Obesity Measures and Definitions of Sarcopenic Obesity in Singaporean Adults - the Yishun Study

OBJECTIVES

Due to the lack of a uniform obesity definition, there is marked variability in reported sarcopenic obesity (SO) prevalence and associated health outcomes. We compare the association of SO with physical function using current Asian Working Group for Sarcopenia (AWGS) guidelines and different obesity measures to propose the most optimal SO diagnostic formulation according to functional impairment, and describe SO prevalence among community-dwelling young and old adults.

DESIGN

Obesity was defined according to waist circumference (WC), percentage body fat (PBF), fat mass index (FMI), fat mass/fat-free mass ratio (FM/FFM), or body mass index (BMI). SO was defined as the presence of both obesity and AWGS sarcopenia. Muscle function was compared among phenotypes and obesity definitions using ANOVA. Differences across obesity measures were further ascertained using multiple linear regressions to determine their associations with the Short Physical Performance Battery (SPPB).

SETTING

Community-dwelling adults 21 years old and above were recruited from a large urban residential town in Singapore.

PARTICIPANTS

535 community-dwelling Singaporeans were recruited (21-90 years old, 57.9% women), filling quotas of 20-40 participants in each sex- and age-group.

MEASUREMENTS

We took measurements of height, weight, BMI, waist and hip circumferences, body fat, muscle mass, muscle strength, and functional assessments. Questionnaire-based physical and cognitive factors were also assessed.

RESULTS

Overall prevalence of SO was 7.6% (WC-based), 5.1% (PBF-based), 2.7% (FMI-based), 1.5% (FM/FFM-based), and 0.4% (BMI-based). SO was significantly associated with SPPB only in the FMI model (p<0.05), and total variance explained by the different regression models was highest for the FMI model.

CONCLUSIONS

Our findings suggest FMI as the most preferred measure for obesity and support its use as a diagnostic criteria for SO.

Malnutrition and Sarcopenia in Community-Dwelling Adults in Singapore: Yishun Health Study

OBJECTIVES

To determine the overlapping prevalence of malnutrition and sarcopenia and the association between parameters of malnutrition with muscle mass and strength in a community-dwelling Singaporean adult population.

DESIGN

This was a cross-sectional study.

SETTING

Large north-eastern residential town of Yishun in Singapore.

PARTICIPANTS

Random sampling of community-dwelling Singaporeans aged 21-90 years old (n=541).

MEASUREMENTS

Anthropometry, body composition and handgrip strength (muscle strength) were measured. Sarcopenia was identified using dual-energy x-ray absorptiometry scan (muscle mass). Nutritional status was measured using Mini Nutritional Assessment (MNA-SF). Other questionnaires collected included physical activity and cognition. Associations between nutritional status with sarcopenia as well as with muscle mass and strength were analysed using multinomial logistics and linear regressions.

RESULTS

The overall population-adjusted prevalence of those at nutritional risk and malnourished were 18.5% and 0.1% respectively. More than a third of participants (35%) who were at nutritional risk were sarcopenic. Malnourished participants were all sarcopenic (100%, N=2) whereas those who were sarcopenic, 27.0% (N=37) were at nutritional risk/malnourished. Being at nutritional risk/malnourished was significantly associated with 2 to 3 times increased odds of sarcopenia in multivariate analyses adjusting for age, gender, physical activity level and cognition, and fat mass index. Favourable MNA parameter scores on food intake and BMI were positively associated with greater muscle mass and handgrip strength (p<0.05).

CONCLUSION

Given the overlapping clinical presentation of malnutrition and sarcopenia, community screening protocols should include combination screening of nutritional status and sarcopenia with appropriate interventions to mitigate risk of adverse health outcomes.

L-theanine attenuates transport stress-induced impairment of meat quality of broilers through improving muscle antioxidant status

This study was to investigate the effect of dietary L-theanine (THE) supplementation (0, 600 mg/kg) on growth performance, carcass traits, immune organ indexes, meat quality, and muscle antioxidant status of transported broilers. A total of 180 one-day-old male Ross 308 broilers were randomly allotted to 2 treatment groups including a THE-free group with 12 replicates of 10 birds each and a THE group with 6 replicates of 10 birds each. On the morning of day 42, after a 9-h fast, the birds of THE-free group were divided into 2 equal groups, and then all birds in the 3 groups were placed into 18 crates and were transported according to the following protocols: 0-h transport of birds in the THE-free group (control group), 3-h transport of birds in the THE-free group (T group), and 3-h transport of birds in the THE group (T + THE group). Results showed that dietary THE supplementation improved feed conversion ratio and birds' final body weight (P < 0.05), while transport and dietary THE supplementation did not affect carcass traits of broilers (P > 0.05). Transport increased bird live weight loss, drip loss, L*24 h, muscle malondialdehyde (MDA), protein carbonyl (PC) and lactate contents, while it decreased thymus, spleen, and bursa of Fabricius indexes, pH24h, a*, and muscle total antioxidant capacity (T-AOC), catalase (CAT), and glutathione peroxidase (GSH-PX) activities and glycogen content (P < 0.05). Nevertheless, compared with birds in the T group, birds in the T + THE group exhibited increased thymus, spleen, and bursa of Fabricius indexes, pH24h, a*24 h, and muscle T-AOC, CAT, and GSH-PX activities and glycogen content, and decreased drip loss, L*24 h, and muscle MDA, PC, and lactate contents (P < 0.05). This study provided the first evidence that dietary THE supplementation prevented transport-stress-impaired immune organ indexes and meat quality of broilers, and the reason for maintenance of meat quality by supplementation of THE may be partly ascribed to the changed muscle glycolysis metabolism and antioxidant status.

Clinical analysis of 48-h emergency department visit post outpatient extracorporeal shock wave lithotripsy for urolithiasis

BACKGROUND

Patients suffering from renal or ureteral stones can undergo significant discomfort, even when timely diagnosed and treated. The aim of this study was to assess the risk factors and safety of outpatient Extracorporeal Shock Wave Lithotripsy (ESWL) in the management of patients with renal or ureteral stones.

METHODS

In this study, our cohort consisted of 844 outpatients who underwent outpatient ESWL treated between February 2012 and November 2014 at Taipei Veterans General Hospital. Patients who visited the emergency room (ER) within 48 h after Outpatient ESWL were included in this article. This article analyzes the stone size, stone shape (long to short axis ratio), stone location, previous medical management, urinalysis data, complications and treatment received in the emergency department.

RESULTS

Among the 844 initial consecutive patients who underwent outpatient ESWL a total of 1095 times, there were 22 (2%) patients who sought help at our emergency room within 48 h after the outpatient ESWL. Of those 22 patients, the mean age was 54.3 ± 12.6 years, and the BMI was 25.9 ± 3.2. The most common complication complaint was flank pain (55.2%). Other complications included hematuria (13.8%), fever (17.2%), nausea with vomiting (6.9%), acute urinary retention (3.4%) and chest tightness with cold sweating (3.4%). In 22 patients who went back to the ER, 7 patients were admitted to the ward and 1 patient again returned to the ER. All patients received medical treatment without ESWL or surgical management. The meaningful risk factor of ER-visiting rate following outpatient ESWL within 48 h was stone location, and the renal stones showed statistic significant (p = 0.047) when compared to ureteral stones.

CONCLUSION

Our study indicated that renal stone contributed to a significantly higher risk of ER-visiting rate to patients than did ureteral stone, following outpatient ESWL within 48 h. This study confirmed that Outpatient ESWL is a safe treatment for renal or ureteral stones, while inpatient ESWL is not absolutely necessary.

Clinical efficacy of transrectal ultrasound-guided prostate biopsy in men younger than 50 years old with an elevated prostate-specific antigen concentration (>4.0 ng/mL)

BACKGROUND

Prostate cancer (PCa) is not commonly found in men younger than 50 years of age. However, serum prostate-specific antigen (PSA) concentration has been examined more frequently at a younger age in Asia partially due to an increased awareness of prostate cancer. The purpose of our study was to investigate the efficacy and complication of PSA-triggered transrectal ultrasonography-guided prostate (TRUSP) biopsies. We retrospectively reviewed TRUSP biopsies in young men with elevated PSA concentration in Taipei Veterans General Hospital.

METHODS

We reviewed the cases of patients younger than 50 years of age with elevated PSA concentration (>4.0 ng/mL), who received 12 cores TRUSP biopsies at TPEVGH from January 2008-December 2013. The age, family history, digital rectal examination (DRE) results, PSA concentration, free/total PSA ratio, total prostate volume, PSA density, lower urinary tract symptoms and complications after the procedure were reviewed. The pathologic findings of TRUSP biopsy and clinical follow-up were reviewed and analyzed according to the Epstein criteria.

RESULTS

A total of 77 patients were included and were divided into 2 groups: 1) the younger group consisted of 20 patients <40 years of age; and 2) the elder group had 57 patients who were 40-50 years of age. The overall detection rate of PCa was 11.69% (9/77), and all of the PCa cases were diagnosed in the elder group (group detection rate: 15.8%). There was a significant difference in the severity of lower urinary tract symptoms (LUTS) between these 2 groups. All PCa patients were clinically significant according to the Epstein criteria. Two patients experienced fever (2.60%) after TRUSP biopsy.

CONCLUSION

From our patient cohort, it appears that no benefit was apparent for patients younger than 40 years old who received TRUSP biopsy, even with elevated PSA. However, PCa detected in men between 40 and 50 years of age were all clinically significant. Overall, our results supported current major practice guidelines which recommend an initial PSA checkup at 40 years of age.

Prostate cancer in young adults-Seventeen-year clinical experience of a single center

BACKGROUND

In the general population, prostate adenocarcinoma affects predominately older men. If fact, most current guidelines suggest that males over the age of 50 years should undergo prostate cancer screening. However, the clinical behavior and prognosis of prostate cancer in young adults is not well defined. The aim of this study was to evaluate the clinical behavior, pathological characteristics, and prognosis of prostate cancer in young adults.

METHODS

We retrospectively reviewed the records of young patients (age, ≤50 years) in our hospital with prostate adenocarcinoma between 1997 and 2013. We compared data including initial presentation, cancer cell type, Gleason score, disease stage, prostate-specific antigen (PSA) level, prostate volume, treatment, and survival between patients both younger and older than 50 years. Data were analyzed using the Kaplan-Meier method to assess survival.

RESULTS

Twenty-six patients were enrolled in our study, accounting for 0.55% of all patients with a diagnosis of prostate cancer at our facility. All 26 patients had a pathology diagnosis of adenocarcinoma, with a mean age on diagnosis of 46.8±2.8 years (range, 39-50 years). On initial presentation, patients older than 50 years more frequently displayed lower urinary tract symptoms (LUTS) than younger patients (62.3% vs. 30.4%, p=0.008). There was no statistical difference in histological grade, disease stage, PSA level, overall survival, and biochemical-free survival between the two groups.

CONCLUSION

The result of our investigation indicated that prostate adenocarcinoma patients younger than 50 years had similar histological grade, disease stage, PSA level, overall survival, and biochemical-free survival as the older population. However, patients younger than 50 years with prostate cancer less frequently showed initial symptoms of LUTS.

Patients with Urinary Incontinence Appear More Likely to Develop Upper Urinary Tract Stones: A Nationwide, Population-Based Study with 8-Year Follow-Up

This study aimed to investigate associations between primary urinary incontinence and development of upper urinary tract stones in a nationwide population in Taiwan. Data of 1,777 adults with primary urinary incontinence and 26,655 controls (groups A, B, and C) without urinary incontinence at study inception were retrieved from the National Health Insurance System database in Taiwan and were analyzed retrospectively. No enrolled subjects had previous diagnosis of upper urinary tract stones or spinal cord injury. All subjects were followed through end of 2009, with a minimum follow-up of 8 years. A greater percentage of study subjects (334/1777, 18.8%) developed upper urinary tract stones than that of control groups A (865/8885, 9.7%) and B (888/8885, 10%), and C (930/8885, 10.5%) (all p-values < 0.0001). Urinary incontinence was associated with significantly increased risk of developing urinary tract stones (HR 1.99, 95% CI, 1.70-2.34, p < 0.001). Age and metabolic syndrome status were both associated with developing upper urinary tract stones (both p-values < 0.0001). After adjusting for metabolic syndrome, regression analysis showed that urinary incontinence was still associated with a significantly increased risk of developing upper urinary tract stones (HR 1.99, 95% CI = 1.76-2.26, p < 0.0001). Long-term follow-up of Taiwanese patients with primary urinary incontinence suggests that urinary incontinence is associated with a significantly increased risk of developing upper urinary tract stones. Study findings suggest that physicians treating patients with urinary incontinence should give attention to early detection of upper urinary tract stones.

Microvascular Injury in Ketamine-Induced Bladder Dysfunction

The pathogenesis of ketamine-induced cystitis (KC) remains unclear. In this study, bladder microvascular injury was investigated as a possible contributing mechanism. A total of 36 KC patients with exposure to ketamine for more than 6 months, and 9 control subjects, were prospectively recruited. All participants completed questionnaires, including the O'Leary-Sant interstitial cystitis symptom index (ICSI) and the interstitial cystitis problem index (ICPI). All KC patients received a urodynamic study and radiological exams. Bladder tissues were obtained from cystoscopic biopsies in the control group and after hydrodistention in the KC group. Double-immunofluorescence staining of N-methyl-d-aspartate receptor subunit 1 (NMDAR1) and the endothelial marker, cluster of differentiation 31 (CD31), was performed to reveal the existence of NMDAR1 on the endothelium. Electron microscopy (EM) was applied to assess the microvascular change in the urinary bladder and to measure the thickening of the basement membrane (BM). A proximity ligation assay (PLA) was used to quantify the co-localization of the endothelial CD31 receptor and the mesenchymal marker [fibroblast-specific protein 1 (FSP-1)]. The Mann-Whitney U test and Spearman's correlation coefficient were used for statistical analysis. The mean ICSI [14.38 (± 4.16)] and ICPI [12.67 (± 3.54)] scores of the KC group were significantly higher than those (0 and 0, respectively) of the control group (both p < 0.001). The KC patients had decreasing cystometric bladder capacity (CBC) with a mean volume of 65.38 (± 48.67) mL. NMDAR1 was expressed on endothelial cells in both groups under immunofluorescence staining. Moreover, KC patients had significant BM duplication of microvessels in the mucosa of the urinary bladder under EM. The co-expression of the endothelial marker CD31 and mesenchymal marker FSP1 was significantly stained and calculated under PLA. In conclusion, microvascular injury and mesenchymal phenotypic alteration of endothelial cells can potentially contribute to KC-induced bladder dysfunction.

Transrectal ultrasound-guided prostate biopsy in Taiwan: A nationwide database study

BACKGROUND

For patients with an elevated prostate specific antigen (PSA) level or a suspected lesion detected by digital rectal examination, transrectal ultrasound-guided (TRUS) prostate biopsy is the standard procedure for prostate cancer diagnoses. In Taiwan, TRUS prostate biopsy has not been well-studied on a nationwide scale. This article aimed to study TRUS prostate biopsy in Taiwan and its related complications, according to the claims generated through the National Health Insurance (NHI) program.

METHODS

We applied for access to claims from the NHI Research Database of Taiwan of all patients who visited the urology clinic during the period of 2006 to 2010. In the 5-year urology profile, we obtained all records, which included admission and ambulatory clinical records. The definition of TRUS biopsy included codes for ultrasound-guided procedure and for prostate puncture; other codes involving complications such as postbiopsy voiding difficulty, significant bleeding, or infection requiring treatment were also included. Risk factors included age, diagnosis of prostate cancer, hospitalization or nonhospitalization, and the Charlson Comorbidity Index (CCI; with a value of 0, 1, 2 or ≥ 3). Descriptive and comparative analyses were also performed.

RESULTS

In the 5-year urology profile, 12,968 TRUS biopsies performed of which 6885 were in-patient procedures and 6083 were ambulatory clinic procedures. After the procedures, 1266 (9.76%) biopsies were associated with voiding difficulty; 148 (1.14%) biopsies, with significant bleeding; and 855 (6.59%) biopsies, with infection that required treatment. The prostate cancer diagnosis rate was 36.02%. The overall biopsy-related mortality rate within 30 days was 0.25%, and the postbiopsy sepsis-related mortality rate was 0.13%. Age, diagnosis of cancer, hospitalization, and CCI value ≥ 1 were all significant factors in univariate analysis and multivariate analysis for postbiopsy voiding difficulty and severe infection. A diagnosis of cancer and a CCI value ≥ 2 were significant factors for significant bleeding after biopsy. Patients diagnosed as having prostate cancer had fewer bleeding complications after biopsy.

CONCLUSION

The most frequent complication was postbiopsy voiding difficulty, followed by infection that required treatment and significant bleeding. The sepsis-related mortality rate was 0.13%. Significant risk factors for postbiopsy complications included age, diagnosis of prostate cancer, hospitalization, and the CCI value.

Vapoenucleation of the prostate using a high-power thulium laser: a one-year follow-up study

BACKGROUND

Prostate vaporization and enucleation is a novel treatment option for bladder outlet obstruction caused by benign prostate enlargement. This surgical technique, however, has not yet been standardized. We present our findings of using a high-power thulium laser to accomplish vapoenucleation of the prostate (ThuVEP).

METHODS

We prospectively collected and analyzed data from 29 patients who underwent ThuVEP between August 2010 and May 2012. The control group included 30 patients who underwent traditional transurethral resection of the prostate (TURP). Operative variables, patient profiles, preoperative and postoperative urine flow rates, prostate volume (measured using transrectal ultrasonography), and the international prostate symptom score (IPSS) were recorded and analyzed using a two-tailed Student's t-test and analysis of variance.

RESULTS

The ages (mean ± SD) of the patients were 76.1 ± 9.4 and 72.6 ± 7.4 years (p = 0.28) in the ThuVEP and TURP groups, respectively. The average urinary flow rates before and 12 months after the operation (volume/maximum flow/average flow) were 243.3/10.5/5.0 and 302.8/17.6/9.4 (in mL, mL/s, mL/s, respectively) in the ThuVEP group and 247.2/10.8/4.6 and 369.9/20.8/12.0, respectively, in the TURP group. Preoperative and postoperative IPSSs were 17.1 ± 5.0 and 6.5 ± 3.8, respectively, in the ThuVEP group and 18.2 ± 4.5 and 6.2 ± 3.3, respectively, in the TURP group. The mean ratio of the estimated postoperative residual prostate volume to the preoperative total volume was 0.47 (p = 0.449) in both groups. The overall complication rate was 20.7% in the ThuVEP group and 30.0% in the TURP group.

CONCLUSIONS

One year of follow-up showed that ThuVEP and TURP effectively alleviated subjective and objective voiding symptoms with a low rate of complications. Thus, vapoenucleation using a high-power laser is feasible in elderly patients.

TRIAL REGISTRATION

ISRCTN registry with study ID ISRCTN52339705 . Date assigned: 06/03/2015.