling below a critical threshold corresponds to follicle depletion, which results in menopause. With this threshold, theoretical predictions of AMP can be made. Comparisons of such predictions with observed AMP from population studies support the role for AMH as a forecaster of menopause. Objective: The objective of the study was to investigate whether previous relationships between AMH and AMP are valid using a much larger data set. Setting: AMH was measured in 27 563 women attending fertility clinics. Study Design: From these data a model of age-related AMH change was constructed using a robust regression analysis. Data on AMP from subfertile women were obtained from the population-based Prospect-European Prospective Investigation into Cancer and Nutrition (Prospect- EPIC) cohort (n � 2249). By constructing a probability distribution of age at which AMH falls below a critical threshold and fitting this to Prospect-EPIC menopausal age data using maximum likelihood, such a threshold was estimated. Main Outcome: The main outcome was conformity between observed and predicted AMP. Results: To get a distribution of AMH-predicted AMP that fit the Prospect-EPIC data, we found the critical AMH threshold should vary among women in such a way that women with low age-specific AMH would have lower thresholds, whereas women with high age-specific AMH would have higher thresholds (mean 0.075 ng/mL; interquartile range 0.038–0.15 ng/mL). Such a varying AMH threshold for menopause is a novel and biologically plausible finding. AMH became undetectable (�0.2 ng/mL) approximately 5 years before the occurrence of menopause, in line with a previous report. Conclusions: The conformity of the observed and predicted distributions of AMP supports the hypothesis that declining population averages of AMH are associated with menopause, making AMH an excellent candidate biomarker for AMP prediction. Further research will help establish the accuracy of AMH levels to predict AMP within individuals.

Increasing Food Production Sustainably in a Changing Climate : Understanding the Pressures and Potential

Australian agriculture is faced with the dilemma of increasing food production for a growing domestic and world population while decreasing environmental impacts and supporting the social and economic future of regional communities. The challenge for farmers is compounded by declining rates of productivity growth which have been linked to changes in climate and decreasing investment in agricultural research. The answer must lie in understanding the ecological functionality of landscapes and matching management of agricultural systems and use of natural resources to landscape capacity in a changing climate. A simplified mixed grain and livestock farm case study is used to illustrate the challenges of assessing the potential for shifts in land allocation between commodities to achieve sustainable intensification of nutrition production. This study highlights the risks associated with overly-simplistic solutions and the need for increased investment in research to inform the development of practical strategies for increasing food production in Australian agro-ecosystems while managing the impacts of climate change and addressing climate change mitigation policies.

A cross-sectional analysis of patterns of obesity in a cohort of working nurses and midwives in Australia, New Zealand, and the United Kingdom

Objective The aim of this study was to examine the prevalence of overweight and obesity and the association with demographic, reproductive work variables in a representative cohort of working nurses and midwives. Design A cross sectional study of self reported survey data. Settings Australia, New Zealand and the United Kingdom. Methods Measurement outcomes included BMI categories, demographic (age, gender, marital status, ethnicity), reproductive (parity, number of births, mother's age at first birth, birth type and menopausal status) and workforce (registration council, employment type and principal specialty) variables. Participants 4996 respondents to the Nurses and Midwives e-Cohort study who were currently registered and working in nursing or midwifery in Australia (n=3144), New Zealand (n=778) or the United Kingdom (n=1074). Results Amongst the sample 61.87% were outside the healthy weight range and across all three jurisdictions the prevalence of obesity in nurses and midwives exceeded rates in the source populations by 1.73% up to 3.74%. Being overweight or obese was significantly associated with increasing age (35–44 yrs aOR 1.71, 95% CI 1.41–2.08; 45–55 yrs aOR 1.90, 95%CI 1.56–2.31; 55–64 aOR 2.22, 95% CI 1.71–2.88), and male gender (aOR 1.46, 95% CI 1.15–1.87). Primiparous nurses and midwives were more likely to be overweight or obese (aOR 1.37, 95% CI 1.06–1.76) as were those who had reached menopause (aOR 1.37, 95% CI 1.11–1.69). Nurses and midwives in part-time or casual employment had significantly reduced risk of being overweight or obese, (aOR 0.81, 95% CI 0.70–0.94 and aOR 0.75, 95% CI 0.59–0.96 respectively), whilst working in aged carried increased risk (aOR 1.37, 95% CI 1.04–1.80). Conclusion Nurses and midwives in this study have higher prevalence of obesity and overweight than the general population and those who are older, male, or female primiparous and menopausal have significantly higher risk of overweight or obesity as do those working fulltime, or in aged care. The consequences of overweight and obesity in this occupational group may impact on their workforce participation, their management of overweight and obese patients in their care as well as influencing their individual health behaviours and risks of occupational injury and chronic disease.

Computer-based assessments of expected satiety predict behavioural measures of portion-size selection and food intake

Previously, expected satiety (ES) has been measured using software and two-dimensional pictures presented on a computer screen. In this context, ES is an excellent predictor of self-selected portions, when quantified using similar images and similar software. In the present study we sought to establish the veracity of ES as a predictor of behaviours associated with real foods. Participants (N = 30) used computer software to assess their ES and ideal portion of three familiar foods. A real bowl of one food (pasta and sauce) was then presented and participants self-selected an ideal portion size. They then consumed the portion ad libitum. Additional measures of appetite, expected and actual liking, novelty, and reward, were also taken. Importantly, our screen-based measures of expected satiety and ideal portion size were both significantly related to intake (p < .05). By contrast, measures of liking were relatively poor predictors (p > .05). In addition, consistent with previous studies, the majority (90%) of participants engaged in plate cleaning. Of these, 29.6% consumed more when prompted by the experimenter. Together, these findings further validate the use of screen-based measures to explore determinants of portion-size selection and energy intake in humans.