Small Meals Research Articles

A Comparative Study Of AmlapittavinashakYoga Kwath& Bhunimbadi KwathIn The Management Of AmlapittaW.S.R. To Acid Peptic Diseases

Now a day, there are so many changes in life style, behavior and diet. To achieve our desires in limited time produces different types problems like anxiety, worry, anger, depression. In modern medical science symptomatology of Amlapittais equivalent to the features of hyperacidity. Hyperacidity and its complications pose a major threat to future public health resources throughout the world. The Ayurvedic management of Amlapitta aims not only control acid secretions in body but also to treat the root cause of the disease. People don’t follow rules like Dincharya and Rutucharya.Peoples are not awair of Rules of consumption of food which are described in “Aharvidhivishayatan” by Acharya Charak. Because of this all factor causes physiological disorders, which causes Annavaha stratus drusti which cause Mandagni and if the hetu sevan is goes on then it cause Ajeerna which ultimately leads to Aamvish .When Aamvish mixed with pittadi dosha, the original KattuRasa of Pitta changes to amla causes amalapitta disease. Amalapitta is characterised by features like Avipaak (indigestion), Klama (tridness), Utklesha (nausea), Tiktta Amlaa Udagar (sour and bitter belching), gauravata (Heaviness) ,Hrudhkantha daha (Heart and throat burning),and Aruchi. These clinical features are closely related to functional dyspepsia. All these symptoms if left untreated may produces Gastrointestinal disorder like peptic ulcer disease .Many disease like Grahani,skin disease like Shitpitta,Udard occurs as complication of Amlapitta. While describing the progonosis of Amlapitta , it has been stated that it can cured easily if promptly treated as earliest with proper Pathyapathya. The etiological factors like Abhojana, Atibhojana, ganigraha, PanchakarmaVyapat and seasonal variation etc. cause vitiation of Doshas and Agni which ultimately results Mandagni which is treated as mother of all the diseases. This Mandagni leads to Avipaka and due to Avipaka even light and small meals are not digested. This undigested and ill digested food gets shuktatva which leads to the formation of Annavisha. This Annavisha is manifestated in the form of Ajirna . As per Charaka it is said that when diet is not properly digested it gets formented and forms Annavisha. This Ama when mixed with Pitta then it develops the disease Amlapitta.

POST-VAGOTOMY GASTROPARESIS – A CASE REPORT

We present Mr M.A. a 27 year old Nigerian of the Yoruba tribe who has been having recurrent dyspeptic symptoms for 5 years but not previously endoscopically evaluated for peptic ulcer disease who now presented with six days history of abdominal pain which was initially epigastric but later became generalized associated with four episodes of vomiting and a day history of abdominal distension and fever. He was acutely ill-looking and dehydrated. The Abdomen was moderately distended, does not move with respiration, generalized tenderness with guarding and rebound tenderness, intra-abdominal organs were difficult to palpate due to the guarding. Bowel sound was absent. Examination of the other systems was not remarkable. A provisional diagnosis of Generalized peritonitis likely secondary to perforated peptic ulcer was made. He had an emergency exploratory laparotomy under general anaesthesia. He was commenced on intravenous fluids and parenteral proton pump inhibitor(PPI) and antibiotics. Intra-op findings include 2 liters of bilious peritoneal fluid, Multiple fibrous adhesions, a 2.5cm x 2cm gastric perforation at the anterior wall of the antrum and a grossly normal bowel. The surgical operation performed was a Graham Omental patch closure of the gastric defect with Bilateral Truncal Vagotomy and Peritoneal lavage. Post-operative state was satisfactory and he was later discharged. He presented at the gastroenterology out-patient clinic eight months later with complaints of early satiety, feeling of indigestion and episodes of vomiting. Vomitus is usually offensive / foul smelling and contains undigested or partially digested stale food substances. Abdominal examination revealed a positive succussion splash. Other clinical examination findings were not remarkable. A Provisional Diagnosis of suspected Gastric outlet obstruction probably secondary to a chronic duodenal ulcer was made. Endoscopy findings revealed copious fluid and food debris in the stomach cavity which had an offensive smell with remnants of partially digested stale food substances seen. There was poor peristaltic activity and the stomach was poorly distensible. There were multiple areas of mucosa erosions seen in the gastric cardia and corpus. No corporal or antral lesion seen. The pyloric ring was normal and the duodenum was normal. Diagnosis- (1) Endoscopic features of Gastroparesis likely secondary to previous Bilateral Truncal Vagotomy. No evidence of mechanical obstruction of the Gastric outlet. (2) Gastric Cardia and Corporal mucosa lesions likely secondary to Stasis Gastritis. Histology of biopsy specimens showed acute on chronic non-specific gastritis and acute duodenitis. He was commenced on empirical first line Helicobacter pylori eradication triple therapy (PPI, Amoxycillin and Clarithromycin) and a prokinetic drug (Domperidone). He had made significant clinical improvement with resolution of the symptoms by the time he was seen in the clinic three weeks later. He was tolerating oral food intake adequately and he had no new complaints. He was counselled on dietary modification and placed on long term prokinetic agent (Domperidone) and long-term PPI therapy with regular clinic follow-up. The initial management of post-vagotomy gastroparesis should be conservative as many symptoms resolve with time, this occurs possibly because the enteric nervous system is able to adapt to the loss of vagal input. Modification of dietary habits, such as regular intake of small meals, and use of prokinetic drugs bring about symptomatic relief in most patients.

Optimizing feed automation: improving timer-feeders and on demand systems in semi-intensive pond culture of shrimp Litopenaeus vannamei

The continued success of shrimp farming will rely on improved feed management and reductions in labor costs. Shrimp are omnivorous, eating many small meals with limited stomach capacity for food storage. Hence, increased performance may be obtained by spreading feed through multiple meals. Initial work has demonstrated that moving from two feeding per day into multiple feeding systems increases growth rate and production. Further advances have been made with on-demand (satiation) feeding systems. The goal of this work was to continue the development of standard feeding protocol's (SFP) for automatic feeding systems to maximize growth rates in semi-intensive pond production of shrimp, Litopenaeus vannamei. For this work a 13-week pond production trial was performed in 16, 0.1 ha outdoors ponds, stocked at a 26 shrimp/m2, and fed 1.5-mm 40% crude protein for the first four weeks, and 2.4-mm protein soy optimized feed (35% crude protein) for last nine weeks, both produced by Zeigler Inc. Four treatments including: three fixed feeding treatments of 130, 145 and 160% of a SFP (SFP + 30%, SFP + 45%, SFP + 60%, respectively) were offered using automatic timer-feeders, and a fourth treatment utilized on-demand AQ1 acoustic feeding system. No statistical differences were found between treatments for survival (ranging 75.2–81.4%) and FCR (ranging 0.96–1.11). In general, increased feed inputs resulted in higher production. The best response was with the AQ1 system which adjusted feed inputs in real time and ended up offered higher feed inputs resulting in larger shrimp and yields. Based on results of this work and previous trials, standard feeding protocols for automated systems can be developed but to date, automated feedback systems which operate in real time out perform the standardized practices.

Premedical Student Exposure to Pharmaceutical Marketing: Too Much, Too Soon?

Direct pharmaceutical marketing to physicians by pharmaceutical representatives is effective in changing behavior of health care providers, resulting in less evidence-based prescribing. Although much has been written about pharmaceutical marketing exposures among medical students, less is known about direct marketing exposures before students matriculate. This study examined the types of pharmaceutical representative direct marketing exposures for premedical students and where they occurred. From June to August of 2017, researchers surveyed students who accepted admission to US public medical schools. These prematriculated students completed our survey just prior to matriculation. The survey inquired about whether the students were exposed to pharmaceutical marketing directly from pharmaceutical salespeople, the types of marketing they observed or received, and where these interactions occurred. Survey participants included 911 prematriculated students from 14 of the 188 medical schools invited to participate. Seventy-one percent (646) of the participants received or observed someone receiving pharmaceutical marketing gifts, small meals or snacks, articles, or samples. The two most common contexts for direct pharmaceutical marketing exposures were during shadowing experiences (54%, 346) and during employment (50%, 323). The findings suggest that it may be common for medical students to have interacted directly with pharmaceutical salespeople or observed other health professionals in these interactions before they matriculate in medical school. Because many of these interactions occur during clinical experiences required by institutions for admission, medical schools and premedical associations should consider delivering conflict-of-interest education early in medical school education or before students matriculate.

A Systematic Review of Medical Nutrition Therapy Guidelines for Liver Cirrhosis: Do We Agree?

Nutrition can play a significant role in the management of liver cirrhosis and its complications. However, adherence to the clinical practice guidelines (CPGs) is essential for the practice of evidence-based medicine and is considered as a health-quality indicator. A systematic search was conducted in scientific databases, and retrieved CPGs fulfilling the inclusion criteria were independently reviewed and appraised from 3 experienced researchers, based on the Appraisal of Guidelines for Research and Evaluation II instrument. A total of 13 relevant CPGs were retrieved, published by 7 associations/societies, focusing on the nutrition management (enteral nutrition and/or parenteral nutrition) on cirrhosis, decompensated cirrhosis, liver transplantation, and cirrhosis-related complications. Most CPGs scored low in the stakeholder, rigor of development, and applicability domains. Half of the CPGs recognized the need for counseling patients with cirrhosis on nutrition-related issues. Small meals spread throughout the day, including a late-night snack, were suggested, with protein intake ranging between 1.2 and 1.5g/kg of body weight. In ascites, Na restriction recommendation appeared unanimous. Several shortcomings and bias were recognized in cirrhosis-related medical nutrition therapy CPGs, indicating the need of improving CPG methodology.

Effect of surgical or immune castration on postprandial nutrient profiles in male pigs

ABSTRACTTo avoid boar taint before slaughtering, late castration by immunisation against gonadotrophin releasing hormone or immunocastration has been developed. The current study aimed at determining whether differences in feed efficiency between castrated male (CM), immune castrated (IM) and entire male pigs (EM) can be explained by differences in nutrient plasma profiles after a meal. In this study, 24 male pigs (n = 8/type) were enrolled between 14 to 19 weeks of age. Entire and IM pigs ate less and were more feed efficient than CM pigs (p < 0.05). The postprandial plasma profiles of glucose, insulin, urea and amino acids (AA) were determined before (d –6), just after (d 8) and well after (d 16) the decrease in testicular hormones in IM pigs. For each test day, pigs were fasted overnight and subsequently fed a small meal (400 g). On d –6, postprandial profiles of plasma glucose of IM pigs did not differ from the two other types of pigs. On d 8, EM pigs had a greater average plasma glucose concentration than IM and CM pigs (p < 0.05) but the profiles did not differ. On d 16, the differences between profiles of glucose suggest a lower clearance of glucose in EM compared with IM and CM pigs. Plasma insulin did not significantly differ between the three types. Plasma urea profiles did not differ between CM, EM and IC pigs on d –6 whereas CM pigs showed higher plasma urea concentrations than EM and IM thereafter (p < 0.01). Among AA, Lys plasma concentrations were greater in CM than in EM and IM pigs on d –6, d 8 and d 16 (p < 0.05), whereas on d 16 plasma Hypro concentrations were lower in CM than in EM and IM pigs (p < 0.05). The finding that plasma glucose profiles were modified by immunocastration much faster and earlier than urea and AA profiles, suggest that the decrease in testicular hormones impacted energy metabolism more rapidly than protein metabolism.

333-OR: Assessing Mealtime Macronutrient Content: Patient Perceptions vs. Expert Analyses via a Novel Phone App

People with type 1 diabetes (T1D) estimate the carbohydrate (CHO) content of meals to enable accurate insulin dosing, yet protein and fat content of meals also influences post-prandial glycemia. As part of an observational study examining the impact of exercise and nutrient consumption on glycemia, we examined accuracy in estimating macronutrient content of free-living meals via a novel phone app. Participant estimates of nutrient content were compared to expert nutrition analyses performed via the Remote Food Photography Method (RFPM). We report results from 30 of 33 randomized with analyzable food photos. Participants were 15-65 years (32±14 years); 27% identified as female. Participants were asked to take photos before and after meals/snacks on up to 16 days over a 28-day period, enter CHO estimates and estimate if meals were low (&amp;lt;13%), typical (13-&amp;lt;18%), or high (≥18%) protein and if meals were low (&amp;lt;26%), medium (26-&amp;lt;32%), or high (≥32%) fat. The phone app plus RFPM captured 92±27% of estimated energy needs. Of 1,292 food photos analyzed, 429 contained &amp;lt; 25 g (small), 641 contained 25-75 g (medium), and 222 contained &amp;gt; 75 g (large) amounts of CHO. Participants estimated CHO in small or medium meals within 10 g of the expert analyses. They were less accurate estimating CHO for larger meals (-56 ± 46 g). Likewise, most correctly categorized low and typical protein (63%, 50%) as well as low and typical fat (62%, 67%) meals. Few correctly categorized meals high in protein (17%) or fat (16%). Participants’ estimation accuracy for larger meals did not differ by T1D duration. The phone app successfully collected individuals’ food intake and estimated macronutrient intake, but showed that participants consistently underestimated nutrient intake for large meals. Accurate estimation of total macronutrients in meals could be leveraged to improve insulin decision support tools and closed loop systems; development of tools to improve macronutrient estimation skills should be considered. Disclosure M.B. Gillingham: None. C.K. Martin: Advisory Panel; Self; EHE. Consultant; Self; ACAP Health, Florida Hospital, WW, Zafgen, Inc. Other Relationship; Self; Academy of Nutrition and Dietetics. S.R. Patton: None. Z. Li: None. P.G. Jacobs: Stock/Shareholder; Self; Pacific Diabetes Technologies. M. Riddell: Advisory Panel; Self; Xeris Pharmaceuticals, Inc. Research Support; Self; Dexcom, Inc. Speaker's Bureau; Self; Insulet Corporation, Medtronic MiniMed, Inc. Stock/Shareholder; Self; Zucara Therapeutics Inc. M.R. Rickels: None. J.R. Castle: Advisory Panel; Self; Novo Nordisk Inc., Zealand Pharma A/S. Consultant; Self; Dexcom, Inc. Research Support; Self; Dexcom, Inc., Xeris Pharmaceuticals, Inc. M.A. Clements: Advisory Panel; Self; Glooko, Inc. Consultant; Self; Eli Lilly and Company. Speaker's Bureau; Self; Medtronic. E. Dassau: Consultant; Self; Eli Lilly and Company, Insulet Corporation. Research Support; Self; Dexcom, Inc., DreaMed Diabetes, Ltd., Insulet Corporation, Roche Diabetes Care, Tandem Diabetes Care, Xeris Pharmaceuticals, Inc. Speaker's Bureau; Self; Roche Diabetes Care. Other Relationship; Self; ModAGC. F.J. Doyle: Consultant; Self; ModeAGC. Other Relationship; Self; Insulet Corporation. P. Calhoun: Stock/Shareholder; Self; Dexcom, Inc. R.L. Gal: None. R. Beck: Other Relationship; Self; Abbott Laboratories, Ascensia Diabetes Care, Bigfoot Biomedical, Dexcom, Inc., Insulet Corporation, Lilly Diabetes, Roche Diabetes Care, Tandem Diabetes Care. Funding The Leona M. and Harry B. Helmsley Charitable Trust

The Impact of a 4-Week Low-FODMAP and mNICE Diet on Nutrient Intake in a Sample of US Adults with Irritable Bowel Syndrome with Diarrhea

BackgroundA diet low in fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) has gained increasing acceptance for the treatment of irritable bowel syndrome but safety concerns have been raised regarding nutritional adequacy. Changes in nutrient intake during the elimination phase of the low-FODMAP diet remain predominantly unknown. ObjectiveTo determine changes in the mean reported daily nutrient content before and after 4 weeks of a low-FODMAP diet vs modified National Institute for Health and Clinical Excellence (mNICE) dietary intervention and to identify nutritional inadequacies based on comparison to the Dietary Reference Intakes in patients with irritable bowel syndrome-diarrhea subtype. DesignPost hoc analysis of a randomized controlled trial entailing a 4-week trial period comparing the low-FODMAP and mNICE diets. Participants and settingA total of 78 patients (41 low FODMAP and 37 mNICE) meeting the Rome III criteria for irritable bowel syndrome-diarrhea subtype were consecutively recruited from gastroenterology and primary care clinics at the University of Michigan Medical Center between October 2012 and November 2015. MethodsParticipants randomized to the low-FODMAP arm were instructed to decrease their dietary intake of FODMAPs, whereas participants randomized to the mNICE intervention arm were instructed to eat small frequent meals, avoid trigger foods, and avoid excess alcohol and caffeine. Main outcome measuresPost hoc evaluation for presence of micronutrient deficiencies per Dietary Reference Intakes when implementing low-FODMAP vs mNICE dietary interventions. Dietary intake was analyzed via 3-day food diaries at baseline and during the final week of the assigned diet. Statistical analyses performedA post hoc analysis utilizing either a t test or χ2 analysis was conducted between before and after data. ResultsBoth diets resulted in fewer daily kilocalories consumed, fewer number of daily meals consumed, and less daily carbohydrate intake. Among the patients following the low-FODMAP diet, there was a statistically significant decrease from baseline in several micronutrients, which was not observed in the mNICE cohort. However, these differences in the low-FODMAP group remained significant only for riboflavin after correcting for calorie-adjusted nutrient intake. Comparing Dietary Reference Intakes of participants pre- and postintervention, fewer patients met the Dietary Reference Intakes for thiamin and iron in the low FODMAP group, and for calcium and copper in the mNICE group. ConclusionsDuring a 4-week dietary intervention, the mean daily intake of most micronutrients remained stable and within the Recommended Dietary Allowances for both diets. Although decrease in several micronutrients was observed with implementation of the low-FODMAP diet relative to the mNICE diet, most of these disappeared after adjusting for energy intake.

MON-491 Persistent Isolated Hypophosphatemia after Intravenous Ferric Carboxymaltose Infusion in a Patient with Total Gastrectomy

Introduction: Intravenous ferric carboxymaltose infusion has been reported by the FDA to cause hypophosphatemia in 2.1% of patients, with transient low phosphorus level (<2mg/dL) observed in 27% of patients. We present a case of persistent hypophosphatemia where intravenous iron appeared to be a significant contributing cause. Clinical case: A 45 year old woman presented with generalized weakness at an outpatient visit and was discovered to have hypophosphatemia with a lab value of 0.9 mg/dL (ref 2.7 – 4.5 mg/dL). She has a history significant for Non-Hodgkin’s Lymphoma (non-Burkitt’s) at age 16 (s/p chemotherapy at age 18),gastroparesis requiring a jejunostomy tube followed by a total gastrectomy 4 months before admission and reactive hypoglycemia from late dumping syndrome due to gastrectomy. Her nutritional intake consisted of small frequent meals along with tube feedings with no recent change in her diet and taking adequate calcium and vitamin D supplements. Nine days prior to this admission, she had a IV ferric carboxymaltose infusion and a phosphorus level of 0.9 mg/dL discovered on outpatient labs. Before the infusion, she had a normal phosphorus level of 3.2 mg/dL, calcium 9.2 mg/dL (ref 8.5-10.5mg/dL) and magnesium 2.3 mg/dL (ref1.6-2.6mg/dL). Blood tests during admission (two weeks after infusion and one week after initial 0.9 mg/dL level) showed phosphorus level 1.3mg/dL, calcium 9.0 mg/dL, magnesium 2.5 mg/dL and albumin 4.6 (ref 3.4-4.8mg/dL). Further in hospital work-up showed intact PTH 111 (ref 11-95 pg/mL), prealbumin 14.5 (ref 14-38 mg/L), Vitamin D 25(OH)-D3 24 (ref20-100 ng/mL) and Vitamin D 1,25(OH)2 15 (ref 18-72 pg/ml) and increased FGF23 204 (ref <180 RU/mL). A 24 hour urine collection was notable for increased urinary phosphorus of 1343 mg(ref<1100mg/day). Phosphorus was repleted with IV potassium phosphate during admission and she was discharged on oral potassium phosphate 500mg PO BID which was later increased to TID. She was also advised to eat a diet high in phosphorus. She was followed as an outpatient and her phosphorus levels remained <2.1 mg/dL for 4 weeks after the IV ferric carboxymaltose infusion returning to normal thereafter. Conclusion: Although gastrectomy with poor nutrition may cause hypophosphatemia, it is worth considering other etiologies in the setting of persistently low phosphorus levels. With correlative evidence of high urinary phosphorus excretion in the setting of low serum phosphorus and elevated FGF23, we believe that IV ferric carboxymaltose infusion may have been a major contributor to hypophosphatemia in our patient. FGF23 is known to be a “phosphatonin” and ferric carboxymaltose may inhibit FGF23 degradation in osteocytes leading to an increase in its levels. Phosphate levels should be monitored before and after parenteral ferric carboxymaltose infusion, which can persist for weeks.

MON-145 An Unusual Cause of Hypoglycemia in a Non-Diabetic Elderly Male

Introduction: Hypoglycemia (HYPO) in non-diabetic patients is an unusual scenario and presents a diagnostic challenge, resulting in serious consequences for patients. We describe the case of an elderly non-diabetic male who developed severe persistent HYPO. Case: A 78-year-old male with history of macroprolactinoma taking bromocriptine, Hashimoto's hypothyroidism, initially treated with low dose L-thyroxine, followed by Graves' hyperthyroidism, Parkinson’s disease (PD), osteopenia was noted to have hypoglycemia (54 mg/dL) on routine lab work. When questioned, he admitted to having had years of lightheaded episodes, "feeling jittery", which improved within minutes after eating sugary foods. His wife mentioned that he “loved to eat sweets” and high simple carbohydrate meals(CARBS). Physical exam - orthostatic hypotension and mild resting tremors, both attributed to PD. Continuous glucose monitoring (CGMS) was performed for 2 weeks which documented HYPO overnight while sleeping, fasting and between meals. The HYPO was associated more frequently with sweet bedtime snacks. Laboratory- Glucose tolerance test was stopped due to HYPO with symptoms. ACTH=19 pg/mL (nl 0-47), AM Cortisol 19.4 microg/dL (nl 5.3-22.5), fasting blood glucose 83 mg/dL(nl 70-99), fasting insulin 6.9 mIU/L( nl 0-24.9), proinsulin 16.9 pmol/L ( nl <=18.8 pmol/L), c-peptide 1.39 ng/mL( nl 0.81-3.85), beta-OH butyrate 0.072 mmol/L( nl 0.020-0.270). Islet cell Ab was normal. Gastric emptying study was negative. Although the dose of bromocriptine was reduced due to HYPO, it continued. He was advised to decrease intake of CARBS, eat small, high protein and fat meals with frequent snacks. On subsequent visits, he reported less hypoglycemic episodes with improved energy level and general well-being, which was confirmed by CGMS. Discussion: Although a wide range of diseases can cause HYPO in nondiabetic patients, differences in characteristics between non-diabetic HYPO and diabetic HYPO have not been well studied. Common underlying diseases associated with HYPO include malignancies, cerebrovascular diseases, infection, major organ failure, and alcohol-related disorders. In addition, comorbidities linked with HYPO include sepsis, kidney diseases, and alcohol dependence, pneumonia, liver diseases and insulin abuse. Malnutrition, alcohol, infection, and post gastrectomy are the leading causes of nondiabetic hypoglycemia. In addition, methimazole use has been associated with insulin autoimmune syndrome resulting in HYPO due to interaction of sulfhydryl group with disulfide bond in the insulin molecule Conclusion: Clinicians should be aware of the potential for hypoglycemia in non-diabetic patients, due to other etiologies, which can also result in severe and possibly life-threatening sequelae. An in-depth evaluation, including the use of CGMS can assist in determining underlying causes.

MON-134 Use of CGMS for Evaluating Hypoglycemia in Non-Diabetic Patients

Introduction: Continuous Glucose Monitoring System (CGMS), is a tool for measuring blood glucose (BG) levels in patients with Diabetes Mellitus (DM). Post-prandial Hypoglycemia (PPH) is a known complication of Roux-en-Y gastric bypass (RYGB). We present two cases of PPH following RYGB, confirmed by CGMS. Case 1: 70-year-old non-diabetic male, with RYGB 20 yrs. ago, presented with episodes of tremors, generalized weakness and blurring of vision, lasting about 10-15 min, occurring after eating simple carbohydrate foods. Onset and duration of episodes were unclear. In clinic, a POCT BG was 40 mg/dl with symptoms after eating doughnuts prior to the visit. VS- BP 122/58 Sitting, BP 108/57 Standing, P 87/m, Wt. 70.9 kg, BMI 22.mkg/m². Labs: BG 74 mg/dL, Sulphonylurea screen-negative, Cortisol AM 15.4 ug/dL, ACTH 23 pg/mL, C-Peptide 1.31 ng/mL (nl 0.81 - 3.85), Fasting Insulin 4.5 mIU/L (nl 0.0 - 24.9), IGF-I 76 ng/mL (nl 41 - 279), IGF-II 299 ng/mL (nl 267 - 616), BOH-butyrate 0.377 mmol/L (nl 0.020 - 0.270); IA-2 Ab <0.8U/mL (nl <0.8 U/mL). CGMS for 15 days-multiple episodes of PPH. Patient was advised to follow high protein, low carbohydrate diet, later started with Acarbose therapy. CGMS was repeated 3 months later, with marked reductions in PPH. Case 2: 32-year-old male, with RYBG 5 years ago, resulting in 150 lbs. weight loss, presented to clinic for progressive episodes of hypoglycemia. He did not test BG on a regular basis, but when tested occasionally in the morning, reported BG were 90-199 mg/dl, unless he skipped a bedtime snack. Patient reported having one episode when he woke up in the middle of the night “jittery and sweaty,” and BG was 37 mg/dl. His symptoms resolved after juice. He reports not being able to eat large meals and has been eating frequent small meals. He noted symptoms of hypoglycemia, when he eats simple carbohydrates. He also reported some high BG levels (170-180 mg/dl) although he is not previously known to have DM. VS-BP 115/67, HR 67; no orthostasis; Wt 287 lbs, BMI 45. Kg/m². POCT Glucose 64, Fasting Labs: BG 86 mg/dL, HbA1C 5.8%, C-Peptide 1.48 ng/mL, BOH-butyrate 0.7 mmol/L, Cortisol AM 12.2 ug/dL, Insulin Fasting 8.0 mIU/L, Proinsulin 2.4 pmol/L (nl ≤8.0), Insulin Antibody <0.4U/mL (nl 0.0-0.4 U/mL). CGMS for 2 weeks demonstrated repeated PPH and nocturnal hypoglycemia. Diet changes were recommended. Discussion: CGMS compared to blood glucose monitoring, is more efficacious in recording hypoglycemic events, especially if hypoglycemia occurs between testing times, or in usual settings like PPH. Current guidelines recommend use of CGMS in DM patients with hypoglycemic unawareness, nocturnal hypoglycemia, postprandial hyperglycemia. In our cases, CGMS was proven to be effective in diagnosing PPH in RYBG patients. CGMS is also an efficient device to measure therapeutic responses and avoiding hypoglycemia, as well as improving quality of life.

Insulin Autoimmune Syndrome Diagnosis and Therapy in a Single Chinese Center

PurposeInsulin autoimmune syndrome (IAS) is a relatively rare cause of hypoglycemia characterized by endogenous hyperinsulinism and autoantibodies against endogenous insulin despite no prior exposure to exogenous insulin. We present a series of IAS cases and describe the clinical characteristics of these cases. MethodsThe medical records of inpatients with the final diagnosis of IAS were collected from August 2007 to August 2017 in Peking Union Medical College Hospital. Clinical characteristics and laboratory test results were summarized. The results of serum glucose, insulin, true insulin, and C-peptide testing during 5-h oral glucose tolerance tests were also summarized. Circulating immune complexes were assessed qualitatively by precipitation with polyethylene glycol (PEG) in some patients. FindingsSixteen patients were included in this study. Insulin autoimmune antibody test results were found positive in 12 patients and weakly positive in 1 patient. Nine patients had an insulin to C-peptide molar ratio >1, whereas 6 patients had an insulin to C-peptide molar ratio <1. Circulating immune complexes were verified in all 4 patients who had been assessed with PEG. During 5-h oral glucose tolerance tests, the C-peptide level responded earlier to the glucose tolerance and had a shorter peak value period compared with insulin, although C-peptide's fluctuation still lagged behind the glucose fluctuation. Three patients presented with self-limited disease courses or limited disease course after discontinuing use of the sulfhydryl group drugs. Some patients' symptoms were relieved after small frequent meals, and some were relieved after taking acarbose. Only 3 patients took glucocorticoids as the anti-immune therapy. ImplicationsThe insulin to C-peptide molar ratios were not consistently >1 in patients with confirmed diagnoses of IAS in our study, which suggested the low sensitivity of insulin to C-peptide molar ratio to detect IAS. The therapy in our study also revealed the self-limited disease course of IAS, and despite the effectiveness of anti-immunity therapy, convenient therapy, such as frequent small meals and adding acarbose, performed well in many patients.

A small yet occasional meal: predatory drill holes in Paleocene ostracods from Argentina and methods to infer predation intensity

AbstractOstracods are common yet understudied prey item in the fossil record. We document drill holes in Paleocene (Danian) ostracods from central Argentina using 9025 specimens representing 66 species. While the percentage of drilled specimens at assemblage‐level is only 2.3%, considerable variation exists within species (0.3–25%), suggesting prey preference by the drillers. This preference is not determined by abundance because no significant correlation is found between species abundance and drilling percentages. Seven methods were used, some of which are new, to quantify drilling percentages for the abundant and commonly drilled Togoina argentinensis. The resulting range, from 9.9% to 14.6%, suggests that drilling percentages are fairly insensitive to the method used, implying that comparisons across studies are possible. This information, combined with data from the literature, suggests the Cretaceous–Palaeogene mass extinction may have had a limited effect on drilling intensity in ostracods. The cylindrical (Oichnus simplex) and parabolic (O. paraboloides) drill holes from Argentina may have been caused primarily by naticid and possibly muricid gastropods. Two oval drill holes (O. ovalis) are morphologically similar to octopod drill holes, but their small size, the fact that extant octopods are not known to drill ostracods and the absence of such holes in co‐occurring gastropods, preclude ascription to a predator clade. Drill holes are located preferentially in the median and dorsal regions, where most soft tissue, including the adductor muscle, is located. Drilled specimens are statistically taller than non‐drilled specimens for T. argentinensis and larger predators selected larger ostracods. The drilling percentage does not significantly differ in ornamented ostracods.

The Management of Nausea and Vomiting of Pregnancy: Synthesis of National Guidelines.

Nausea and vomiting of pregnancy (NVP) affects a high proportion of the pregnant population. The aim of this study was to compare and synthesize recommendations from national guidelines regarding the management of NVP. A descriptive review of 3 recently published national guidelines on NVP was conducted: Royal College of Obstetricians and Gynaecologists on "The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum," American College of Obstetricians and Gynecologists on "Nausea and Vomiting of Pregnancy," and Society of Obstetricians and Gynaecologists of Canada on "The Management of Nausea and Vomiting of Pregnancy." These guidelines were summarized and compared in terms of the recommended management of pregnant women. The quality of evidence was also reviewed based on the method of reporting. Several differences were identified on the different guidelines regarding the management of NVP. Frequent small meals and avoidance of iron supplements are recommended for prevention. The consumption of ginger, acustimulations, antihistamines, phenothiazines, dopamine, and serotonin 5-hydroxytryptamine type 3 receptor antagonists is routinely recommended for use in the community as treatment. Evidence-based medicine may lead to the adoption of an international guideline for the management of NVP, which may lead to a more effective management of that entity.

Do You Aware of Hypotension

If want to become a healthy person, need to do many changes in day-to-day life. Same like in human body if the heart works without any difficulties, it maintains a healthy body. One of the Alteration in blood pressure is Hypotension .it is nothing but the blood pressure that is lower than 90/60mmhg. It has four types that are orthostatic or postural hypotension, postprandial hypotension, neurally mediated hypotension and severe hypotension. Each one different from others. General causes for hypotension are:1. Heart rate problem [too fast heart rate or too slow], 2. A heart muscle or pump problem[myocardial infarction, cardiomyopathy], 3.A volume problem [hemorrhage, GI fluid loss, renal injury, large volume fluid loss, prolonged intake of alcohol, posture changes, stand or sit after heavy meal, a faulty brain signals, shock etc]. General measures to treat or prevent hypotension includes increase salt intake, foot end elevation, take plenty of oral fluids, avoid alcohol, do exercises regularly, avoid bending at waist, wear compression stockings, tale small and frequent meals, take vitamin supplements etc.

Dimensioning of the physical area and required number of food handlers for school food services

ABSTRACT Objective We aimed to establish equations for dimensioning of the physical area and determining the required number of food handlers in food services of schools and to compare them with reference equations. Methods It was visited 44 municipalities located in the states of São Paulo (n=36) and Rio de Janeiro (n=8) between 2013 and 2014. The physical area for school food services was evaluated using a measuring tape. For all food services, we calculated the Maximum Attendance Capacity, which is the sum of small and large meals served during the busiest shift. A validated checklist was used to evaluate food safety practices. Linear regression models were developed to establish the proposed equations. Results In total, we evaluated 205 school units. Based on the data, the following equations were established: Equation A: area of production=15.22+(maximum attendance capacity×0.02), which estimates the minimum area needed for a school food service; and Equation B: the number of food handlers=2.17+(maximum attendance capacity×0.002), to determine the minimum number of food handlers needed. These equations were established based on school food services that presented adequate food safety practices (i.e., low health risk). Conclusion It was established new equations for calculating the size of the physical area for school food services and the required number of food handlers. These new equations can be used as a starting point in management planning of a school food service.

The influence of meal size on the digestive energetics of Gould’s wattled bat, Chalinolobus gouldii

Although variation in meal size is known to have an impact on digestive energetics, there is limited information on how it influences metabolic rate and energy assimilation in insectivorous bats. We investigated the influence of meal size, representing 10% or 20% of an individual’s weight, on the digestive energetics of Gould’s wattled bat, Chalinolobus gouldii (n = 61 bats). Using open-flow respirometry, we recorded a median resting metabolic rate of 2.0 mL g–1 h–1 (n = 51, range = 0.4–4.8) at an air temperature of 32°C. Median postprandial metabolic rate peaked at 6.5 (range = 3.4–11.6, n = 4) and 8.2 (range = 3.8–10.6, n = 7), representing 3.3- and 4.1-fold increases from resting metabolic rate for the two meal sizes. Using bomb calorimetry, we calculated the calorific value of the two meal sizes, and the calories lost during digestion. Following gut passage times of 120 min (range = 103–172, n = 15) and 124 min (range = 106–147, n = 12), C. gouldii assimilated 88.0% (range = 84.6–93.8, n = 5) and 93.3% (range = 84.0–99.4, n = 10) of the kilojoules available from the 10% and 20% meal sizes, respectively. When fed ad libitum, C. gouldii consumed a mean of 23.2% of their body weight during a single sitting (n = 18, range = 6.3–34.1%). Overall, digestive energetics were not significantly different between 10% or 20% meal sizes. The ability to ingest small and large meals, without compromising the rate or efficiency of calorie intake, indicates that free-ranging C. gouldii are likely limited by food available in the environment, rather than the ability to assimilate energy.

Production of a water-soluble protein powder from anchovy and soybean meal by endogenous enzymatic hydrolysis and solid-state fermentation

Anchovy (Engraulis japonicus), a small, low-valued, marine fish, and soybean meal (Glycine max), a by-product of soybean oil extraction, are both abundant protein resources (approximately 65 and 46 g per 100 g dry weight, respectively). In this study, water-soluble protein powder from anchovy and soybean meal was obtained by two processes, anchovy endogenous enzymatic hydrolysis (stage 1), and solid-state fermentation of anchovy hydrolysis residue and soybean meal (stage 2). The parameters of hydrolysis stage were optimized with single factor experiments and fermentation stage was optimized using central composite design and validated. Maximum protein recovery (91%) was achieved. The protein was successfully converted into a low molecular weight powder for potential use in supplementation of animal and human diets. Furthermore, anti-nutritional factors mainly composed of 7S, 11S globulin and oligosaccharide in soybean meal were effectively degraded. This work provides a value-added method for novel protein from anchovy and soybean meal. Practical applications Obtaining protein yields from readily available resource materials is essential in overcoming the protein resource shortage. This work provides a novel technique for the advanced utilization of low-value resources. The product obtained in this study contained abundant peptides, and the amino acid composition, such as the percentage of essential amino acid and flavor amino acid in water-soluble protein was more reasonable than the raw material. The results of this study are suitable for the industrial production of food or feed additive.

A meal concept designed for older adults - Small, enriched meals including dessert.

BackgroundThe population of older adults is growing and many are at risk of disease-related malnutrition. This is a serious condition which increases the risk for other diseases and distress, human suffering and puts a high load on health care costs. Meal concepts tailored to suit the needs of older adults are required to decrease the incidence of disease-related malnutrition.ObjectiveTo evaluate sensory perception regarding a concept of small, protein and energy-enriched multi-component meals designed according to the nutritional needs of older adults.DesignA meal concept of small main courses with complementary desserts and protein and energy-enriched products was evaluated using triangle tests, hedonic evaluation and focus group discussion. Enriched sauces and meals were compared to corresponding commercial products regarding appearance, taste, consistency and overall acceptance.ResultsThe concept of a small main course with a complementary dessert was generally perceived as positive by the target group. The acceptance scores for the enriched meals were generally lower than for the commercial meals, mainly owing to the packaging of the enriched meals which required covering the food in sauce. Enriched sauces contained approximately 90% more protein than the commercial sauces. However, protein enrichment affected the sensory properties of the sauces and they were perceived as thicker, creamier and less flavour-intensive.ConclusionsA concept based on small, protein and energy-enriched meals supplemented with a dessert was considered suitable for increasing the energy and protein intakes of older adults provided that the method of enrichment ensures attractive sensorial properties.

Guidelines for Antenatal and Preoperative care in Cesarean Delivery: Enhanced Recovery After Surgery Society Recommendations (Part 1)

This Enhanced Recovery After Surgery (ERAS) Guideline for perioperative care in cesarean delivery will provide best practice, evidenced-based, recommendations for preoperative, intraoperative, and postoperative phases with, primarily, a maternal focus. The focused pathway process for scheduled and unscheduled cesarean delivery for this ERAS Cesarean Delivery Guideline will consider from the time from decision to operate (starting with the 30-60 minutes before skin incision) to hospital discharge. The literature search (1966-2017) used Embase and PubMed to search medical subject headings that included "Cesarean Section," "Cesarean Section," "Cesarean Section Delivery" and all pre- and intraoperative ERAS items. Study selection allowed titles and abstracts to be screened by individual reviewers to identify potentially relevant articles. Metaanalyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series were considered for each individual topic. Quality assessment and data analyses that evaluated the quality of evidence and recommendations were evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system, as used and described in previous ERAS Guidelines. The ERAS Cesarean Delivery Guideline/Pathway has created a maternal focused pathway (for scheduled and unscheduled surgery starting from 30-60 minutes before skin incision to maternal discharge) with ERAS cesarean delivery consensus recommendations preoperative elements (anesthetic medications, fasting, carbohydrate supplementation, prophylactic antibiotics/skin preparation, ), intraoperative elements (anesthetic management, maternal hypothermia prevention, surgical technique, hysterotomy creation and closure, management of peritoneum, subcutaneous space, and skin closure), perioperative fluid management, and postoperative elements (chewing gum, management of nausea and vomiting, analgesia, timing of food intake, glucose management, antithrombotic prophylaxis, timing of ambulation, urinary management, and timing of maternal and neonate discharge). Limited topics for optimized care and for antenatal education and counselling and the immediate neonatal needs at delivery are discussed. Strong recommendations for element use were given for preoperative (antenatal education and counselling, use of antacids and histamine, H2 receptor antagonists, 2-hour fasting and small meal within 6 hours surgery, antimicrobial prophylaxis and skin preparation/chlorhexidine-alcohol), intraoperative (regional anesthesia, prevention of maternal hypothermia [forced warm air, warmed intravenous fluids, room temperature]), perioperative (fluid management for euvolemia and neonatal immediate care needs that include delayed cord clamping), and postoperative (fluid management to prevent nausea and vomiting, antiemetic use, analgesia with nonsteroidal antiinflammatory drugs/paracetamol, regular diet within 2 hours, tight capillary glucose control, pneumatic compression stocking for venous thromboembolism prophylaxis, immediate removal of urinary catheter). Recommendations against the element use were made for preoperative (maternal sedation, bowel preparation), intraoperative (neonatal oral suctioning or increased inspired oxygen), and postoperative (heparin should not be used routinely venous thromboembolism prophylaxis). Because these ERAS cesarean delivery pathway recommendations (elements/processes) are studied, implemented, audited, evaluated, and optimized by the maternity care teams, this will create an opportunity for the focused and optimized areas of care research with further enhanced care and recommendation.