667 EFFECT OF LEUCINE SUPPLEMENTATION ON PHYSICAL PERFORMANCE, MUSCLE MASS AND QUALITY OF LIFE IN OLDER PEOPLE WITH SARCOPENIA

Introduction

Leucine supplementation improves muscle protein synthesis in physiological studies and has been proposed as a treatment to improve muscle mass and physical performance. We tested the effects of leucine supplementation in a randomised controlled trial enrolling patients with sarcopenia.

Methods

We conducted a placebo-controlled, parallel group, double-blind, randomised two-by-two factorial trial. Participants aged 70 and over with low muscle mass by bioimpedance and either low grip strength or low walk speed, were recruited from 14 UK sites. Participants were randomised to receive one year of leucine powder 2.5 g three times a day or matching placebo, plus perindopril 4 mg once daily or matching placebo. The primary outcome was the between-group difference in the Short Physical Performance Battery, measured at baseline, 6 and 12 months, analysed using repeated-measures mixed models. Secondary outcomes included grip strength, quadriceps strength, six-minute walk distance, appendicular muscle mass measured by dual x-ray absorptiometry, quality of life measured using the EQ5D tool, falls rates and adverse events.

Results

We screened 320 people and randomised 145 participants, mean age 79 (SD 6) years; 78 (54%) were women and the mean SPPB was 7.0 (SD 2.4). 72 were randomised to leucine and 73 to placebo. Median adherence was the same in both groups (76% vs 76%; p < 0.001). Leucine had no significant effect on the primary outcome (adjusted treatment effect 0.1 points [95%CI -1.0 to 1.1]). No significant treatment effect was seen for any secondary outcome. There were similar numbers of adverse events in both groups (leucine 187, placebo 196) and falls rates were similar (leucine 1.9 [95%CI 0.9 to 2.9] per year; placebo 2.9 [95%CI 0.8 to 5.0] per year).

Conclusion

Leucine did not improve measures of physical performance, muscle mass or quality of life in older people with sarcopenia.

666 EFFECT OF PERINDOPRIL ON PHYSICAL PERFORMANCE, MUSCLE MASS AND QUALITY OF LIFE IN OLDER PEOPLE WITH SARCOPENIA: RESULTS: FROM THE

Introduction

Angiotensin-converting enzyme inhibitors such as perindopril have been proposed as treatments to improve muscle mass and physical performance but have not been tested in randomised controlled trials enrolling patients with sarcopenia.

Methods

We conducted a placebo-controlled, parallel group, double-blind, randomised two-by-two factorial trial. Participants aged 70 and over with low muscle mass by bioimpedance and either low grip strength or low walk speed, were recruited from 14 UK sites. Participants were randomised to receive one year of perindopril 4 mg once daily or matching placebo, and to receive leucine powder 2.5 g three times a day or matching placebo. The primary outcome was the between-group difference in the Short Physical Performance Battery, measured at baseline, 6 and 12 months, analysed using repeated-measures mixed models. Secondary outcomes included grip strength, quadriceps strength, six-minute walk distance, appendicular muscle mass measured by dual x-ray absorptiometry, quality of life measured using the EQ5D tool, falls rates and adverse events.

Results

We screened 320 people and randomised 145 participants, mean age 79 (SD 6) years; 78 (54%) were women and the mean SPPB was 7.0 (SD 2.4). 73 were randomised to perindopril and 72 to placebo. Median adherence was lower for perindopril (76% vs 96%; p < 0.001). Perindopril had no significant effect on the primary outcome (adjusted treatment effect −0.1 points [95%CI -1.2 to 1.0]). No significant treatment effect was seen for any secondary outcome except for worse EQ5D thermometer scores in the perindopril group (treatment effect −12 points [95%CI -21 to −3]). More adverse events were seen in the perindopril group (218 vs 165) but falls rates were similar (perindopril 2.0 [95%CI 1.1 to 3.0] per year; placebo 2.8 [95%CI 0.6 to 5.1] per year).

Conclusion

Perindopril did not improve measures of physical performance, muscle mass or quality of life in older people with sarcopenia.

Dysphagia presentation and management following COVID-19: an acute care tertiary centre experience

OBJECTIVES

As the pathophysiology of COVID-19 emerges, this paper describes dysphagia as a sequela of the disease, including its diagnosis and management, hypothesised causes, symptomatology in relation to viral progression, and concurrent variables such as intubation, tracheostomy and delirium, at a tertiary UK hospital.

RESULTS

During the first wave of the COVID-19 pandemic, 208 out of 736 patients (28.9 per cent) admitted to our institution with SARS-CoV-2 were referred for swallow assessment. Of the 208 patients, 102 were admitted to the intensive treatment unit for mechanical ventilation support, of which 82 were tracheostomised. The majority of patients regained near normal swallow function prior to discharge, regardless of intubation duration or tracheostomy status.

CONCLUSION

Dysphagia is prevalent in patients admitted either to the intensive treatment unit or the ward with COVID-19 related respiratory issues. This paper describes the crucial role of intensive swallow rehabilitation to manage dysphagia associated with this disease, including therapeutic respiratory weaning for those with a tracheostomy.

Predicting drinking outcomes: Evidence from the United Kingdom Alcohol Treatment Trial (UKATT)

AIMS

To explore client characteristics that predict drinking outcomes using data from the UK Alcohol Treatment Trial (UKATT).

METHODS

Multiple linear regression was used to determine if there were any characteristics, measured before the start of treatment, that could predict drinking outcomes at three and 12months, as measured by percent day abstinent (PDA) and drinks per drinking day (DDD) over the preceding 90days.

RESULTS

Lower baseline DDD score and greater confidence to resist drinking predicted lower DDD at both three and twelve months following entry to treatment. In addition to baseline PDA and having greater confidence to resist heavy drinking, female gender, aiming for abstinence, more satisfaction with family life and a social network that included less support for drinking were predictors of percent days abstinent.

CONCLUSIONS

Overall the strongest and most consistent predictors of outcome were confidence to avoid heavy drinking and social support for drinking. More predictors were identified for percent of days abstinent than for drinks per drinking day. For percent of days abstinent, a number of client characteristics at baseline consistently predicted outcome at both month three and month twelve.

First reported outbreak of locally acquired hepatitis E virus infection in Australia

OBJECTIVE

To determine the source and extent of a locally acquired hepatitis E virus (HEV) infection outbreak.

DESIGN, SETTING AND PARTICIPANTS

A cluster of notified cases of HEV infection linked to a single restaurant (X) was identified in May 2014. People with laboratory-confirmed HEV infection in New South Wales between January 2013 and December 2014 were interviewed about potential risk factors for HEV infection. Co-diners at restaurant X and patients with suspected but unexplained viral hepatitis were retrospectively tested. Foods eaten by the infected persons were compared with those of seronegative co-diners. HEV RNA detected in sera from infected persons was sequenced and genotyped. Implicated foods were traced back to their sources.

MAIN OUTCOME MEASURES

Potential sources of infection, including overseas travel and foods eaten, and origin of implicated food products.

RESULTS

In 55 serologically confirmed cases of HEV infection, 24 people had not travelled overseas during their incubation periods. Of the 24, 17 reported having eaten at restaurant X, 15 of whom could be interviewed. All reported consuming pork liver pâté, compared with only four of seven uninfected co-diners (P < 0.05). The other seven people with locally acquired infections each reported consuming a pork product during their incubation periods. HEV RNA was detected in 16 of the 24 cases; all were of genotype 3. Sequencing indicated greater than 99% homology among restaurant X isolates. HEV RNA was isolated from pork sausages from a batch implicated in one of the locally acquired infections not linked with restaurant X. The pork livers used for pâté preparation by restaurant X were traced to a single Australian farm.

CONCLUSIONS

This is the first reported HEV outbreak in Australia. HEV should be considered in patients presenting with a compatible illness, even without a history of overseas travel. Pork products should be thoroughly cooked before consumption.

Transcriptional activation of antioxidants may compensate for selenoprotein deficiencies in Amblyomma maculatum (Acari: Ixodidae) injected with selK- or selM-dsRNA

The Gulf-Coast tick, Amblyomma maculatum, possesses an elaborate set of selenoproteins, which prevent the deleterious effects from oxidative stress that would otherwise occur during feeding. In the current work, we examined the role of selenoprotein K (SelK) and selenoprotein M (SelM) in feeding A. maculatum by bioinformatics, transcriptional gene expression, RNA interference and antioxidant assays. The transcriptional expression of SelK did not vary significantly in salivary glands or midguts throughout the bloodmeal. However, there was a 58-fold increase in transcript levels of SelM in tick midguts. Ticks injected with selK-dsRNA or selM-dsRNA did not reveal any observable differences in egg viability but oviposition was reduced. Surprisingly, salivary antioxidant activity was higher in selenoprotein knockouts compared with controls, which is probably the result of compensatory transcriptional expression of genes involved in combating reactive oxygen species. In fact, quantitative real-time PCR data suggest that the transcriptional expression of catalase increased in ticks injected with selM-double-stranded RNA. Additionally, the transcriptional expression of selN decreased ∼90% in both SelK/SelM knockdowns. These data indicate that SelK and SelM are salivary antioxidants but are not essential for tick survival or reproduction and are compensated by other antioxidant systems.

Pandemic clinical case definitions are non-specific: multiple respiratory viruses circulating in the early phases of the 2009 influenza pandemic in New South Wales, Australia

Background

During the early phases of the 2009 pandemic, subjects with influenza-like illness only had laboratory testing specific for the new A(H1N1)pdm09 virus.

Findings

Between 25^th May and 7^th June 2009, during the pandemic CONTAIN phase, A(H1N1)pdm09 virus was detected using nucleic acid tests in only 56 of 1466 (3.8%) samples meeting the clinical case definition required for A(H1N1)pdm09 testing. Two hundred and fifty-five randomly selected A(H1N1)pdm09 virus-negative samples were tested for other respiratory viruses using a real-time multiplex PCR assay. Of the 255 samples tested, 113 (44.3%) had other respiratory viruses detected: rhinoviruses 63.7%, seasonal influenza A 17.6%, respiratory syncytial virus 7.9%, human metapneumovirus 5.3%, parainfluenzaviruses 4.4%, influenza B virus 4.4%, and enteroviruses 0.8%. Viral co-infections were present in 4.3% of samples.

Conclusions

In the very early stages of a new pandemic, limiting testing to only the novel virus will miss other clinically important co-circulating respiratory pathogens.

Harmful drinking and talking about alcohol in primary care: New Zealand population survey findings

OBJECTIVE

Existing evidence suggests low recognition of alcohol problems in primary care. This study aimed to determine the 12-month prevalence of harmful or hazardous drinking (HHD) in a population sample and to measure the relationship between HHD and talking about alcohol in primary care consultations in that period.

METHOD

A New Zealand population survey of 12 488 adults. Alcohol use in the past 12 months was assessed by the Alcohol Use Disorders Identification Test (AUDIT), with HHD defined as a total score of eight or above. Talking about alcohol was self-reported.

RESULTS

HHD was present in 17.7% and was commoner in men and in younger age groups, with the highest prevalence 53.6% in men aged 18-24. Three per cent of those who attended their usual primary care provider in the past 12 months reported being talked to about alcohol. Talking about alcohol increased with AUDIT score, but was not commoner in young people despite their higher prevalence of HHD. Overall, 9.4% of attendees with HHD reported talking about alcohol.

CONCLUSION

HHD is common but largely not detected in primary care. Improved detection would permit the delivery of effective treatments such as brief interventions.

One Health in NSW: coordination of human and animal health sector management of zoonoses of public health significance

Zoonoses of public health significance may occur in wildlife, livestock or companion animals, and may be detected by the human or animal health sectors. Of particular public health interest are foodborne, arboviral and emerging zoonoses (known/unknown, endemic/exotic). A coordinated One Health approach to the management of zoonoses in NSW uses measures including: mutually agreed intersectoral procedures for detection and response; surveillance and notification systems for defined endemic and exotic diseases; joint meetings and exercises to ensure currency of response plans; and intersectoral communication during a response. This One Health approach is effective and ensures the interests of both the human health and animal health sectors are addressed.

Lessons from the NSW laboratory response to pandemic (H1N1) 2009 influenza

Procedures undertaken by NSW Health in the laboratory response to pandemic (H1N1) 2009 influenza were reviewed to assist planning for a future infectious disease emergency. Laboratory plans developed prior to the pandemic sought rapid detection of pandemic virus in the early phases of the pandemic response until demonstration of widespread community transmission, followed then by limited testing when indicated clinically. As planned, the laboratory response was based on the Pandemic Influenza Management System with a web-based outbreak management tool, NetEpi, as the single public health database used for cases and test results. This was found to be effective for tracking specimens and results, and enhanced the public health response. The sustained large volume of community testing during this mild pandemic had an adverse effect on the timely delivery of priority results.

The manufacturing process for recombinant factor IX

Advances in recombinant DNA manufacturing technology have now made possible the production of a highly purified and active recombinant factor IX (rFIX) product. Recombinant factor IX was developed by (1) stable insertion of the genes for both factor IX and PACE-SOL (a truncated, soluble serine protease needed to enhance the capacity of cells to remove the amino-terminal propeptide from rFIX) into Chinese hamster ovary cells; (2) selection of a cell line that was capable of expressing high amounts of active rFIX while growing in bioreactors containing a completely defined culture medium that does not contain blood or plasma products; and (3) inclusion of four independent chromatography steps, none of which require monoclonal antibodies. Furthermore, rFIX has been extensively tested to demonstrate similarity to plasma-derived factor IX and has been shown to be a consistent, high-purity product. For example, a high-specific-activity product (276+/-23 IU/mg) has been consistently produced throughout 65 consecutive batches from five consecutive manufacturing campaigns. Thus, rFIX offers a consistent and high-purity source of factor IX treatment for patients with hemophilia B.

Viral safety of recombinant factor IX

The viral safety of Chinese hamster ovary (CHO)-cell-based pharmaceuticals is well established. There have been more than 100 million infusions of CHO-derived pharmaceuticals without a single documented case of viral transmission. The recombinant factor IX (rFIX) process builds on this safety record by using a state-of-the-art multitiered approach to viral safety. This includes extensive testing of the CHO cells used to produce rFIX, routine viral monitoring of the cell culture production process, a manufacturing process and formulation that do not use blood or plasma products, and validation of the viral removal capacity of the purification process. The multifaceted viral safety program for rFIX has sufficient redundancy between approaches to compensate for potential limitations of any single safety measure. Together, the elements of the rFIX multitiered viral safety program offer patients and physicians a product that is inherently free of human blood-borne pathogens, including any risk of human immunodeficiency virus (HIV) hepatitis, parvovirus, and Creutzfeldt-Jakob disease (CJD).

Teaching baby massage to new parents

In this paper the author reviews six years of running an on-going baby massage group in a health clinic and makes observations, based on experience, on the importance of offering these classes in health centres where they are accessible to all parents with young babies. As baby massage classes are becoming increasingly popular, private individuals are offering classes and, in some cases, there is doubt as to the qualifications of the instructors, their understanding, and their ability to give sufficient support to young mothers at a vulnerable stage in their lives. The quality of training given by the International Association of Infant Massage Instructors based in the USA is appraised and some thoughts are given as to the way ahead in making more baby massage classes available to all parents within the Primary Preventive Health setting.

Actions of interleukin-4 on prostaglandin biosynthesis by human amnion cells

The effects of interleukin-4 (IL-4) on amnion prostaglandin (PG) production have been determined. Human amnion cells from term placentae were grown to confluence and incubated with IL-4 either alone or with various concentrations of epidermal growth factor (EGF) of ionomycin. PGE2 production was determined using a specific radioimmunoassay. IL-4 alone stimulated PGE2 production in amnion cells in a concentration-related manner. IL-4 significantly enhanced the stimulatory actions of ionomycin and EGF on amnion cell PGE2 production. Ionomycin and IL-4 acted synergistically in their effects on PGE2 production by amnion cells whereas EGF and IL-4 acted more additively in this respect. We suggest that IL-4 production by immune effector cells in gestational tissues may contribute to the mechanisms of labor at term and preterm.

Regulation of intrauterine prostaglandin biosynthesis: interactions between protein kinase C and interleukin 1 beta

Activation of protein kinase C with phorbol esters stimulates prostaglandin (PG) biosynthesis in many cell types whereas down-regulation of protein kinase C can suppress stimulatory responses. Interleukin-1 beta (IL-1 beta) can stimulate PG production by intrauterine tissues and may play a significant part in the mechanisms of preterm labor associated with intrauterine infection. Hence we have evaluated the effects of staurosporine and H7 (inhibitors of protein kinase C) on IL-1 beta stimulation of amnion, chorion and decidual prostaglandin E2 (PGE2) production. Staurosporine and H7 alone were without effect on PGE2 production by any cell type. However with minor exceptions both protein kinase C inhibitors enhanced the stimulatory actions of IL-1 beta on PGE2 production by all three cell types. Hence we believe that protein kinase C is closely linked to the regulation of intrauterine PG biosynthesis and that these links may have multiple layers of complexity.

Actions of interleukin-4 on prostaglandin biosynthesis at the chorion-decidual interface

OBJECTIVE

We determined the effects of interleukin-4 on chorion and decidual prostaglandin production.

STUDY DESIGN

Chorion and decidual cells from term placentas were grown to confluence. Cells were then incubated with interleukin-4 either alone or with other known stimulants of prostaglandin production: interleukin-1 beta, epidermal growth factor, ionomycin, or phorbol 12-myristate 13-acetate. Prostaglandin E2 production was determined with a specific radioimmunoassay.

RESULTS

Interleukin-4 alone stimulated prostaglandin E2 production in chorion and decidual cells. Interleukin-4 significantly enhanced the stimulatory actions of phorbol 12-myristate 13-acetate, ionomycin, and epidermal growth factor but not interleukin-1 beta on prostaglandin E2 production.

CONCLUSION

Interleukin-4 stimulates prostaglandin E2 production by chorion and decidual cells. These data suggest that interleukin-4 production by immune effector cells in gestational tissues may contribute to the pathophysiologic features of preterm labor.

Hands-on therapy

Touch is a primary need for babies to develop as healthy human beings, writes Suzanne Adamson. Here she describes the success of her baby massage class, run as part of her health visitor remit.

Co-localization of calcitonin gene-related peptide- and substance P-like immunoreactivity in mucosal intra-epithelial nerves in the toad colon

Mucosal intra-epithelial nerve terminals have been found in the colon of the toad, Bufo marinus. Co-localized in the fibres are calcitonin gene-related peptide (CGRP)-like immunoreactivity (LI) and substance P (SP)-LI. The intraepithelial nerves are likely to be terminals of primary afferent sensory neurones. Fibres with vasoactive intestinal peptide (VIP)-LI or neuropeptide Y (NPY)-LI also supply the mucosa but do not penetrate the epithelium.

The distribution of 5-hydroxytryptamine in the gastrointestinal tract of reptiles, birds and a prototherian mammal. An immunohistochemical study

The distribution of 5-hydroxytryptamine in the gut of several species of birds and reptiles, and of a prototherian mammal, the platypus, was studied using a monoclonal antibody. 5-Hydroxytryptamine-like immunoreactivity was found in enterochromaffin cells and, in birds, in thrombocytes. Immunoreactivity was not found in enteric neurons fixed immediately after dissection. A detailed study was made on one avian species, the budgerigar. Following incubation of intestine in physiological solution, immunoreactivity was found in nerve fibres in the gut wall that was more marked after incubation with the monoamine oxidase inhibitor pargyline. These fibres took up exogenous 5-hydroxytryptamine. Similar fibres were found in the intestinal nerves and in perivascular plexuses on mesenteric arteries. Both the uptake of 5-hydroxytryptamine and the appearance of neuronal immunoreactivity after incubation were inhibited by the amine uptake inhibitors desmethylimipramine or fluoxetine. Fibres taking up 5-hydroxytryptamine were damaged by pretreatment with 6-hydroxydopamine. It was concluded that the fibres showing immunoreactivity after incubation were adrenergic fibres that had taken up 5-hydroxytryptamine released in vitro from enterochromaffin cells or thrombocytes. These, and more limited observations made on the other species, suggest that birds, reptiles and prototherian mammals lack enteric neurons that use 5-hydroxytryptamine as a transmitter substance.