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Ephraim Joseph Fuchs, M.D.


https://www.hopkinsmedicine.org/profiles/results/directory/profile/0001532/ephraim-fuchs

The shaded areas (total 5%) give the probability that the null hypothesis is wrongly rejected medicine 8 - love shadow order asacol 400 mg with mastercard. The continuous/ curve shows the real sampling distribution of the sample difference symptoms irritable bowel syndrome buy asacol cheap, while the dashed curve shows the sampling distribution under the null hypothesis medicine game discount 800mg asacol mastercard. The shaded area is the probability (b%) that the null hypothesis fails to be rejected treatment question cheap asacol 400 mg. Another common misinterpretation is that the P-value is the probability that the null hypothesis is true medications japan cheap 400 mg asacol mastercard. It is based on considering what would happen if 1000 different null hypotheses were tested and significance at the 5 % level (P < 0:05) used as a threshold for rejection medications similar to abilify asacol 400mg amex, under the following plausible assumptions: 35. Reality Conclusion of significance test Null hypothesis true Null hypothesis false Total Reject null hypothesis (P<0:05) 45 (Type I errors Do not reject null hypothesis (P! Percentage of significant results that are falsepositives Proportion of studies in which the null hypothesis is false Power of study P fi 0:05 P fi 0:01 P fi 0:001 20% 5. This is conceivable given the large numbers of factors searched for in the epidemiological literature. For example by 1985 nearly 300 risk factors for coronary heart disease had been identified; it is unlikely that more than a fraction of these factors actually increase the risk of the disease. This is consistent with published surveys of the size of clinical trials (see, for example, Moher et al. Assumption (1) determines the column totals in the table; the null hypothesis is true in 900 of the tests and false in 100 of them. This means that we will incorrectly reject 45 of 428 Chapter 35: Calculation of required sample size the 900 true null hypotheses. It can be seen from the table that of the 95 tests that result in a statistically significant result, only 50 are correct; 45 (47. The table suggests that unless the proportion of meaningful hypotheses is very small, it is reasonable to regard P-values less than 0. Such errors may occur in a variety of ways, including: 1 Instrumental errors, arising from an inaccurate diagnostic test, an imprecise instrument or questionnaire limitations. In some instances the respondent may deliberately give the wrong answer because, for example, of embarrassment in questions connected with sexually transmitted diseases or because of suspicion that answers could be passed to income tax authorities. Our focus is on the detection, measurement and implications of random error, in the sense that we will assume that any errors in measuring a variable are independent of the value of other variables in the dataset. Detailed discussion of differential bias arising from the design or conduct of the study, such as selection bias,is outside the scope of this book. Readers are referred to textbooks on epidemiology and study design: recommended books are listed at the beginning of Chapter 34. We cover: 430 Chapter 36: Measurement error: assessment and implications 1 How to evaluate a diagnostic test or compare a measurement technique against a gold standard, that gives a (more) precise measurement of the true value. Often, the gold-standard method is expensive, and we wish to examine the performance of a cheaper or quicker alternative. In this section we consider how to assess the ability of a procedure to correctly classify individuals between the two categories of a binary variable. For example, individuals may be classified as diseased or non-diseased, exposed or non-exposed, positive or negative, or at high risk or not. Note that there is an inverse relationship between the two measures, tightening (or relaxing) criteria to improve one will have the effect of decreasing the magnitude of the other. For example, in designing a study to test a new leprosy vaccine, it would be important initially to exclude any lepromatous patients. One would therefore want a test with a high success rate of detecting positives, or in other words a highly sensitive test. One would be less concerned about specificity, since it would not matter if a true negative was incorrectly identified as positive and so excluded. In contrast, for the detection of cases during the post-vaccine (or placebo) follow-up period, one would want a test with high specificity, since it would then be more important to be confident that any positives detected were real, and less important if some were missed. Predictive values A clinician who wishes to interpret the results of a diagnostic test will want to know the probability that a patient is truly positive if the test is positive and similarly the probability that the patient is truly negative if the test is negative. The values of the positive and negative predictive values depend on the prevalence of the disease in the population, as well as on the sensitivity and specificity of the procedure used. The lower the prevalence of true positives, the lower will be the proportion of true positives among test positives and the lower, therefore, will be the positive predictive value. Similarly, increasing prevalence will lead to decreasing negative predictive value. This is a plot of sensitivity against 1A specificity, for different choices of cut-off. The name of the curve derives from its original use in studies of radar signal detection. In this example, we can see that if we required 75 % sensitivity from our cut-off then specificity would be around 50 %, while a lower cut-off value that gave around 60 % sensitivity would yield a specificity of about 75 %. This is because decreasing the specificity by lowering the cut-off would maintain sensitivity at 100 %, since a lower cut-off can only capture an equal or higher percentage of cases. In contrast, if the continuous measure is not able to discriminate at all, then 100 % sensitivity 36. This is particularly important for any variable that is subjectively assessed, such as in Example 36. Kappa statistic for categorical variables For categorical variables, the extent of reproducibility is usually assessed using a kappa statistic. This is based on comparing the observed proportion of agreement 434 Chapter 36: Measurement error: assessment and implications (Aobs) between two readings made by two different observers, or on two different occasions, with the proportion of agreements (Aexp) that would be expected simply by chance. It is denoted by the Greek letter kappa, and is defined as: Aobs A Aexp fi 1 A Aexp If there is complete agreement then Aobs fi 1 and so fi 1. If there is no more agreement than would be expected by chance alone then fi 0, and if there is less agreement than would be expected by chance alone then will be negative. Based on criteria originally proposed by Landis and Koch: kappa values greater than about 0. Standard errors for kappa have been derived, and are presented in computer output by many statistical packages. These may be used to derive a P-value corresponding to the null hypothesis of no association between the ratings on the two occasions, or by the two raters. In general, such P-values are not of interest, because the null hypothesis of no association is not a reasonable one. We will illustrate the calculation of kappa statistics using data from a study of the way in which people tend to explain problems with their health. We will do this first using a binary classification, and then a fuller 4-category classification. On the basis of this questionnaire they were classified according to whether or not they tended to provide a normalizing explanation of symptoms. This means discounting symptoms, externalizing them and explaining them away as part of normal experience. It can be seen that while 76 participants were consistently classified as normalizers, and 47 as non-normalizers, the classification changed for a total of 56 participants. More participants were classified as normalizers on the second than the first occasion. The observed proportion of agreement between the assessment on the two occasions, denoted by Aobs is therefore given by: Aobs fi (76 fi 47)=179 fi 123=179 fi 0:687 (68:7 %) Part (b) of Table 36. These expected numbers are calculated in a similar way to that described for the 36. The overall proportion classified as normalizers on the second occasion was 115=179. If this classification was unrelated to that on the first, then one would expect this same proportion of second occasion normalizers in each first occasion group, that is 115=179 A 93 fi 59:7 classified as normalizers on both occasions, and 115=179 A 86 fi 55:3 of those classified as non-normalizers on the first occasion classified as normalizers on the second. Similarly 64=179 A 93 fi 33:3 of those classified as normalizers on the first occasion would be classified as non-normalizers on the second, while 64=179 A 86 fi 30:7 would be classified as non-normalizers on both occasions. The expected proportion of chance agreement is therefore: Aexp fi (59:7 fi 30:7)=179 fi 0:505 (50:5%) Giving a kappa statistic of: fi (0:687 A 0:505)=(1 A 0:505) fi 0:37 this would usually be interpreted as representing at most moderate agreement between the two classifications made over the three-year follow-up period. Those classed as nonnormalizers (see earlier explanation) have been divided into somatizers, those who 436 Chapter 36: Measurement error: assessment and implications Table 36. The observed proportion of agreement between the two occasions using the four category classification is: Aobs fi (76 fi 0 fi 15 fi 11)=179 fi 102=179 fi 0:570 (57:0 %) the expected numbers for the various combinations of first and second occasion classification can be calculated in exactly the same way as argued in the twocategory example. For the kappa statistic, we need these only for the numbers of agreements; these are shown in Table 36. Aexp fi (59:7 fi 0:1 fi 6:9 fi 0:2)=179 fi 72:9=179 fi 0:407 (40:7%) giving Aobs A Aexp fi fi (0:570 A 0:407)=(1 A 0:407) fi 0:27 1 A Aexp representing poor to moderate agreement. As the number of categories increases, the value of kappa will tend to decrease, because there are more opportunities for misclassification. For instance, classification into adjacent categories might count as 50 % agreement, such as normalizers classified as somatizers and vice versa in Table 36. This is done using a weighted kappa statistic, in which the observed and expected proportions of agreement are modified to include partial agreements, by assigning a weight between 0 (complete disagreement) and 1 (complete agreement) to each category. Kappa statistics can also be derived when there are more than two raters: for more details see Fleiss (1981) or Dunn (1989). Numerical variables: reliability and the intraclass correlation coefficient We now describe how to quantify the amount of measurement error in a numerical variable. As with the kappa statistic, this may be done using replicate measurements of the variable: for example measurement of blood pressure made on the same patient by two observers at the same time, or using the same automated measuring device on two occasions one week apart. The intraclass correlation coefficient may be estimated using a one-way analysis of variance (see Chapter 11), or by using a simple random-effects model (see Chapter 31). While there is clearly an association between the measurements on the first and second occasions, there is also substantial between-occasion variability. The mean and standard deviation of log selenium intake (measured in log (base e) g=week) in the 94 subjects with repeat measurements were 3. There was some evidence that measured intake declined between the two measurements (mean reduction 0. The estimated components of variance were: 2 Within-subject (measurement error) variance, e fi 0:0535 2 Between-subject variance, u fi 0:0955 2 2 Total variance fi u fi e fi 0:1491 Fig. Links between weighted kappa and the intraclass correlation coefficient For ordered categorical variables, there is a close link between the weighted kappa statistic (defined above) and the intraclass correlation coefficient. For example, for an ordered categorical variable with four categories the weights would be 0 w11 fi w22 fi w33 fi w44 fi 1 A 2 fi 1 3 12 w12 fi w21 fi w23 fi w32 fi w34 fi w43 fi 1 A 2 fi 0:889 3 22 w13 fi w31 fi w24 fi w42 fi 1 A 2 fi 0:556 3 32 w14 fi w41 fi 1 A 2 fi 0 3 36. For example, lung function might be measured using a spirometer, which is expensive but relatively accurate, or with a peak flow meter, which is cheap (and can therefore be used by asthma patients at home) but relatively inaccurate. The appropriate analysis of such studies was described, in an influential paper, by Bland and Altman (1986). The women were asked to report their weight as part of a general questionnaire, and their weight was subsequently measured using accurate scales. The two measures are clearly strongly associated: the Pearson correlation between them is 0. It is important to note, however, that the correlation measures the strength of association between the measures and not the agreement between them. For example, if the measurements made with the new method were exactly twice as large as those made with the standard method then the correlation would be 1, even though the new method was badly in error. It can be seen that more of the points lie below the line than above it, suggesting that self-reported weight tends to be lower than measured weight. Bland and Altman suggested that the extent of agreement could be examined by plotting the differences between the pairs of measurements on the vertical axis, against the mean of each pair on the horizontal axis. If (as here) one method is known to be accurate, then the mean difference will tell us whether there is a systematic bias (a tendency to be higher or lower than the true value) in the other measurement. Data displays and analyses by kind permission of Dr Debbie Lawlor and Professor Shah Ebrahim. The dashed horizontal line corresponds to the mean difference (A0:93kg) while the dotted horizontal lines correspond to the 95% limits of agreement. There was thus a clear tendency for the women to under-report their weight, by an average of 0. If the differences are normally distributed then approximately 95 % of differences will lie within this range. Further, there was a tendency for greater (negative) differences with greater mean weight. Having calculated the mean difference and the 95 % limits of agreement, it is for the investigator to decide whether the methods are sufficiently in agreement for one (perhaps the cheaper method) to be used in place of the other. In this example, the systematic underreporting of weight in questionnaires, and the reduced 442 Chapter 36: Measurement error: assessment and implications accuracy, would have to be considered against the increased cost of inviting women to a visit at which their weight could be measured accurately. Note that the focus here is on random errors, in the sense that we are assuming that any errors in measuring a variable are independent of the values of other variables in the dataset. Frost and Thompson (2000) compare a number of methods to correct for regression dilution bias. However, methods to do this are more complex than those for numerical exposure variables, because the errors will be correlated with the true values. For example, if the true value of a binary variable is 0 then the size of the error is either 0 or 1, while if the true value is 1 then the size is 0 or A1. As mentioned above, correcting for regression dilution bias requires that we make replicate measurements on some or all subjects.

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People who develop short bowel syndrome (a condition that sometimes occurs after a signifcant portion of the small intestine has been removed or damaged) are also at risk medicine 377 cheap asacol uk. Symptoms of zinc defciency include a rash symptoms queasy stomach and headache order cheap asacol, changes in taste treatment definition cheap asacol online master card, smell and sight symptoms 8 days post 5 day transfer order asacol paypal, and difculty with wound healing medications beginning with z purchase asacol discount. If a defciency is suspected medicine buy asacol with visa, your physician can advise you on the proper amount needed for replacement. Your health care provider can help determine if you need additional supplementation of these vitamins. Omega-3 fatty acids: these are essential fats found in fatty fsh, faxseed, walnuts and fortifed products. These supplements should be stopped before procedures/surgery because they may prolong bleeding time. Probiotics: Probiotics are microorganisms contained in foods or supplements that provide benefcial health efects. The idea behind taking probiotic supplements and eating foods containing live bacteria is to restore the normal balance of microorganisms in the intestines. Lactobacillus preparations and live-culture yogurt are recommended for everyone. If the normal method of eating food by the mouth is not allowing enough nutrients to be absorbed, than other methods of getting nutrients must be used. Amino acids are the simplest forms of proteins that are needed for growth and development. Enteral Nutrition this form of nutrition can be taken by mouth or delivered through a feeding tube that is inserted directly into the stomach or small intestine. Intake of oral and/or enteral nutrition can help preserve or improve the absorption ability of the remaining small intestine. When extra nutrient-rich calories are needed, supplemental nutrition may also be obtained by formulas that contain a balance of protein, carbohydrates, fat and vitamins. The liquid mixture contains all the necessary proteins, carbohydrates, sugars, fats, vitamins, minerals and other nutrients. Parenteral nutrition may be needed when a fare is too severe, medical therapy alone is not enough and bowel rest is needed. Depending on the type and extent of the surgery, dietary changes, restrictions or other considerations may be necessary. There may be times when modifying your diet can be helpful, particularly during a fare. Keep in mind that your individual needs may be diferent based on such things as your disease symptoms, nutritional defciencies or food intolerances. Sample Meal Plan 1 Breakfast: fi cup egg substitute (= 1 ounce of protein) scrambled with 1. The following are some of the questions you may want to ask your doctor, dietitian or health care provider: Do I have any nutritional defcienciesfi Position of the American Dietetic Association: Health Implications of Dietary Fiber. Common causes include iron defciency, vitamin defciency and chronic infammation and other diseases Bile acid: Present in the digestive track, these agents can prevent stimulation of the colon, slow down the passage of stool and eliminate cholesterol from the body Celiac disease: A digestive disease. People with this disease cannot tolerate a protein called gluten, which is contained in wheat, rye and barley. Constipation: Bowel movements that are infrequent and hard to pass Dehydration: Excessive loss of water from the body Diarrhea: Passage of excessively frequent or excessively liquid stools Electrolytes: Minerals, including sodium, potassium and magnesium, that afect the amount of water in the body, acidity in the blood (pH level), muscle function and other processes. Many people cannot digest 43 lactose because they lack enzymes needed to digest simpler sugars Large intestine: Also known as the colon. The diet consists mainly of meats, vegetables, oils and honey, and excludes grains and most dairy products Supplementation: To add to , increase, or make up for a defciency Stricture: A narrowing of a section of the intestine caused by scarring. Today, the organization has grown to 40 local chapters, with more than $200 million invested in research for a cure and improved treatments. This funding has enabled many groundbreaking treatments, improved the quality of care for individuals with these conditions and brought hope to countless lives. Writing down when, what and how Absorption: Break down of food to be added much you eat can help you determine which, if any, foods afect your symptoms. Make sure to write down any unusual Colitis to the blood stream and nutrients carried symptoms you may experience after eating, and include the time they began. Anemia: A disorder of the blood where there colitis belong to a group of is not enough red blood cells. OnConstipation: Bowel movements that are infregoing infammation leads to symptoms such as quent and hard to pass abdominal pain and cramping, diarrhea, rectal bleeding, weight loss and fatigue. Crispy Chicken Breast Nuggets Food choices can become lactose is obtained from whey, a liquid byRecipes and Shitake Mushrooms Many kids and their parents love chicken or product of cheese. Chicken and fsh are both sources lactose because they lack enzymes needed to of protein. These fatty acids have been shown that worsen symptoms for a fare-up for your to help reduce the infammatory response and Ingredients symptoms. Recommended foods 3 cup (sweet) Marsala cooking wine become more complicated since certain foods mixing bowl, add bread crumbs, salt, pepper, are unprocessed, unrefned and untreated with Ingredients 1 pound baby spinach (washed and may worsen symptoms. Working in pesticides or hormones 1 premade pie crust stems removed) paid to avoiding foods that worsen or trigger batches, soak chicken in egg wash just enough 2 whole sweet potatoes cooked 6-ounce can sliced pitted black olives disease symptoms. Dip Mucus membranes: Cell linings of the intes 3 cup pumpkin puree (canned is fne) fi pound cleaned, dried and sliced shitake to learn how to make healthy food choices, chicken again in egg wash. Dip chicken in third tines and other organs involved in absorption 2 Tbsp butter mushrooms replace nutritional defciencies and maintain a bowl of crushed cereal. Spray baking sheet with and secretion fi cup Greek yogurt Salt and pepper to taste well-balanced nutrient-rich diet. Osteoporosis: Loss of bone density, causing 2 whole eggs and provides practical information to help you Wash and dry salmon, then dredge in seasoned Bake approximately 400 degrees Fahrenheit for skeletal weakness 2 teaspoons cinnamon eat well, stay healthy, learn to minimize dietfour. The Nutrition Facts Sweet Potato Pumpkin Pie Nutrition Facts Wild Salmon Nutrition Facts Chicken Nuggets diet consists mainly of meats, vegetables, oils Number of Servings: 8 Number of Servings: 4 Number of Servings: 4 and honey, and excludes grains and most dairy Serving Size: 1/8 of pie Serving Size: 4 ounces Serving Size: 4 ounces products Calories: 300 Calories: 460 Calories: 190 Calories from Fat: 130 Calories from Fat: 220 Calories from Fat: 45 Total Fat: 5 grams Supplementation: To add to , increase, or make Total Fat: 15 grams Total Fat: 25 grams Cholesterol: 55 mg Cholesterol: 80 mg Cholesterol: 155 mg up for a defciency Sodium: 170 mg Sodium: 860 mg Sodium: 140 mg Total Carbohydrates: 39 grams Total Carbohydrates: 26 grams Total Carbohydrates: 7 grams Stricture: A narrowing of a section of the Dietary Fiber: 3 grams Dietary Fiber: 9 grams Dietary Fiber: 0 grams intestine caused by scarring. This can lead to Sugars: 18 grams Sugars: 7 grams Sugars: 1 gram an intestinal blockage. Nausea and vomiting or Protein: 5 grams Protein: 28 grams Protein: 27 grams constipation may be a sign of a stricture Vitamin A: 170% Vitamin A: 90% Vitamin A: 8% Vitamin C: 4% Vitamin C: 25% Vitamin C: 4% Calcium: 6% Calcium: 15% Calcium: 4% Iron: 8% Iron: 35% Iron: 15% 44 1. The nutrient requirements of goats are determined by age, sex, breed, production system (dairy or meat), body size, climate and physiological stage. Feeding strategies should be able to meet energy, protein, mineral, and vitamin needs depending on the condition of the goats. Goats do not depend on intensive feeding systems except some supplemental feeding during growth, lactation, pregnancy and winter. Goats belong to the small ruminant group of animals and have no upper incisor or canine teeth but a dental pad instead. The rumen is the largest part of four stomach compartments with the capacity of roughly 2-6 pounds. Some bacteria and protozoa are normal habitants of the rumen which break down plant food into volatile fatty acids along with vitamins and amino acids. The daily feed intake of goats ranges from 3-4% of body weight as expressed in pounds (dry matter/head/day). The daily feed intake is influenced by body weight, % of dry matter in the feeds eaten (12-35% in forages, 86-92% in hays and concetrates), palatability, and physiological stage of the goats (growth, pregnancy, and lactation). Essential Nutrients Carbohydrates Sugars, starches (found in grains) and fibre (cellulose) are the carbohydrates that convert into volatile fatty acids (energy) by rumen flora (beneficial bacteria). Normal goat diet (browse, forbs, and grasses) is high in cellulose and requires digestion by rumen flora to be converted into energy. Fresh pastures and young plants may have highly digestible fibre and provide high energy compared to older plants. It is important to supply half of the goat ration in the form of hay or pasture to avoid high energy related problems. Energy requirements for different physiological stages -maintenance, pregnancy, lactation and growth -vary. The maintenance requirement for energy remains the same for most goats except dairy kids; they require 21% energy higher than the average. It is important to feed high-energy rations at the time of breeding, late gestation and lactation. Proteins Proteins are digested and broken down into amino acids and are eventually absorbed in the small intestine. The rumen plays a major role in breaking down consumed protein into bacterial protein through bacterial fermentation. Feeds like forages, hays, pellets (alfalfa), barley, peas (screenings, whole, split), corn, oats, distilled grains and meals (soybean, canola, cottonseed meals) are common sources of protein for goat rationing. The protein requirements are higher during growth (kids), milk synthesis (lactation), and mohair growth. Producers may need to supplement protein sometimes during the year, especially in late fall or winter. It is very important for a commercial goat operation to do cost-effective rationing as proteins can be an expensive feed ingredient. If the hay has about 12-13% protein content then provide fi lb of protein source in the form of corn, barley, peas or oats (with 20% protein in total). Goats should be 25 kg dairy doelings consuming more water with and castrates, gaining high protein ration feedings. Minerals and Vitamins Goats need certain minerals and vitamins for their maintenance as well as proper functioning of their physiological systems. Microminerals usually supplemented in goat rations are iron, copper, cobalt, manganese, zinc, iodine, selenium, molybdenum, and others. Feed tags report microminerals as parts per million (ppm) and macrominerals on a percentage basis. Feeding of calcium and phosphorus (2:1 ratio) is recommended for better structural and bone strength, while other minerals are necessary for other systems like nervous and reproductive. Minerals should be added into the feed keeping in mind the quality of forages as some forages can be high in some of the minerals and low in others. If the supplied minerals include enough salts then the producer should be careful in providing separate free choice salt. It is important to feed enough copper (10-80 ppm) to goats as they have a tendency to be copper deficient. Goats are not sensitive to copper, whereas in sheep even 20 ppm of copper can be very toxic. Most of the soils in Manitoba are deficient in selenium, and forages from those soils may need selenium supplementation in the form of mineral supplements. Excess energy produced by carbohydrates is stored in the form of fat especially around internal organs. The stored fat in the body is used during high energy needs, especially the lactation period.

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This might that despite raised serum osmolality none of the major combe of particular importance in situations of increased risk of ponents (sodium keratin treatment cheap generic asacol canada, potassium medicine cabinets surface mount cheap asacol 400mg amex, urea or glucose) is raised out of dehydration 88 treatment essence generic asacol 400 mg. Where directly measured osmolality is not available then Recommendation 65 the osmolarity equation (osmolarity fi 1 medicine keppra buy asacol 400mg amex. The raised osmolality Work with a set of European cohorts of older adults has sugis the key physiological trigger of protection mechanisms (such as gested that most existing serum osmolarity equations are not thirst and increased concentration of urine by the kidney) treatment models order asacol 400 mg online. In older diagnosticallyaccurate tocalculateserumosmolality in olderadults adults renal function is often poor so that renal parameters no [341 treatment advocacy center discount asacol online american express,343]. This statement sets a range of ages, health, cognitive and functional status [341,343]. It is based Given costs and prevalence of dehydration in older people, a cut on physiology and biochemistry and has been well agreed by hypoint of 295 mOsm/L will identify most adults with low-intake dration experts for many decades [282e284]. In contrast, extradehydration (sensitivity 85%, specificity 59%) and should trigger cellular water loss (volume depletion) due to diarrhea, vomiting or advice and support with drinking and fiuid intake. A directly renal sodium loss is connected with normal or low plasma measured serum osmolality test a few days later will identify older osmolality. This equation has also been found to be useful inyounger Recommendation 66 adults [344]. Note on terms: osmolality is directly measured osmolality, An action threshold of directly measured serumosmolality measured using freezing point depression, while osmolarity aims >300 mOsm/kg should be used to identify low-intake to approximate osmolality and is an estimate based on an dehydration in older adults. The terms are often used Grade of recommendation B e strong consensus (94% incorrectly. They assessed the range of plasma osmolality in hydrated younger adults, then in the same persons Grade of recommendation A e consensus (83% agreement) who had been dehydrated, identifying the cut-off that best separated the two states. Their suggested threshold is that serum or plasma osmolality >300 mOsm/kg is classified as dehydrated. Interpretation of raised serum agreement) osmolality (>300 mOsm/kg) as sign of dehydration depends on Please cite this article in press as: Volkert D, et al. In mild dehysingle clinical signs and tests against serum osmolality, osmolarity dration older persons should be encouraged to drink more fiuid, or weight change [287]. It found that none was consistently useful which can be in the form of drinks preferred by the older person, in indicating hydration status in older adults [287]. The signs have such as hot or iced tea, coffee, fruit juice, sparkling water, carboneither not been shown to be usefully diagnostic or have been ated beverages/soda, lager or water [293,294]. The Cochrane reviewalso found no evidence dration status should be reassessed regularly until corrected, then of the utility of bioelectrical impedance in assessment of hydration monitored periodically alongside excellent support for drinking. Recommendation 72 Recommendation 70 For older adults with measured serum or plasma osmoOlder persons and their informal carers may use approlality >300 mOsm/kg (or calculated osmolarity >295 priate tools to assess fiuid intake, but should also ask mmol/L) who appear unwell, subcutaneous or intravenous healthcare providers for assessment of serum osmolality fiuids shall be offered in parallel with encouraging oral periodically. A recent study in residential care compared For older adults with measured serum or plasma osmostaff-completed drinks intake assessment with direct observation lality >300 mOsm/kg (or calculated osmolarity >295 over 24 h for 22 older adults, finding a very low correlation mmol/L) and unable to drink, intravenous fiuids shall be (r fi 0. On average agreement) staff assessments were 700 ml/d lower than direct observation would suggest. This poor ability to assess drinks intake in residential and nursing care facilities has been reported numerous Commentary to recommendations 72 and 73 times [348e351]. Measurement of serum osmolality is the method Several systematic reviews of moderate quality have reviewed of choice (see recommendations 65 and 66). The informal carers may be more aware of the full drinks intake of the earlier systematic review assessing evidence for hypodermoclysis in older adult. We have evidence that when older adults record their older people searched until 1996 and included 13 studies, mainly own drinks intake it is more accurate than that assessed by care case reports, which reported on 668 patients receiving electrolytestaff [352]. Older adults and their informal carers may like to use a containing, electrolyte-free or hypertonic solutions [291],suggesttool like the Drinks Diary (which explicitly assesses amount ing that 23 patients (3. Re-siting of the infusion was required in four Recommendation 77 patients (13%) of the subcutaneous and seven (23%) of the intravenous group, and one of the intravenous group was switched to Care plans for older adults in institutions should record subcutaneous because of access difficulties. Groups were similar in individual preferences for drinks, how and when they are terms of amount of fiuid delivered, serum creatinine and urea. Agitation related to the fiuid provision was noted for 80% of those Assessment of individual barriers and promoters of on intravenous and 37% on subcutaneous fiuids (p fi 0. The drinking should lead to plans for supporting drinking only complications noted were local edema in two receiving subspecific to each older person. Older adults who show signs of dysphagia should be A systematic data review suggests that financial costs of subassessed, treatedandfollowed upbyanexperiencedspeech cutaneous rehydration are probably lower than intravenous, but and language therapist. Their nutrition and hydration stathe systematic review is methodologically poor and the evidence tus should be carefully monitored in consultation with the base it collates is of low quality e better designed studies are speech and language therapist and a dietician. Recommendation 74 Commentary to recommendations 74 e 79 No interventions to support adequate drinks intake have been To prevent dehydration in older persons living in resiclearly shown to prevent or treat low-intake dehydration in older dential care, institutions should implement multicompoadults. A recent systematic review assessed the effectiveness of nent strategies across their institutions for all residents. The review identified 19 intervention and four observational studies from seven countries but suggested that overall the studies were at high risk of bias. The evidence suggests Recommendation 75 that multicomponent interventions (including increased staff awareness, assistance with drinking, support using the toilet and a these strategies should include high availability of drinks, greater variety of drinks on offer) may be effective [285]. No At a regulatory level, the strategy of mandatory moniclear relationships were observed between staffing levels and toring and reporting by institutions of hydration risks in dehydration prevalence [285,358,359]. Included losses of fiuid and electrolytes, such as bleeding, vomiting and studies were small and fiuid intake and hydration status were diarrhea [281e284]. No further strategies for supporting fiuid intake the clearest signs following excessive blood loss are a large were identified within these reviews, but a key suggestion from postural pulse change (! The authors offered to older adults in residential care is strongly positively report that postural hypotension has little additional predictive associated with fiuid intake [13,305]. Signs following fiuid and salt loss with vomiting or diarrhea are Patients with dysphagia are at specific high risk of dehydration less clear. A systematic review of signs associated with volume and fiuid intake has been reported to be low, especially when depletion after vomiting or diarrhea suggests that no signs are thickened fiuids are used to make swallowing safer [360]. A high quality systematic review, though not mucous membranes, dry tongue, furrowed tongue, sunken eyes, specific to older adults, has suggested that use of chin down swalHowever, the authors suggested that this form of diagnosis needs lowing and thin fiuids should be the first choice of therapy in further assessment [288]. Use of pre-thickened drinks rather than drinks thickened cutaneously or intravenously. Commentary Treatment for volume depletion aims to replace lost water and Recommendation 80 electrolytes and involves administration of isotonic fiuids In older adults, volume depletion following excessive [284,356]. Their resultant guidance and Grade of recommendation B e strong consensus (100% fiowchart suggests that where a patient is hypovolaemic and agreement) needs fiuid resuscitation then this should occur immediately. Where electrolyte levels are low this would In older adults, volume depletion following fiuid and salt suggest replacement with isotonic fiuids (fiuids with sodium, loss with vomiting or diarrhea should be assessed by potassium and glucose concentrations similar to those within the checking a set of signs. Isotonic or slightly hypofollowing seven signs is likely to have moderate to severe tonic fiuids are ideal [284]. Outcome models the working group or from co-authorship because of serious conin clinical studies: implications for designing and evaluating trials in clinical fiicts. A practical approach to estimate two group meetings in Biedenkopf an der Lahn, Germany to discuss resting energy expenditure in frail elderly people. Furthermore we want to thank Anna [25] Gaillard C, Alix E, Salle A, Berrut G, Ritz P. Are the equations published in literature for predicting resting metabolic rate accurate for use in the elderlyfi European Working Group on sarcopenia in older people: Protein intake and exercise for optimal muscle function with aging: recsarcopenia: European consensus on definition and diagnosis. Anorexia of ageing: a key component in the pathogenesis of both homes requiring a texture modified diet: the role of snacks. Frequency of malnutrition in older adults: a multinational perspective [38] Shankardass K, Chuchmach S, Chelswick K, Stefanovich C, Spurr S, Brooks J, using the mini nutritional assessment. Clin Nutr diarrhea incidence by soluble fiber in patients receiving total or supple2016;35(6):1282e90. Maintaining oral hydration in older adults: a [41] Nakao M, Ogura Y, Satake S, Ito I, Iguchi A, Takagi K, et al. Overweight and [43] Jakobsen L, Wirth R, Smoliner C, Klebach M, Hofman Z, Kondrup J. Challenges in the fiber-enriched tube feed in hospitalized patients initiated on tube nutrition: management of geriatric obesity in high risk populations. J Am Geriatr Soc [72] Olofsson B, Stenvall M, Lundstrom M, Svensson O, Gustafson Y. Dietary assessment methods for older persons: what is rounds: an essential aspect of quality nutrition services in long-term care. Restrictive diets in the from the French Health High Authority: nutritional support strategy in elderly: never say never againfi Nutritional management in elderly living in residential care: a systematic review and meta-analysis. National Clinical Guideline Effectiveness of interventions to directly support food and drink intake in for exercise and nutrition to old people with geriatric problems. J Clin Nurs [55] Rypkema G, Adang E, Dicke H, Naber T, De Swart B, Disselhorst L, et al. The effect of directed verbal prompts and positive reinforcement prevent malnutrition. Prevention of quality of life in patients with hip fractures: a controlled prospective cohort unintentional weight loss in nursing home residents: a controlled trial of study. Feeding assistance needs of long-stay nursing home quality of life in malnourished medical patients. Can Nurs Home 2012;23(2): prevents undernutrition, increases muscle strength and improves QoL 8e13. Older adults and the outcome of hip fracture: a randomised controlled trial of nutritional patients in need of nutritional support: review of current treatment options support in an acute trauma ward. The amount eaten in meals by humans is a power [65] Neelemaat F, van Keeken S, Langius J, de van der Schueren M, Thijs A, function of the number of people present. Sharing meals with institutionalized people with intervention among old (>65 years) Danish nursing home residents. J Nutr Multidisciplinary nutritional support for undernutritionin nursinghome and Elder 2003;22(4):1e11. Supportive interventions for performance in activities of daily living and mobility after a multidisciplinary enhancing dietary intake in malnourished or nutritionally at-risk adults. Results of a [71] Stenvall M, Olofsson B, Lundstrom M, Englund U, Borssen B, Svensson O, systematic review. Effects of two models postoperative falls and injuries after femoral neck fracture. Osteoporos Int of nutritional intervention on homebound older adults at nutritional risk. J Am Society for swallowing disorderseEuropean Union Geriatric Medicine SociDiet Assoc 2008;108(12):2084e9. J Nutr Health Aging 2006;10(3): nity dwelling older people: a systematic review of randomised controlled 171e5. Are informal carers and community view and evidence based recommendations on texture modified foods and care workers effective in managing malnutrition in the older adult comthickened fiuids for adults (18 years) with oropharyngeal dysphagia. Systematic review and evi[104] Arends J, Bachmann P, Baracos V, Barthelemy N, Bertz H, Bozzetti F, et al. Clin Nutr 2017;36(1): liquids for adults (above 17 years) with oropharyngeal dysphagiaeAn 11e48. Individualised dietary counselling for nutritionally at-risk older pafrail elderly. Nutritional suppleimproving quality of life in malnourished care home residents. Clin Nutr mentation anddietary advice ingeriatric patients at risk of malnutrition. Effects of a physical and nutritional Nutritional support and outcomes in malnourished medical inpatients: a intervention program for frail elderly people over age 75. Effects of nutritional intervention and yearsfi) medical and surgical patients after discharge from hospital: sysphysical training on energy intake, resting metabolic rate and body tematic review and meta-analysis of randomized controlled trials. Systematic review and meta-analysis of the activity level and activities of daily livingda randomized controlled pilot effects of high protein oral nutritional supplements. Should oral nutritional home visits with registered dietitians have a positive effect on the functional supplementation be given to undernourished older people upon hospital and nutritional status of geriatric medical patients after discharge: a randischargefi Post-discharge nutritional during recovery from chest infection and the role of nutritional supplesupport in malnourished elderly individuals improves functional limitations. Effectiveness of food-based fortificaReadmission and mortality in malnourished, older, hospitalized adults tion in older people. J Nutr Health treated with a specialized oral nutritional supplement: a randomized clinical Aging 2016;20(2):178e84. Effects of dietary enrichment with conventional [143] Hebuterne X, Schneider S, Peroux J-L, Rampal P. Effects of refeeding by cyclic foods on energy and protein intake in older adults: a systematic review. Nutr enteral nutrition on body composition: comparative study of elderly and Rev 2015;73(9):624e33. A systematic review of food fortification for residential care: a scoping review of current incompliance to oral nutritional supplements. The effects of menu modification to increase dietary [146] Klose J, Heldwein W, Rafferzeder M, Sernetz F, Gross M, Loeschke K. Am J Alzheim Dis tional status and quality of life in patients with percutaneous endoscopic 1995;10(6):20e3. Survival after percutaneous endoscopic gastrostomy [123] Wong A, Burford S, Wyles C, Mundy H, Sainsbury R. J Gerontol A Biol Sci Med Sci 2000;55(12): to improve nutrition in people with dementia in an assessment unit.

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During the early 1980s studies showed a hypercholesterolemic effect of trans fatty acids in rabbits (Kritchevsky medications 126 purchase asacol canada, 1982; Ruttenberg et al medicine 513 buy cheap asacol line. Renewed interest in the topic of hydrogenated fat in human diets medications in pregnancy buy generic asacol pills, or more precisely trans fatty acid intake moroccanoil oil treatment cheap asacol 400mg with mastercard, started in the early 1990s symptoms 22 weeks pregnant order online asacol. The availability of a methodology to distinguish the responses of individual lipoprotein classes to dietary modification expanded the depth to which the topic could be readdressed medications causing hyponatremia generic 800 mg asacol amex. Lipoprotein(a) (Lp(a)) concentrations in plasma have been associated with increased risk for developing cardiovascular and cerebrovascular disease, possibly via inhibition of plasminogen activity (Lippi and Guidi, 1999; Nielsen, 1999; Wild et al. Lp(a) concentrations have been reported by some investigators to be increased after the consumption of diets enriched in hydrogenated fat/trans fatty acids (Tables 8-9, 8-10, and 8-11) (Almendingen et al. The magnitude of the mean increases in Lp(a) concentrations reported to date that is associated with trans fatty acid intake for the most part would not be predicted to have a physiologically significant effect on cardiovascular disease risk. However, an unresolved issue at this time is the potential effect of relatively high levels of trans fatty acids in individuals with initially high concentrations of Lp(a). The effect of trans fatty acids on hemostatic factors has been assessed by a number of investigators (Almendingen et al. In general, these researchers have concluded that hydrogenated fat/trans fatty acids had little effect on a variety of hemostatic variables. Similarly, Muller and colleagues (1998) reported that hemostatic variables were unaffected by the substitution of a vegetable oilbased margarine relatively high in saturated fatty acids when compared with a hydrogenated fish oil-based margarine. A few reports addressed the issue of trans fatty acid intake and blood pressure (Mensink et al. The authors concluded that consumption of diets high in saturated, monounsaturated, or trans fatty acids resulted in similar diastolic and systolic blood pressures. Because trans fatty acids are unavoidable in ordinary, nonvegan diets, consuming 0 percent of energy would require significant changes in patterns of dietary intake. It is possible to consume a diet low in trans fatty acids by following the dietary guidance provided in Chapter 11. The effects of dietary fi-linolenic acid compared with docosahexaenoic acid on brain, retina, liver, and heart in the guinea pig. Fasting serum cholesterol and triglycerides in a tenyear prospective study in old age. Developmental quotient at 24 months and fatty acid composition of diet in early infancy: A follow up study. Effects of partially hydrogenated fish oil, partially hydrogenated soybean oil, and butter on serum lipoproteins and Lp[a] in men. Effects of partially hydrogenated fish oil, partially hydrogenated soybean oil, and butter on hemostatic variables in men. Docosahexaenoic acid is the preferred dietary n-3 fatty acid for the development of the brain and retina. Effect of n-3 fatty acid supplementation on lipid peroxidation and protein aggregation in rat erythrocyte membranes. Stearic acid, trans fatty acids, and dairy fat: Effects on serum and lipoprotein lipids, apolipoproteins, lipoprotein(a), and lipid transfer proteins in healthy subjects. The effect of repeated stimulation of the pancreas on thes pancreatic secretion in young and aged men. Membrane fatty acids associated with the electrical response in visual excitation. In contrast with docosahexaenoic acid, eicosapentaenoic acid and hypolipidaemic derivatives decrease hepatic synthesis and secretion of triacylglycerol by decreased diacylglycerol acyltransferase activity and stimulation of fatty acid oxidation. Visual acuity and the essentiality of docosahexaenoic acid and arachidonic acid in the diet of term infants. Low plasma cortisol and hematologic abnormalities associated with essential fatty acid deficiency in man. Alpha-linolenic acid deficiency in patients on long-term gastric-tube feeding: Estimation of linolenic acid and long-chain unsaturated n-3 fatty acid requirement in man. Alpha-linolenic acid deficiency in man: Effect of essential fatty acids on fatty acid composition. Linseed and cod liver oil induce rapid growth in a 7-year-old girl with n-3 fatty acid deficiency. Proand anti-inflammatory cytokines in healthy volunteers fed various doses of fish oil for 1 year. The effects of dietary fi-linolenic acid on the composition of nerve membranes, enzymatic activity, amplitude of electrophysiological parameters, resistance to poisons and performance of learning tasks in rats. Docosahexaenoic acid status of preterm infants at birth and following feeding with human milk or formula. First year growth of preterm infants fed standard compared to marine oil n-3 supplemented formula. Visual acuity and fatty acid status of term infants fed human milk and formulas with and without docosahexaenoate and arachidonate from egg yolk lecithin. Effect of long-chain n-3 fatty acid supplementation on visual acuity and growth of preterm infants with and without bronchopulmonary dysplasia. Structural position and amount of palmitic acid in infant formulas: Effects on fat, fatty acid, and mineral balance. The effect on human tumor necrosis factor fi and interleukin 1fi production of diets enriched in n-3 fatty acids from vegetable oil or fish oil. Trans fatty acids in human milk lipids: Influence of maternal diet and weight loss. Similar distribution of trans fatty acid isomers in partially hydrogenated vegetable oils and adipose tissue of Canadians. Conjugated linoleic acid (9,11and 10,12-octadecadienoic acid) is produced in conventional but not germ-free rats fed linoleic acid. Cloning, expression, and nutritional requirements of the mammalian fi-6 desaturase. Determination of the optimal ratio of linoleic acid to fi-linolenic acid in infant formulas. Increased incidence of epistaxis in adolescents with familial hypercholesterolemia treated with fish oil. Pathway of fi-linolenic acid through the mitochondrial outer membrane in the rat liver and influence on the rate of oxidation. The influence of trans-acids on desaturation and elongation of fatty acids in developing brain. Differences in energy expenditure and substrate oxidation between habitual high fat and low fat consumers (phenotypes). Vascular prostacyclin is increased in patients ingesting fi-3 polyunsaturated fatty acids before coronary artery bypass graft surgery. Docosahexaenoic and arachidonic acid prevent a decrease in dopaminergic and serotoninergic neurotransmitters in frontal cortex caused by a linoleic and fi-linolenic acid deficient diet in formula-fed piglets. Infant plasma trans, n-6, and n-3 fatty acids and conjugated linoleic acids are related to maternal plasma fatty acids, length of gestation, and birth weight and length. Nutrition and biochemistry of trans and positional fatty acid isomers in hydrogenated oils. Dietary linoleic acid influences desaturation and acylation of deuterium-labeled linoleic and linolenic acids in young adult males. Effect of dietary docosahexaenoic acid on desaturation and uptake in vivo of isotope-labeled oleic, linoleic, and linolenic acids by male subjects. The effect of dietary supplementation with n-3 polyunsaturated fatty acids on the synthesis of interleukin-1 and tumor necrosis factor by mononuclear cells. Long-term effects of dietary fi-linolenic acid from perilla oil on serum fatty acids composition and on the risk factors of coronary heart disease in Japanese elderly subjects. Effect of ionophores on conjugated linoleic acid in ruminal cultures and in the milk of dairy cows. Dietary fish oil reduces survival and impairs bacterial clearance in C3H/Hen mice challenged with Listeria monocytogenes. Gallai V, Sarchielli P, Trequattrini A, Franceschini M, Floridi A, Firenze C, Alberti A, Di Benedetto D, Stragliotto E. Blood fatty acid composition of pregnant and nonpregnant Korean women: Red cells may act as a reservoir of arachidonic acid and docosahexaenoic acid for utilization by the developing fetus. Effect of increasing breast milk docosahexaenoic acid on plasma and erythrocyte phospholipid fatty acids and neural indices of exclusively breast fed infants. Essential fatty acid deficiency in total parenteral nutrition: Time course of development and suggestions for therapy. The effects of dietary fi3 fatty acids on platelet composition and function in man: A prospective, controlled study. Brain docosahexaenoate accretion in fetal baboons: Bioequivalence of dietary fi-linolenic and docosahexaenoic acids. Conjugated linoleic acid is synthesized endogenously in lactating cows by fi9-desaturase. Essential function of linoleic acid esterified in acylglucosylceramide and acylceramide in maintaining the epidermal water permeability barrier. Evidence from feeding studies with oleate, linoleate, arachidonate, columbinate and fi-linolenate. Deficiency of essential fatty acids and membrane fluidity during pregnancy and lactation. Dietary fat and coronary heart disease: A comparison of approaches for adjusting for total energy intake and modeling repeated dietary measurements. Effects of dietary 9-trans,12-trans linoleate on arachidonic acid metabolism in rat platelets. Trans fatty acids in human milk are inversely associated with concentrations of essential all-cis n-6 and n-3 fatty acids and determine trans, but not n-6 and n-3, fatty acids in plasma lipids of breast-fed infants. Effect of dietary linoleic/alpha-linolenic acid ratio on growth and visual function of term infants. Effect of formula supplemented with docosahexaenoic acid and fi-linolenic acid on fatty acid status and visual acuity in term infants. Dietary trans fatty acids: Effects on plasma lipids and lipoproteins of healthy men and women. Effects of margarine compared with those of butter on blood lipid profiles related to cardiovascular disease risk factors in normolipemic adults fed controlled diets. Serum cholesterol and mortality in a Japanese-American population: the Honolulu Heart Program. Docosahexaenoic acid ingestion inhibits natural killer cell activity and production of inflammatory mediators in young healthy men. A stearic acidrich diet improves thrombogenic and atherogenic risk factor profiles in healthy males. Fatty acids and eicosanoids regulate gene expression through direct interactions with peroxisome proliferator-activated receptors fi and fi. Fatty acid composition of breast milk from three racial groups from Penang, Malaysia. Adipose tissue trans fatty acids and breast cancer in the European Community Multicenter Study on Antioxidants, Myocardial Infarction, and Breast Cancer. Maintenance of lower proportions of (n-6) eicosanoid precursors in phospholipids of human plasma in response to added dietary (n-3) fatty acids. Effect of dietary enrichment with eicosapentaenoic and docosahexaenoic acids on in vitro neutrophil and monocyte leukotriene generation and neutrophil function. Assessment of trans-fatty acid intake with a food frequency questionnaire and validation with adipose tissue levels of trans-fatty acids. A high-steric acid diet does not impair glucose tolerance and insulin sensitivity in healthy women. Randomised controlled trial of a synthetic triglyceride milk formula for preterm infants. Fatty acid composition of brain, retina, and erythrocytes in breastand formula-fed infants. A randomized trial of different ratios of linoleic to fi-linolenic acid in the diet of term infants: Effects on visual function and growth. A critical appraisal of the role of dietary long-chain polyunsaturated fatty acids on neural indices of term infants: A randomized controlled trial. Serum cholesterol, blood pressure, and mortality: Implications from a cohort of 361,662 men. Total fatty acids, plasmalogens, and fatty acid composition of ethanolamine and choline phosphoglycerides. The proportion of trans monounsaturated fatty acids in serum triacylglycerols or platelet phospholipids as an objective indicator of their short-term intake in healthy men. Immunologic effects of National Cholesterol Education Panel Step-2 Diets with and without fish-derived n-3 fatty acid enrichment. Dietary supplementation with fi-3-polyunsaturated fatty acids decreases mononuclear cell proliferation and interleukin-1fi content but not monokine secretion in healthy and insulin-dependent diabetic individuals. Astrocytes, not neurons, produce docosahexaenoic acid (22:6fi-3) and arachidonic acid (20:4fi-6). Alcohol and the regulation of energy balance: Overnight effects on diet-induced thermogenesis and fuel storage. The effect of a salmon diet on blood clotting, platelet aggregation and fatty acids in normal adult men.

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