Developing a knowledge translation program for health practitioners: Allied Health Translating Research into Practice

Background

Front-line health practitioners lack confidence in knowledge translation, yet they are often required to undertake projects to bridge the knowledge-practice gap. There are few initiatives focused on building the capacity of the health practitioner workforce to undertake knowledge translation, with most programs focusing on developing the skills of researchers. This paper reports the development and evaluation of a knowledge translation capacity building program for allied health practitioners located over geographically dispersed locations in Queensland, Australia.

Methods

Allied Health Translating Research into Practice (AH-TRIP) was developed over five years with consideration of theory, research evidence and local needs assessment. AH-TRIP includes five components: training and education; support and networks (including champions and mentoring); showcase and recognition; TRIP projects and implementation; evaluation. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation Maintenance) guided the evaluation plan, with this paper reporting on the reach (number, discipline, geographical location), adoption by health services, and participant satisfaction between 2019 and 2021.

Results

A total of 986 allied health practitioners participated in at least one component of AH-TRIP, with a quarter of participants located in regional areas of Queensland. Online training materials received an average of 944 unique page views each month. A total of 148 allied health practitioners have received mentoring to undertake their project, including a range of allied health disciplines and clinical areas. Very high satisfaction was reported by those receiving mentoring and attending the annual showcase event. Nine of sixteen public hospital and health service districts have adopted AH-TRIP.

Conclusion

AH-TRIP is a low-cost knowledge translation capacity building initiative which can be delivered at scale to support allied health practitioners across geographically dispersed locations. Higher adoption in metropolitan areas suggests that further investment and targeted strategies are needed to reach health practitioners working in regional areas. Future evaluation should focus on exploring the impact on individual participants and the health service.

Dietary Education Delivered by Digital Health for Improving Dietary Intake and Clinical Outcomes in Chronic Conditions: A Systematic Review and Meta-Analysis

Objectives

To determine the effectiveness of dietary education delivered by digital health interventions for improving dietary intake and clinical outcomes in chronic conditions.

Methods

CINAHL, Cochrane CENTRAL, Embase and MEDLINE databases were systematically searched. Controlled trials involving dietary education delivered via digital health interventions (mobile or electronic health technology) to adults with chronic conditions were included. The dietary intervention component must have been developed or delivered by health professionals, or in line with best practice guidelines. Data was meta-analyzed by a random effects model for diet quality, fruit and vegetable consumption, dietary intake of fat, sodium, protein, fibre and energy, and various clinical outcomes. Screening, data extraction and quality assessment were completed in duplicate.

Results

Thirty-eight studies compromising 7,303 participants met the inclusion criteria. Digital health interventions included: mobile phone apps and messaging systems (n = 16), internet-based (n = 16), electronic software (n = 1) or a combination of these methods (n = 5). Studies showed digital health was effective at improving Mediterranean diet adherence score [standardized mean difference: 0.79; 95% confidence interval (CI): 0.18, 1.40] and overall fruit and vegetable intake [mean difference (MD): 0.58 serves per day; 95% CI: 0.01, 1.14]. However, no significant effects were found for other measures of diet quality, single food group intake, nutrients and energy intake. Digital health interventions significantly reduced waist circumference [MD: −2.34 cm; 95% CI: −4.29, −0.38cm), body weight [MD: −1.88; 95% CI: −2.60, −1.16 kg) and hemoglobin A1c levels [MD: −0.18%; 95% CI: −0.30, −0.05%). Overall the studies were rated as poor quality.

Conclusions

Dietary education delivered via digital health interventions significantly improved Mediterranean diet adherence, overall fruit and vegetable intake, waist circumference, weight and hemoglobin A1c levels. However, given the relatively poor quality of the studies, additional robust trials are needed to the guide implementation and scale-up of these interventions in health services.

Funding Sources

None.

Are Telehealth-Delivered Nutrition Care Interventions Cost-Effective for Managing Chronic Diseases? A Systematic Review of All Payer Perspectives

Objectives

To systematically evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults living with chronic disease.

Methods

PubMed, CENTRAL, CINAHL and Embase were systematically searched from database inception to November 2021. Included studies were randomized controlled trials implementing a telehealth-delivered diet intervention in adults with chronic disease compared to non-telehealth (either alone or in combination with an exercise prescription), which reported on cost-effectiveness or cost-utility analysis. All studies were independently screened, and data extraction and quality appraisal adhered to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist by two review authors. Data analysis was conducted by grouping studies according to their telehealth modality and payer perspective.

Results

Twelve randomized controlled trials; five phone-only interventions, three mobile health (mHealth), two online, and one each using a combination of phone-online or phone-mHealth interventions) were included in the review. mHealth interventions were found to be the most cost-effective intervention (in 100% (n = 3) of studies. Across all telehealth interventions analyzed from health system perspectives (n = 10), 60% studies were found to be cost-effective. One of the three (33%) studies analysed from societal perspectives reported that the intervention was cost-effective. Cost-utility analyses (n = 10) found 30% of studies were cost-saving and more effective, making the interventions dominant over usual care. One study reported no difference in costs or effectiveness and the remaining six studies reported increased cost and effectiveness, requiring payers to determine whether the incremental cost per additional quality-adjusted life year (QALY) gained falls within an acceptable willingness-to-pay threshold. Quality of study reporting varied with between 63% to 92%.

Conclusions

Telehealth-delivered nutrition care programs appear to be cost-effective from a health system perspective, particularly mHealth modalities for managing chronic disease nutrition care. These findings support telehealth-delivered nutrition care as an effective intervention to deliver high-quality care in a cost-effective way.

Funding Sources

None.

Implementation science for dietitians: The 'what, why and how' using multiple case studies

AIM

Implementation science theories, models and frameworks help to address evidence-practice gaps, which have increasing importance for dietetic practice. This paper aims to provide dietitians with insight into how implementation science can be applied to practice, using multiple 'real-life' case studies.

METHODS

Three case studies were purposively selected across areas of dietetics practice to demonstrate application of commonly-used implementation theories, models and frameworks. Reflections from the authors were provided in response to a structured set of questions outlining how the theoretical approach was selected and used, and considerations for future application. Within and cross-case analysis was undertaken.

RESULTS

Dietitians used diverse implementation theories, models and frameworks to identify barriers and enablers, to plan for implementation, and to guide the selection of implementation strategies. Implementation theory was used to evaluate the implementation process in one case study. Cross-case analysis identified that mentoring by those with implementation expertise, multidisciplinary implementation teams, and leadership and investment in research and translation at an organisational and departmental level as key enablers.

CONCLUSIONS

This paper offers dietitians insight into how implementation science can be applied to improve the uptake of evidence-based practices within nutrition and dietetics, and suggests that there needs to be investment in implementation science as a foundation science within nutrition and dietetics, including education, training and mentoring for dietitians.

An Experimental Series Investigating the Effects of Hyperinsulinemic Euglycemia on Myocardial Blood Flow Reserve in Healthy Individuals and on Myocardial Perfusion Defect Size following ST-Segment Elevation Myocardial Infarction

BACKGROUND

Incomplete restoration of myocardial blood flow (MBF) is reported in up to 30% of ST-segment elevation myocardial infarction (STEMI) despite prompt mechanical revascularization. Experimental hyperinsulinemic euglycemia (HE) increases MBF reserve (MBFR). If fully exploited, this effect may also improve MBF to ischemic myocardium. Using insulin-dextrose infusions to induce HE, we conducted four experiments to determine (1) how insulin infusion duration, dose, and presence of insulin resistance affect MBFR response; and (2) the effect of an insulin-dextrose infusion given immediately following revascularization of STEMI on myocardial perfusion.

METHODS

The MBFR was determined using myocardial contrast echocardiography. Experiment 1 (insulin duration): 12 participants received an insulin-dextrose or saline infusion for 120 minutes. MBFR was measured at four time intervals during infusion. Experiment 2 (insulin dose): 22 participants received one of three insulin doses (0.5, 1.5, 3.0 mU/kg/minute) for 60 minutes. Baseline and 60-minute MBFRs were determined. Experiment 3 (insulin resistance): five metabolic syndrome and six type 2 diabetes (T2DM) participants received 1.5 mU/kg/minute of insulin-dextrose for 60 minutes. Baseline and 60-minute MBFRs were determined. Experiment 4 (STEMI): following revascularization for STEMI, 20 patients were randomized to receive either 1.5 mU/kg/minute insulin-dextrose infusion for 120 minutes or standard care. Myocardial contrast echocardiography was performed at four time intervals to quantify percentage contrast defect length.

RESULTS

Experiment 1: MBFR increased with time through to 120 minutes in the insulin-dextrose group and did not change in controls. Experiment 2: compared with baseline, MBFR increased in the 1.5 (2.42 ± 0.39 to 3.25 ± 0.77, P = .002), did not change in the 0.5, and decreased in the 3.0 (2.64 ± 0.25 to 2.16 ± 0.33, P = .02) mU/kg/minute groups. Experiment 3: compared with baseline, MBFR increase was only borderline significant in metabolic syndrome and T2DM participants (1.98 ± 0.33 to 2.59 ± 0.45, P = .04, and 1.67 ± 0.35 to 2.14 ± 0.21, P = .05). Experiment 4: baseline percentage contrast defect length was similar in both groups but with insulin decreased with time and was significantly lower than in controls at 60 minutes (2.8 ± 5.7 vs 13.7 ± 10.6, P = .02).

CONCLUSIONS

Presence of T2DM, insulin infusion duration, and dose are important determinants of the MBFR response to HE. When given immediately following revascularization for STEMI, insulin-dextrose reduces perfusion defect size at one hour. Hyperinsulinemic euglycemia may improve MBF following ischemia, but further studies are needed to clarify this.

Knowledge Translation in Dietetics: A Survey of Dietitians' Awareness and Confidence

This study aimed to determine dietitians' familiarity with knowledge translation (KT), confidence in undertaking KT, and preferences for receiving KT training. An online questionnaire was designed and disseminated to all dietitians working across hospital and health services in Queensland, Australia, for completion over a 6-week period (April-May 2018). Of the 124 respondents, 69% (n = 85) reported being familiar with KT, but only 28% (n = 35) reported being confident in applying KT to their practice. Higher confidence was reported with problem identification, evidence appraisal, and adapting evidence to local context, compared with implementation, evaluation, and dissemination. Almost all respondents reported an interest in learning more about KT (n = 121, 98%), with a preference for easily accessible and short "snippets" of training aimed at beginner-intermediate level. Lack of management support, difficulty attending multi-day courses, cost, travel requirements, and lack of quarantined time were reported barriers to attending KT training. There is a high awareness and interest but low confidence in undertaking KT amongst dietitians. This highlights an opportunity for workforce development to prepare dietitians to be skilled and confident in KT. Training and support needs to be low-cost and multi-modal to meet diverse needs.

A qualitative exploration of factors influencing medical staffs' decision-making around nutrition prescription after colorectal surgery

BACKGROUND

Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients' diets after surgery, this study explored factors which influenced medical staffs' decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions.

METHODS

This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation.

RESULTS

Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition.

CONCLUSIONS

Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs' decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations.

Treatment of clozapine-associated obesity and diabetes with exenatide in adults with schizophrenia: A randomized controlled trial (CODEX)

Clozapine causes obesity and type 2 diabetes (T2DM). Glucagon-like peptide-1 (GLP-1) receptor agonists (e.g. exenatide) can counter clozapine-associated GLP-1 dysregulation in animals, and may be beneficial in people on clozapine. This randomized, controlled, open-label, pilot trial evaluated weekly exenatide for weight loss among clozapine-treated obese adults with schizophrenia, with or without T2DM. A total of 28 outpatients were randomized to once-weekly extended-release subcutaneous exenatide or usual care for 24 weeks. The primary outcome was proportion of participants with >5% weight loss. All 28 participants completed the study; 3/14 in the exenatide group and 2/14 in the usual care group had T2DM. Six people on exenatide achieved >5% weight loss vs one receiving usual care (P = .029). Compared with usual care, participants on exenatide had greater mean weight loss (-5.29 vs -1.12 kg; P = .015) and body mass index reduction (-1.78 vs -0.39 kg/m² ; P = .019), and reduced fasting glucose (-0.34 vs 0.39 mmol/L; P = .036) and glycated haemoglobin levels (-0.21% vs 0.03%; P = .004). There were no significant differences in other metabolic syndrome components. Exenatide may be a promising therapeutic agent for glycaemic control and weight loss in clozapine-treated people with obesity, and could assist in reducing clozapine-associated cardio-metabolic morbidity and mortality.

Allied health research positions: a qualitative evaluation of their impact

Background

Research positions embedded within healthcare settings have been identified as an enabler to allied health professional (AHP) research capacity; however, there is currently limited research formally evaluating their impact. In 2008, a Health Practitioner industrial agreement funded a research capacity building initiative within Queensland Health, Australia, which included 15 new allied health research positions. The present project used a qualitative and realist approach to explore the impact of these research positions, as well as the mechanisms which facilitated or hindered their success within their respective organisations.

Methods

Forty-four AHP employees from six governmental health services in Queensland, Australia, participated in the study. Individual interviews were undertaken, with individuals in research positions (n = 8) and their reporting line managers (n = 8). Four stakeholder focus groups were also conducted with clinicians, team leaders and professional heads who had engaged with the research positions.

Results

Nine key outcomes of the research positions were identified across individual, team/service and organisational/community levels. These outcomes included clinician skill development, increased research activity, clinical and service changes, increased research outputs and collaborations, enhanced research and workplace culture, improved profile of allied health, development of research infrastructure, and professional development of individuals in the research positions. Different mechanisms that influenced these outcomes were identified. These mechanisms were grouped by those related to the (1) research position itself, (2) organisational factors and (3) implementation factors.

Conclusions

The present findings highlight the potential value of the research positions for individuals, teams and clinical services across different governmental healthcare services, and demonstrate the impact of the roles on building the internal and external profile of allied health. Results build upon the emerging evidence base for allied health research positions and have important implications for a number of stakeholders (i.e. individuals in the research positions, AHPs and their managers, university partners and state-wide executives). Key recommendations are provided for all stakeholders to enhance the ongoing impact of these roles and the potential advocacy for additional positions and resources to support them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0166-4) contains supplementary material, which is available to authorized users.

Helicobacter pylori infection and ischemic heart disease: could experimental data lead to clinical studies?

Despite the remarkable advances made in primary prevention and treatment, ischemic heart disease (IHD) remains the leading cause of death and a significant cause of disability in developed countries. Since traditional cardiovascular risk factors failed to predict all cases of IHD, there is an intensive research to explore other potential etiologic factors. Among these, numerous studies have considered the theoretical link between IHD and chronic infections, including Helicobacter pylori (H. pylori). Considering that epidemiologic studies have produced conflicting results, due to geographical variations of IHD and H. pylori prevalence as well as heterogeneity of study designs, an alternative way to analyze this topic is to assess if consistency for a biological plausibility exists. In this review we critically analyzed the experimental data on this topic, to assess whether their results could lead future clinical studies.

Growth hormone (GH) enhances anaerobic capacity: impact on physical function and quality of life in adults with GH deficiency

CONTEXT

Anaerobic capacity is impaired in adults with GH deficiency (GHD), adversely affecting physical function and quality of life (QoL).

OBJECTIVE

To investigate whether GH replacement improves anaerobic capacity, physical function and QoL in adults with GHD.

DESIGN

One-month double-blind placebo-controlled crossover study of GH (0·5 mg/day), followed by a 6-month open phase.

PATIENTS

A total of 18 adults with GHD.

MEASUREMENTS

Anaerobic power (watts) was assessed by the 30-s Wingate test, and aerobic capacity by the VO2 max (l/min) test. Physical functional was assessed by the stair climb test, chair stand test, 7-day pedometry and QoL by the AGHDA questionnaire. Lean body mass (LBM) was quantified by dual-energy X-ray absorptiometry.

RESULTS

GH replacement normalized IGF-1 levels during both study phases. During the 1-month placebo-controlled study, improvement in stair climb and chair stand performance was observed during GH and placebo treatment; however, there were no significant GH effects observed in any outcome measure compared to placebo. Six months of GH treatment significantly increased anaerobic power (P < 0·05), chair stand repetitions (P < 0·0001), daily step count (P < 0·05) and QoL scores (P < 0·001) compared to baseline measurements. GH treatment did not significantly improve VO2 max. Improvement in anaerobic power independently predicted an improvement in energy and vitality domain of QoL (P = 0·03).

CONCLUSIONS

GH replacement improves anaerobic capacity, physical function and QoL in a time-dependent manner in adults with GHD. Improvement in the anaerobic but not aerobic energy system is likely to underlie the improvement in QoL in patients with GHD during GH replacement.

Impairment of anaerobic capacity in adults with growth hormone deficiency

CONTEXT

The anaerobic energy system underpins the initiation of all physical activities, including those of daily living. GH supplementation improves sprinting in recreational athletes, a performance measure dependent on the anaerobic energy system. The physiological and functional link between GH and the anaerobic energy system is unknown.

OBJECTIVE

The objective was to investigate whether anaerobic capacity is impaired in adults with GH deficiency (GHD) and to assess its functional significance.

DESIGN

This was a cross-sectional study.

PARTICIPANTS

The participants were 13 adults with GHD and 13 age-, gender- and body mass index-matched normal subjects.

MAIN OUTCOME MEASURES

Anaerobic power (watts) was assessed by the 30-second Wingate test, and aerobic capacity was assessed by the VO2max (L/min) test. The functional assessment comprised the stair-climb test, chair-stand test, and 7-day pedometry. Quality of life (QoL) was assessed by the QoL-AGHDA questionnaire. Lean body mass (LBM) was quantified by dual-energy x-ray absorptiometry.

RESULTS

Mean anaerobic power (5.8 ± 0.4 vs 7.1 ± 0.3 W · kg LBM(-1); P < .05) and VO2max were significantly lower in adults with GHD. The duration of the stair-climb test was longer (19.4 ± 0.7 vs 16.5 ± 0.7 s; P < .01) in adults with GHD and correlated negatively (R(2) = 0.7; P < .0001) with mean anaerobic power. The mean number of chair-stand repetitions and daily step counts were lower, and the QoL-AGHDA score was higher in adults with GHD (P < .05). In a multiple regression analysis, age, gender, LBM, and GH status were significant predictors of mean anaerobic power. Mean anaerobic power significantly predicted stair-climb performance (P < .01) and QoL (P < .05).

CONCLUSIONS

Anaerobic capacity is subnormal, and it independently predicts stair-climbing capacity and QoL in adults with GHD. We conclude that GH regulates anaerobic capacity, which determines QoL and selective aspects of physical function.

Reproducibility of Fatmax and fat oxidation rates during exercise in recreationally trained males

Aerobic exercise training performed at the intensity eliciting maximal fat oxidation (Fat(max)) has been shown to improve the metabolic profile of obese patients. However, limited information is available on the reproducibility of Fat(max) and related physiological measures. The aim of this study was to assess the intra-individual variability of: a) Fat(max) measurements determined using three different data analysis approaches and b) fat and carbohydrate oxidation rates at rest and at each stage of an individualized graded test. Fifteen healthy males [body mass index 23.1 ± 0.6 kg/m(2), maximal oxygen consumption (VO2max) 52.0 ± 2.0 ml/kg/min] completed a maximal test and two identical submaximal incremental tests on ergocycle (30-min rest followed by 5-min stages with increments of 7.5% of the maximal power output). Fat and carbohydrate oxidation rates were determined using indirect calorimetry. Fat(max) was determined with three approaches: the sine model (SIN), measured values (MV) and 3rd polynomial curve (P3). Intra-individual coefficients of variation (CVs) and limits of agreement were calculated. CV for Fat(max) determined with SIN was 16.4% and tended to be lower than with P3 and MV (18.6% and 20.8%, respectively). Limits of agreement for Fat(max) were -2 ± 27% of VO2max with SIN, -4 ± 32 with P3 and -4 ± 28 with MV. CVs of oxygen uptake, carbon dioxide production and respiratory exchange rate were <10% at rest and <5% during exercise. Conversely, CVs of fat oxidation rates (20% at rest and 24-49% during exercise) and carbohydrate oxidation rates (33.5% at rest, 8.5-12.9% during exercise) were higher. The intra-individual variability of Fat(max) and fat oxidation rates was high (CV>15%), regardless of the data analysis approach employed. Further research on the determinants of the variability of Fat(max) and fat oxidation rates is required.

Helicobacter pylori infection and respiratory diseases: actual data and directions for future studies

Helicobacter pylori (H. pylori) has been conclusively related to several gastroduodenal diseases. The possible role of the bacterium in the development of extragastric manifestations has been investigated in the past few years. To identify all publications on the association between H. pylori and respiratory diseases, a MEDLINE search of all studies published in English from 1965 to 2013 was conducted. All data are based on case-control studies. Controversial findings of H. pylori seroprevalence have been obtained in patients with bronchial asthma, lung cancer, pulmonary tuberculosis, sarcoidosis, cystic fibrosis, chronic bronchitis and bronchiectasis. At present, on epidemiological bases, there is no definite evidence of a causal relationship between H. pylori infection and respiratory diseases. There is a low consideration of confounding factors as poorer socioeconomic status and tobacco use. The activation of pro-inflammatory cytokines by H. pylori might be a possible pathogenetic mechanism. However, there are no convincing data about the influence of H. pylori on the inflammatory changes of the bronchoepithelium so far. Further studies are needed on the impact of H. pylori eradication, on the prevention, development and natural history of these disorders.

Resting energy expenditure of morbidly obese patients using indirect calorimetry: a systematic review

The increasing proportion of acutely ill hospital patient admissions presenting with a morbidly obese body mass index (BMI ≥ 40 kg m(-2) ) as a comorbidity is an emerging clinical concern. Suboptimal food intake and malnutrition is prevalent in the acute care hospital setting. The energy requirements necessary to prevent malnutrition in acutely ill patients with morbid obesity remains unclear. The aim of this systematic review was to identify studies in the literature that have used indirect calorimetry to measure the resting energy expenditure of patients with morbid obesity to establish their minimum energy requirements and the implications for optimal feeding practices in acutely ill hospitalized patients. A total of 20 studies from PubMed, Cochrane Library and Embase met the inclusion criteria and were reviewed. All articles were graded using the Australian National Health and Medical Research Council levels of evidence and given a quality rating using the American Dietetic Association recommendations. Studies were categorized according to the mean BMI of its subjects. The most commonly measured resting energy expenditures for morbidly obese patients are between 2,000 and 3,000 kcal d(-1) (8,400-12,600 kJ d(-1) ). Activity and injury factors of acutely ill morbidly obese patients could result in significantly greater energy requirements for this patient group and are unlikely to be met by standard hospital menus. Establishing the minimum energy requirements for this population group will help inform adequate and accurate energy provision in the acute setting. Outcomes of underfeeding and overfeeding in morbidly obese patients warrant further research.

Sites and mechanisms of insulin resistance in nonobese, nondiabetic patients with chronic hepatitis C

Chronic hepatitis C (CHC) has been associated with type 2 diabetes and insulin resistance, but the extent of impairment in insulin action, the target pathways involved, and the role of the virus per se have not been defined. In this study, we performed a euglycemic hyperinsulinemic clamp (1 mU x minute(-1) x kg(-1)) coupled with infusion of tracers ([6,6-(2)H(2)]glucose, [(2)H(5)]glycerol) and indirect calorimetry in 14 patients with biopsy-proven CHC, who were selected not to have any features of the metabolic syndrome, and in seven healthy controls. We also measured liver expression of inflammatory cytokines/mediators and tested their association with the metabolic parameters. Compared to controls, in patients with CHC: (1) total glucose disposal (TGD) during the clamp was 25% lower (P = 0.003) due to impaired glucose oxidation (P = 0.0002), (2) basal endogenous glucose production (EGP) was 20% higher (P = 0.011) and its suppression during the clamp was markedly reduced (P = 0.007), and (3) glycerol appearance was not different in the basal state or during the clamp, but lipid oxidation was less suppressed by insulin (P = 0.004). Lipid oxidation was higher in patients with CHC who had more steatosis and was directly related to EGP, TGD, and glucose oxidation. The decreased insulin-stimulated suppression of EGP was associated with increased hepatic suppressor of cytokine signaling 3 (SOCS3; P < 0.05) and interleukin-18 (P < 0.05) expression.

CONCLUSION

Hepatitis C infection per se is associated with peripheral and hepatic insulin resistance. Substrate competition by increased lipid oxidation and possibly enhanced hepatic expression of inflammatory cytokines/mediators could be involved in the defective glucose regulation.

Changes in serum adiponectin concentrations in critical illness: a preliminary investigation

INTRODUCTION

Adiponectin plays an important role in the regulation of tissue inflammation and insulin sensitivity. Perturbations in adiponectin concentration have been associated with obesity and the metabolic syndrome. Data on adiponectin pathophysiology in critical illness are limited.

METHODS

Twenty three critically ill patients (9 severe sepsis, 7 burns, 7 trauma). Adiponectin assays on Days 3 (D3) and 7 (D7). Simultaneous, cortisol, cortisone and CRP measurements. Data from 16 historical controls were used for comparison.

RESULTS

The mean plasma adiponectin concentration for the ICU cohort on D3 and D7 were not significantly different (4.1 +/- 1.8 and 5.0 +/- 3.3 mcg/ml respectively, P = 0.38). However, these were significantly lower than the mean plasma adiponectin in the control population (8.78 +/- 3.81 mcg/ml) at D3 (P < 0.0001) and D7 (P = 0.002). Plasma adiponectin showed a strong correlation with plasma cortisol in the ICU group on both D3 (R2 = 0.32, P < 0.01) and D7 (R2 = 0.64, 0.001). There was an inverse correlation between plasma adiponectin and CRP on D7, R = -0.35.

CONCLUSIONS

In this preliminary study, critical illness was associated with lower adiponectin concentrations as compared with controls. A significant relationship between plasma cortisol and adiponectin in critically ill patients was evident, both during the early and late phases. These data raise the possibility that adiponectin may play a part in the inflammatory response in patients with severe illness.

Evidence of altered cortisol metabolism in critically ill patients: a prospective study

CONTEXT

Changes in cortisol metabolism due to altered activity of the enzyme 11beta-hydroxysteroid dehydrogenase (11beta-HSD) have been implicated in the pathogenesis of hypertension, obesity and the metabolic syndrome. No published data exist on the activity of this enzyme in critical illness.

OBJECTIVE

To investigate cortisol metabolism in critically ill patients utilising plasma cortisol: cortisone ratio as an index of 11beta-HSD activity.

SETTING

Tertiary level intensive care unit.

PATIENTS

Three cohorts of critically ill patients: sepsis (n = 13); multitrauma (n = 20); and burns (n = 19).

MAIN OUTCOME MEASURES

Serial plasma cortisol: cortisone ratios.

MEASUREMENTS AND MAIN RESULTS

Plasma total cortisol cortisone ratios were determined serially after admission to the intensive care unit. As compared with controls, the plasma cortisol:cortisone ratio was significantly elevated in the sepsis and trauma cohorts on day 1 (22 +/- 9, p = 0.01, and 23 +/- 19, p = 0.0003, respectively) and remained elevated over the study period. Such a relationship was not demonstrable in burns. The ratio was significantly correlated with APACHE II (r = 0.77, p = 0.0008) and Simplified Acute Physiology Score (r = 0.7, p = 0.003) only on day 7 and only in the burns cohort. There were no significant correlations observed between total plasma cortisol or cortisone and sickness severity in the sepsis and trauma cohorts.

CONCLUSIONS

In critically ill patients, there is evidence of altered cortisol metabolism due to an increase in 11beta-HSD activity as demonstrated by an elevation of plasma cortisol: cortisone ratios. Further studies with larger sample sizes specifically designed to examine altered tissue 11beta-HSD activity and its clinical significance and correlation with outcome are warranted.

Residential camps as a setting for nutrition education of Australian girls

OBJECTIVE

To implement a planned nutrition education program aiming to promote healthy eating and consumption of a variety of foods in a residential camp setting for Australian girls aged 9-15 years.

METHODS

1,600 girls attending a seven-day residential camp in Queensland (2000) participated in a program involving the provision of healthy, tasty foods based on the Australian Dietary Guidelines for Children and Adolescents and a nutrition education package for use at the camp restaurants each evening that included nutrition information together with individual 'passport booklets involving puzzles and questions with incentives for completion. Process and impact evaluations were conducted by surveying a sample of participants using questionnaires and focus groups.

RESULTS

Of those surveyed, 77% felt they had leamed something from the health promotion material; 94% said they had changed their eating habits to include more core food groups during the camp, with more than 40% stating they had increased vegetable consumption compared with their usual intake. However, approximately 60% of campers were apparently unaware of the incentives offered and less than 30% demonstrated completion of their passports.

CONCLUSIONS

Barriers to the involvement of this target group in the health promotion activities need to be explored further. Involvement and training of key personnel is suggested to ensure consistent implementation and encouragement for all participants. Long-term behaviour changes outside the camp environment should also be assessed in any future programs.

IMPLICATIONS

Using residential camp settings to target children is an innovative strategy for nutrition education. Integration of such strategies into longer time frame programs may benefit participants and improve effectiveness of nutrition education programs aimed at this group.