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Plant-based, i.e. vegetarian (without meat and fish) or vegan (exclusively plant-based foods) diets are in trend also among children and adolescents, but data on food intake in this group are lacking. Here, we compare the consumption of food groups of vegetarian (n 145), vegan (n 110) and omnivore (n 135) children and adolescents (6–18 years) in Germany using data of the VeChi Youth Study. Each food item reported in 3 d weighed dietary records was assigned to one of eighteen food groups and individual mean intake per day (g/MJ) was calculated. Group differences were assessed using covariance analyses adjusted for age, sex and other covariates. For food groups with a high number of non-consumers, non-parametric Kruskal–Wallis tests were run. Pairwise comparison of vegetarian and vegan groups indicated significantly higher intakes of legumes, nuts, milk alternatives (all P = 0·0003) and meat alternatives (P = 0·0065) among vegan subjects. Intake of these food groups of omnivore participants was low (Q3:0·0 g/MJ for legumes, milk alternatives and meat alternatives, 0·5 g/MJ for nuts). Dairy intake of vegetarians (11·6 g/MJ) was significantly lower than of omnivore subjects (24·7 g/MJ) (P = 0·0003). Intake of fats/oils and sweet foods was lowest in vegan compared with vegetarian and omnivore participants (P< 0·05). Whole grain intake was higher in vegan participants (14·5 g/MJ) than of vegetarian (9·1 g/MJ) and omnivore (6·5 g/MJ) participants (P = 0·0003). Longitudinal studies are necessary to evaluate the long-term health consequences of vegetarian, vegan and omnivore food patterns, especially in childhood and adolescence.

ZusammenfassungUngeachtet der sozialgesetzlichen Vorgaben existieren im deutschen Gesundheitssystem in der Patientenversorgung nebeneinander Unter‑, Fehl- und Überversorgung. Überversorgung bezeichnet diagnostische und therapeutische Maßnahmen, die nicht angemessen sind, da sie die Lebensdauer oder Lebensqualität der Patienten nicht verbessern, mehr Schaden als Nutzen verursachen und/oder von den Patienten nicht gewollt werden. Daraus können hohe Belastungen für die Patienten, deren Familien, die Behandlungsteams und die Gesellschaft resultieren. Dieses Positionspapier erläutert Ursachen von Überversorgung in der Intensivmedizin und gibt differenzierte Empfehlungen zu ihrer Erkennung und Vermeidung. Zur Erkennung und Vermeidung von Überversorgung in der Intensivmedizin erfordert es Maßnahmen auf der Mikro‑, Meso- und Makroebene, insbesondere die folgenden: 1) regelmäßige Evaluierung des Therapieziels im Behandlungsteam unter Berücksichtigung des Patientenwillens und unter Begleitung von Patienten und Angehörigen; 2) Förderung einer patientenzentrierten Unternehmenskultur im Krankenhaus mit Vorrang einer qualitativ hochwertigen Patientenversorgung; 3) Minimierung von Fehlanreizen im Krankenhausfinanzierungssystem gestützt auf die notwendige Reformierung des fallpauschalbasierten Vergütungssystems; 4) Stärkung der interdisziplinären/interprofessionellen Zusammenarbeit in Aus‑, Fort- und Weiterbildung; 5) Initiierung und Begleitung eines gesellschaftlichen Diskurses zur Überversorgung.

In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient’s general health status prior to the current illness.

Angesichts der beginnenden COVID-19-Pandemie haben die deutschen Krankenhauser ihre intensivmedizinischen Kapazitaten erhoht. Trotz optimaler Nutzung erscheint es moglich, dass die intensivmedizinischen Ressourcen nicht mehr fur alle Patienten ausreichen, die ihrer bedurfen. Vor diesem Hintergrund wurden von einer multidisziplinaren Autorengruppe und mit Unterstutzung von acht medizinisch-wissenschaftlichen Fachgesellschaften Empfehlungen zur Verteilung intensivmedizinischer Ressourcen im Kontext der COVID-19-Pandemie erarbeitet. Die Empfehlungen zu Verfahren und Kriterien fur Priorisierungsentscheidungen bei Ressourcenknappheit wurden auf Grundlage der verfugbaren wissenschaftlichen Evidenz, ethischer und rechtlicher Uberlegungen sowie praktischer Erfahrungen erstellt. Medizinische Entscheidungen mussen sich immer am Bedarf und den Behandlungspraferenzen des einzelnen Patienten orientieren. Erganzend zu dieser patientenzentrierten Betrachtung kommt mit der Priorisierung bei absoluter Mittelknappheit eine uberindividuelle Perspektive hinzu. In dieser Situation sollte die Priorisierung anhand des Kriteriums der Erfolgsaussicht einer Behandlung erfolgen, um die Anzahl der vermeidbaren Todesfalle zu minimieren und eine Diskriminierung von Patienten aufgrund des Alters, von Behinderungen oder des sozialen Status zu vermeiden. Die Einschatzung der klinischen Erfolgsaussicht berucksichtigt den Schweregrad der aktuellen Erkrankung, das Vorliegen schwerer Komorbiditaten und den allgemeinen pramorbiden Gesundheitsstatus des Patienten.

Supplemental Digital Content is available in the text., Objectives: To develop a consensus framework that can guide the process of decision-making on continuing or limiting life-sustaining treatments in ICU patients, using evidence-based items, supported by caregivers, patients, and surrogate decision makers from multiple countries. Design: A three-round web-based international Delphi consensus study with a priori consensus definition was conducted with experts from 13 countries. Participants reviewed items of the decision-making process on a seven-point Likert scale or with open-ended questions. Questions concerned terminology, content, and timing of decision-making steps. The summarized results (including mean scores) and expert suggestions were presented in the subsequent round for review. Setting: Web-based surveys of international participants representing ICU physicians, nurses, former ICU patients, and surrogate decision makers. Patients: Not applicable. Interventions: Not applicable. Measurements and Main Results: In three rounds, respectively, 28, 28, and 27 (of 33 invited) physicians together with 12, 10, and seven (of 19 invited) nurses participated. Patients and surrogates were involved in round one and 12 of 27 responded. Caregivers were mostly working in university affiliated hospitals in Northern Europe. During the Delphi process, most items were modified in order to reach consensus. Seven items lacked consensus after three rounds. The final consensus framework comprises the content and timing of four elements; three elements focused on caregiver-surrogate communication (admission meeting, follow-up meeting, goals-of-care meeting); and one element (weekly time-out meeting) focused on assessing preferences, prognosis, and proportionality of ICU treatment among professionals. Conclusions: Physicians, nurses, patients, and surrogates generated a consensus-based framework to guide the process of decision-making on continuing or limiting life-sustaining treatments in the ICU. Early, frequent, and scheduled family meetings combined with a repeated multidisciplinary time-out meeting may support decisions in relation to patient preferences, prognosis, and proportionality.

Background: Time-restricted eating is a promising dietary strategy for weight loss, glucose and lipid metabolism improvements, and overall well-being. However, human studies demonstrated contradictory results for the restriction of food intake to the beginning (early TRE, eTRE) or to the end of the day (late TRE, lTRE) suggesting that more carefully controlled studies are needed.Objective: The aim of the ChronoFast trial study is to determine whether eTRE or lTRE is a better dietary approach to improve cardiometabolic health upon minimized calorie deficits and nearly stable body weight.Methods: Here, we present the study protocol of the randomized cross-over ChronoFast clinical trial comparing effects of 2 week eTRE (8:00 to 16:00 h) and lTRE (13:00 to 21:00 h) on insulin sensitivity and other glycemic traits, blood lipids, inflammation, and sleep quality in 30 women with overweight or obesity and increased risk of type 2 diabetes. To ensure timely compliance and unchanged dietary composition, and to minimize possible calorie deficits, real-time monitoring of dietary intake and body weight using a smartphone application, and extensive nutritional counseling are performed. Continuous glucose monitoring, oral glucose tolerance test, 24 h activity tracking, questionnaires, and gene expression analysis in adipose tissue and blood monocytes will be used for assessment of study outcomes.Discussion: The trial will determine whether eTRE or lTRE is more effective to improve cardiometabolic health, elucidate underlying mechanisms, and contribute to the development of recommendations for medical practice and the wider population.Clinical Trial Registration:www.ClinicalTrials.gov, Identifier [NCT04351672]

Background Previous studies have shown beneficial effects of therapeutic fasting and plant-based dietary interventions on disease activity in patients with rheumatoid arthritis (RA) for a duration of up to 1 year. To date, the effects of such interventions on the gut microbiome and on modern diagnostic markers in patients with RA have not been studied. This trial aims to investigate the clinical effects of therapeutic fasting and a plant-based diet in patients with RA, additionally considering current immunological diagnostic tools and microbiome analyses. Methods/design This trial is an open-label, single-centre, randomised, controlled, parallel-group clinical trial. We will randomly assign 84 patients with RA under a stable standard therapy to either (1) therapeutic fasting followed by a plant-based dietary intervention or (2) to a conventional nutritional counselling focusing on an anti-inflammatory dietary pattern according to the recommendations of the Deutsche Gesellschaft für Ernährung (German society for nutrition). Primary outcome parameter is the group difference from baseline to 12 weeks on the Health Assessment Questionnaire (HAQ). Other secondary outcomes include established clinical criteria for disease activity and treatment response in RA (Disease Activity Score 28, Simple Disease Activity Index, ACR-Response Criteria), changes in self-reported health and physical functional ability, mood, stress, quality of life, dietary behaviour via 3-day food records and a modified Food Frequency Questionnaire, body composition, changes in the gut microbiome, metabolomics and cytometric parameters. Outcomes will be assessed at baseline and day 7, after 6 weeks, 12 weeks and after 6 months. Ethics and dissemination Ethical approval to process and analyse data, and to publish the results was obtained through the institutional review board of Charité-Universitätsmedizin Berlin. Results of this trial will be disseminated through peer-reviewed publications and scientific presentations. Trial registration number NCT03856190.

ZUSAMMENFASSUNGAlternierende Phasen des Nahrungsüberangebots und des Hungerns waren bei den Frühmenschen vermutlich der Regelfall. Es scheint naheliegend, dass der menschliche Körper evolutionsbedingt Phasen des Fastens sehr gut bewältigen kann und sich die genetische Ausstattung, der Körpermetabolismus und die Ernährungsphysiologie gut darauf eingestellt haben. Im Gegensatz dazu ist anzunehmen, dass die mehrmals tägliche, regelmäßige Nahrungszufuhr mit Snacks, Zwischenmahlzeiten und energiehaltigen Getränken, die Hormon- und Stoffwechselsysteme überfordert. Die günstigen metabolischen Wirkungen des Fastens sind in physiologischen Arbeiten beschrieben. Der Artikel gibt einen Überblick zu den verschiedenen Formen des Fastens und dessen mögliche Effekte.

There is a lack of data on associations between modern vegetarian and vegan diets and health among children and adolescents. The aim of the Vechi Youth Study was to cross-sectionally examine anthropometry, dietary intakes and nutritional status in a sample of 149 vegetarian, 115 vegan and 137 omnivore children and adolescents (6–18 years old, mean age: 12.7 ± 3.9 years). Group differences of dietary intake (calculated from three-day dietary records), nutrient biomarker and blood lipid concentrations were assessed using an analysis of covariance, adjusted for sex, age and other covariates. The total energy intake did not differ significantly between groups, but intake of carbohydrates was higher among vegetarians and vegans than among omnivores (p = 0.0002, respectively). The median protein intake exceeded 0.9 g/kg body weight/day in all diet groups and was lowest among vegetarians (p &lt, 0.02). There was no significant difference of haemoglobin, vitamin B2, 25-OH vitamin D3, HDL-C and triglycerides blood concentrations between diet groups. Vegan participants had higher folate concentrations than vegetarian participants (p = 0.0053). Ferritin concentration was significantly higher in omnivores than in vegetarians (p = 0.0134) and vegans (p = 0.0404). Vegetarians had lower concentrations of holotranscobalamin (p = 0.0042) and higher concentrations of methylmalonic acid (p = 0.0253) than omnivores. Vegans had the lowest non-HDL-C and LDL-C concentrations in comparison to vegetarians (p = 0.0053 and p = 0.0041) and omnivores (p = 0.0010 and p = 0.0010). A high prevalence (&gt, 30%) of 25-OH vitamin D3 and vitamin B2 concentrations below reference values were found irrespective of the diet group. In conclusion, the Vechi Youth Study did not indicate specific nutritional risks among vegetarian and vegan children and adolescents compared to omnivores.

Purpose: To evaluate the association between provider religion and religiosity and consensus about end-of-life care and explore if geographical and institutional factors contribute to variability in practice. Materials and Methods: Using a modified Delphi method 22 end-of-life issues consisting of 35 definitions and 46 statements were evaluated in 32 countries in North America, South America, Eastern Europe, Western Europe, Asia, Australia and South Africa. A multidisciplinary, expert group from specialties treating patients at the end-of-life within each participating institution assessed the association between 7 key statements and geography, religion, religiosity and institutional factors likely influencing the development of consensus. Results: Of 3049 participants, 1366 (45%) responded. Mean age of respondents was 45 ± 9 years and 55% were females. Following 2 Delphi rounds, consensus was obtained for 77 (95%) of 81 definitions and statements. There was a significant difference in responses across geographical regions. South African and North American respondents were more likely to encourage patients to write advance directives. Fewer Eastern European and Asian respondents agreed with withdrawing life-sustaining treatments without consent of patients or surrogates. While respondent’s religion, years in practice or institution did not affect their agreement, religiosity, physician specialty and responsibility for end-of-life decisions did. Conclusions: Variability in agreement with key consensus statements about end-of-life care is related primarily to differences among providers, with provider-level variations related to differences in religiosity and specialty. Geography also plays a role in influencing some end-of-life practices. This information may help understanding ethical dilemmas and developing culturally sensitive end-of-life care strategies.

Background - This study investigated the completion rates, scores and factors associated with non-completion and low scores on physical capability tests in a health survey administered to adults with intellectual disabilities. Method - Assessment comprised body mass index (BMI), the Short Physical Performance Battery (SPPB), the timed up-and-go (TUG) test, the one-legged stance (OLS) test; and gross motor, communication and behavioural functioning tests. Results - The completion rates among 93 participants (aged 17–78) were 46% for the SPPB, 42% for the TUG, and 31% for the OLS. More severe intellectual disability (OR = 3.12, p Conclusions - Including physical capability tests in health surveys among adults with intellectual disabilities is important to monitor functional status and guide prevention strategies.

AIM To determine the potential anti-inflammatory effect of a multimodal periodic fasting programme on surrogate parameters of periodontal inflammation in hospitalized patients diagnosed for metabolic syndrome (MetS). MATERIAL AND METHODS A total of 47 patients were recruited and hospitalized in an integrative ward for an intensified two-week multimodal fasting, diet and lifestyle programme. Patients were periodontally examined at baseline (t1), after the 2-week fasting protocol (t2) and, subsequently, 4 months after fasting (t3). The following parameters were determined: periodontal screening index (PSI), bleeding on probing (BOP), gingival crevicular fluid volume (GCF), plaque index (PI), C-reactive protein (CRP), blood pressure (BP), waist circumference (WC), fasting glucose (FGLU), triglycerides (TRG), high-density lipoprotein (HDL) and HbA1c. RESULTS A total of 28 female and 8 male patients fulfilled the defined criteria for MetS and were analysed separately by gender. At t2, BOP and GCF were reduced when compared to t1 (median: t2 = 39; t1 = 33.1%; p

Background The mortality of metabolic-obesity phenotypes has been thoroughly studied, but it is not known if or how the association between mortality and body mass index (BMI), waist circumference or a body shape index (ABSI) differ in strata of cardiometabolic health status. Methods We linked data on 12,815 men and women aged 36–79 years from the SAMINOR 1 Survey with mortality data from the Norwegian Cause of Death Registry. We defined metabolically healthy and unhealthy as having zero and ≥ 1, respectively, of the following: MetS, pre-existing diabetes or cardiovascular disease (CVD), or prescribed drugs for high blood pressure, hyperglycaemia or dyslipidaemia. We defined general and abdominal obesity as BMI ≥ 30 kg/m2 and waist circumference ≥ 88 cm (women) or 102 cm (men), respectively, and cross-classified these categories with metabolic status to create metabolically healthy non-obese and obese (MHNO and MHO) and metabolically unhealthy non-obese and obese (MUNO and MUO) phenotypes. We used Cox regression to estimate the hazard ratio (HR) for all-cause and CVD mortality for 1) the four phenotypes and 2) BMI, waist circumference and ABSI fitted with restricted cubic splines. We adjusted for age and lifestyle, and tested for interactions with sex and metabolic status (only continuous measures). Results The MHO phenotype was present in 7.8% of women and 5.8% of men. During a median follow-up of 15.3/15.2 years, 596/938 women/men had died, respectively. The MUNO and MUO groups had higher mortality than the MHNO group. Sex and phenotypes interacted with respect to CVD mortality: relative to the MHNO group, the MHO group had an adjusted HR (95% confidence interval) for CVD mortality of 1.05 (0.38–2.88) in women and 2.92 (1.71–5.01) in men. We found curvilinear associations between BMI/waist circumference and all-cause mortality irrespective of metabolic status. Corresponding relationships with CVD mortality were linear and the slope differed by sex and metabolic status. ABSI was linearly and positively associated with all-cause and CVD mortality in men. Conclusion The relationships between BMI, waist circumference or ABSI and mortality differed by sex, metabolic status and cause of death. Poor metabolic health substantially increases mortality regardless of obesity status.

Aims: To compare the effects of Ayurvedic and conventional nutritional therapy in patients with irritable bowel syndrome (IBS). Methods: Sixty-nine patients with IBS were randomized to Ayurvedic (n = 35) or conventional nutritional therapy according to the recommendations of the German Nutrition Society including the low-FODMAP diet (n = 34). Study visits took place at baseline and after 1, 3, and 6 months. The primary outcome was IBS symptom severity (IBS-SSS) after 3 months; secondary outcomes included stress (CPSS), anxiety and depression (HADS), well-being (WHO-5) and IBS-specific quality of life (IBS-QOL). A repeated measures general linear model (GLM) for intent-to-treat-analyses was applied in this explorative study. Results: After 3 months, estimated marginal means for IBS-SSS reductions were 123.8 [95% confidence interval (95% CI) = 92.8–154.9; p < 0.001] in the Ayurvedic and 72.7 (95% CI = 38.8–106.7; p < 0.001) in the conventional group. The IBS-SSS reduction was significantly higher in the Ayurveda group compared to the conventional therapy group (estimated marginal mean = 51.1; 95% CI = 3.8–98.5; p = 0.035) and clinically meaningful. Sixty-eight percentage of the variance in IBS-SSS reduction after 3 months can be explained by treatment, 6.5% by patients' expectations for their therapies and 23.4% by IBS-SSS at pre-intervention. Both therapies are equivalent in their contribution to the outcome variance. The higher the IBS-SSS score at pre-intervention and the larger the patients' expectations, the greater the IBS-SSS reduction. There were no significant group differences in any secondary outcome measures. No serious adverse events occurred in either group. Conclusion: Patients with IBS seem to benefit significantly from Ayurvedic or conventional nutritional therapy. The results warrant further studies with longer-term follow-ups and larger sample sizes. Clinical Trial Registration: https://clinicaltrials.gov/ct2/show/NCT03019861, identifier: NCT03019861. CA extern

BACKGROUND End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices. METHODS In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision. FINDINGS Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p

Background We investigated daily blood pressure (BP) changes during fasting periods ranging from 4 to 41 (10.0±3.8) days in a cohort of 1610 subjects, including 920 normotensive, 313 hypertensive nonmedicated, and 377 hypertensive medicated individuals. Methods and Results Subjects underwent a multidisciplinary fasting program with a daily intake of ≈250 kcal. Weight and stress scores decreased during fasting, and the well‐being index increased, documenting a good tolerability. BP mean values decreased from 126.2±18.6/81.4±11.0 to 119.7±15.9/77.6±9.8 mm Hg (mean change, −6.5/3.8 mm Hg). BP changes were larger for hypertensive nonmedicated subjects (>140/90 mm Hg) and reduced by 16.7/8.8 mm Hg. This reduction reached 24.7/13.1 mm Hg for hypertensive nonmedicated subjects (n=76) with the highest BP (>160/100 mm Hg). In the normotensive group, BP decreased moderately by 3.0/1.9 mm Hg. Interestingly, we documented an increase of 6.3/2.2 mm Hg in a subgroup of 69 female subjects with BP Conclusions Long‐term fasting tends to decrease BP in subjects with elevated BP values. This effect persisted during the 4 days of stepwise food reintroduction, even when subjects stopped their antihypertensive medication. Registration URL: https://www.drks.de/drks_web/ ; Unique identifier: DRKS00010111.

ObjectivesWhen bloodstream infections are caused by resistant bacteria, rapid antimicrobial susceptibility testing (RAST) is important for adjustment of therapy. The EUCAST RAST method, directly from positive blood cultures, was validated in a multi-laboratory study in Europe.MethodsRAST was performed in 40 laboratories in northern Europe (NE) and 15 in southern Europe (SE) from clinical blood cultures positive for Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus or Streptococcus pneumoniae. Categorical results at 4, 6 and 8 h of incubation were compared with results for EUCAST standard 16–20 h disc diffusion. The method, preliminary breakpoints and the performance of the laboratories were evaluated.ResultsThe total number of isolates was 833/318 in NE/SE. The number of zone diameters that could be read (88%, 96% and 99%) and interpreted (70%, 81% and 85%) increased with incubation time (4, 6 and 8 h). The categorical agreement was acceptable, with total error rates in NE/SE of 2.4%/4.9% at 4 h, 1.1%/3.5% at 6 h and 1.1%/3.3% at 8 h. False susceptibility at 4, 6 and 8 h of incubation was below 0.3% and 1.1% in NE and SE, respectively, and the corresponding percentages for false resistance were below 1.9% and 2.8%. After fine-tuning breakpoints, more zones could be interpreted (73%, 89% and 93%), with only marginally affected error rates.ConclusionsThe EUCAST RAST method can be implemented in routine laboratories without major investments. It provides reliable antimicrobial susceptibility testing results for relevant bloodstream infection pathogens after 4–6 h of incubation.

Aims/Hypothesis: Intermittent as well as prolonged fasting are receiving considerable attention and appear favorable in conditions like the metabolic syndrome, type 2 diabetes, rheumatic diseases and others. Fasting for people with type 1 diabetes is generally considered too risky. However, the ability and possibility to change from carbohydrate to ketone-based fuel supply might also be relevant for people with type 1 diabetes. The aim of this patient-led research was to investigate the feasibility, benefit and safety of a seven-day multimodal fasting intervention in people with type 1 diabetes. Methods: A non-randomized controlled pilot study, with 20 participants with and 10 without type 1 diabetes. Data acquisition took place prior, post and four months after the intervention and daily during intervention. Results: 29 of 30 participants finished the intervention. Mean ß-hydroxybutyrate as representative ketone body increased to 2.8 ± 1.9 mmol/L on day 7 while average glucose remained between 4.9 ± 1.5 to 7.5 ± 2.3 mmol/L [89 ± 27 and 136 ± 40 mg/dL]. Fasting-related side effects were all temporary, and slightly more prevalent in those with type 1 diabetes. Mean daily insulin dose was adjusted from 24.4 (3-50) IU on the day before fasting to 7.6 (0-26.7) IU on day 7. Quality of life (WHO-5) normalized from 54.0 ± 4.4 to 68.8 ± 15.0 (p = 0.01) after fasting. There was a decrease from before until the follow-up four month later of weight from 77.6 ± 20.4 kg to 76.6 ± 20.9 kg (p = 0.023) and for the BMI from (27.68 ± 7.04) to (26.74 ± 7.15) kg/m2 (p = 0.008). Diastolic blood pressure increased from 69.75 ± 11.41 mmHg to 75.74 ± 8.42 mmHg (p = 0.028) and stayed in a healthy range on average. Conclusions/Interpretation: This study demonstrates the feasibility, benefits and safety aspects of a 7-day fast in adults with type 1 diabetes.

Hintergrund und Stand (inter)nationaler Forschung: Patienten mit rheumatoider Arthritis (RA) kennen tägliche Veränderungen ihrer Symptome und müssen bei Krankheitsschüben rechtzeitig reagieren. Sie sind aufgrund der Entzündung und immunsuppressiven Therapie Risikopatienten für[zum vollständigen Text gelangen Sie über die oben angegebene URL], 19. Deutscher Kongress für Versorgungsforschung (DKVF)

Medically supervised fasting has long tradition and broad acceptance in some European countries. The exact amount to which ketone bodies are produced as well as their possible contribution to beneficial effects in this procedure are open. Open-label observational trial with in-patients undergoing medically supervised fasting with supplementation of approximately 40 g/d carbohydrates as part of an established routine care. Daily finger-stick blood samples for measurement of glucose and s-hydroxybutyrate. Descriptive analysis for all data. Complete sets of data of 17 patients (5 m, mean age 63.1) could be evaluated. Mean concentrations of s-hydroxybutyrate rose continuously to a mean maximum of 3.6 mmol/L with an individual maximum of 5.1 mmol/L, while glucose decreased within normal range. Two patients with type 2 diabetes produced significantly less s-hydroxybutyrate. Courses for s-hydroxybutyrate and glucose showed a weak inverse correlation, while no serious adverse effects could be observed. Medically supervised fasting with definite small amounts of carbohydrates by fluid intake may lead to limited increases of ketone bodies in their biopositive range, as known e.g. from epileptology or sports medicine. Clinical consequences deserve further research.

Metabolism is controlled by macro- and micronutrients. Protein-rich diets should lead to latent acidosis at tissue level with further negative implications. Food supplements with alkaline salts are available and popular pretending to prevent these changes. Within a randomised double-blind placebo-controlled trial we tested the hypotheses that (1) a 4-week protein-rich diet induces a latent tissue acidosis and (2) an alkaline supplement can compensate this. Acid–base balance and important metabolic parameters were determined before and after 4 weeks of supplementation by peripheral blood samples, indirect calorimetry and muscle microdialysis before and after a protein-rich test meal. Fourty volunteers were randomised 1:1 to either verum or placebo supplements. Protein-rich diet by itself did not significantly affect acid–base balance. Alkaline supplementation increased plasma bicarbonate concentration without changing pH. Postprandial increases in serum glucose and insulin tended to be lower for verum vs. placebo. Resting and postprandial energy metabolism, and carbohydrate and fat oxidation did not differ significantly before and after supplementation in both groups. In muscle, postprandial glucose uptake and aerobic glucose oxidation were significantly higher for verum. In addition, verum significantly increased serum magnesium concentrations. Four weeks of protein-rich diet did not significantly influence acid–base balance. However, alkaline supplementation improved systemic and tissue acid–base parameters and oxidative glucose metabolism.

Objectives Intermittent as well as prolonged fasting are receiving considerable attention and appear favorable in conditions such as metabolic syndrome, type 2 diabetes, and rheumatic diseases. Fasting for individuals with type 1 diabetes (T1D) is generally considered too risky. However, the ability and possibility to change from carbohydrate- to ketone-based fuel supply might be relevant for individuals with T1D. The aim of this patient-led research was to investigate the feasibility, benefit, and safety of a 7-d multimodal fasting intervention in individuals with T1D. Methods This was a non-randomized controlled pilot study, with 20 participants with T1D and 10 without the disease. Data acquisition took place before, after, and 4 mo after the intervention and daily during intervention. Results Of the individuals with T1D, 19 finished fasting. A mean β-hydroxybutyrate as representative ketone body increased to 2.8 ± 1.9 mmol/L on day 7; whereas average glucose remained between 4.9 (±1.5) and 7.5 (±2.3) mmol/L (89 ± 27 and 136 ± 40 mg/dL). Mean daily insulin dose was adjusted from 24.4 (3–50) IU on the day before fasting to 7.6 (0–26.7) IU on day 7. Quality of life (WHO-5) normalized from 54 (±4.4) to 68.8 (±15; P = 0.01) after fasting. There was a decrease from before until the follow-up 4 mo later of weight from 77.6 (±20.4) to 76.6 (±20.9) kg (P = 0.023) and for body mass index from 27.68 (±7.04) to 26.74 (±7.15) kg/m2 (P = 0.008). Diastolic blood pressure increased from 69.75 (±11.41) to 75.74 (±8.42) mm Hg (P = 0.028) and stayed in a healthy range on average. Fasting-related side effects were all temporary, and slightly more prevalent in those with type 1 diabetes compared with the reference group. Conclusions This study demonstrated the feasibility, benefits, and safety aspects of a 7-d fast in adults with T1D.

Background Individuals with intellectual disabilities (IDs) have lower levels of physical activity (PA) and greater barriers for participation in fitness activities compared with members of the general population. As increased PA has positive effects on cardiovascular and psychosocial health, it is exceedingly important to identify effective interventions for use in everyday settings. Mobile health (mHealth) methods such as motion sensor games (exergames) and smartphone reminders for PA have been explored and found to be promising in individuals with IDs. Objective The purpose of this study is to examine the effectiveness of an individually tailored PA program with motivational mHealth support on daily levels of PA in youth and adults with IDs. Methods The trial uses a randomized controlled design comprising 30 intervention participants and 30 control group participants, aged 16 to 60 years, with sedentary lifestyles or low PA levels. While the controls will receive standard care, the intervention aims to increase the level of PA, measured as steps per day, as the primary outcome. Secondary outcome variables are body mass index, blood pressure, physical performance, social support for PA, self-efficacy in a PA setting, behavior problems, and goal attainment. The intervention involves the delivery of tailored mHealth support, using smartphones or tablets to create structure with focus on the communicative abilities of individual participants. Rewards and feedback are provided in order to motivate individuals to increase participation in PA. Participants in the intervention group, their close relatives, and care staff will be invited to participate in a preintervention goal-setting meeting, where goal attainment scaling will be used to select the participants’ PA goals for the intervention period. All participants will be assessed at baseline, at 3 months, and at 6 months. Results Enrollment was planned to start in April 2020 but will be delayed due to the pandemic situation. The main contribution of this paper is a detailed plan to run our study, which will produce new knowledge about tailored mHealth to support PA in individuals with intellectual disabilities. Conclusions We expect the new intervention to perform better than standard care in terms of improved PA, improved self-efficacy, and social support for activities. Technology offers new opportunities to promote healthy behaviors. The results of the study will determine the effectiveness and sustainability of a tailored mHealth support intervention to increase PA in youth and adults with IDs. Trial Registration ClinicalTrials.gov NCT04079439; https://clinicaltrials.gov/ct2/show/NCT04079439 International Registered Report Identifier (IRRID) PRR1-10.2196/19213

The state of the art for monitoring hypertension relies on measuring blood pressure (BP) using uncomfortable cuff-based devices. Hence, for increased adherence in monitoring, a better way of measuring BP is needed. That could be achieved through comfortable wearables that contain photoplethysmography (PPG) sensors. There have been several studies showing the possibility of statistically estimating systolic and diastolic BP (SBP/DBP) from PPG signals. However, they are either based on measurements of healthy subjects or on patients on intensive care units (ICUs). Thus, there is a lack of studies with patients out of the normal range of BP and with daily life monitoring out of the ICUs. To address this, we created a dataset (HYPE) composed of data from hypertensive subjects that executed a stress test and had 24-hours monitoring. We then trained and compared machine learning (ML) models to predict BP. We evaluated handcrafted feature extraction approaches vs image representation ones and compared different ML algorithms for both. Moreover, in order to evaluate the models in a different scenario, we used an openly available set from a stress test with healthy subjects (EVAL). The best results for our HYPE dataset were in the stress test and had a mean absolute error (MAE) in mmHg of 8.79 (±3.17) for SBP and 6.37 (±2.62) for DBP; for our EVAL dataset it was 14.74 (±4.06) and 7.12 (±2.32) respectively. Although having tested a range of signal processing and ML techniques, we were not able to reproduce the small error ranges claimed in the literature. The mixed results suggest a need for more comparative studies with subjects out of the intensive care and across all ranges of blood pressure. Until then, the clinical relevance of PPG-based predictions in daily life should remain an open question.

Periods of fasting and refeeding may reduce cardiometabolic risk elevated by Western diet. We show that in hypertensive metabolic syndrome (MetS) patients (n=35), a 5-day fast followed by a modified DASH diet (Dietary Approach to Stop Hypertension) reduced systolic blood pressure (SBP), antihypertensive medication need, and body-mass index (BMI) at three months post intervention compared to a modified DASH diet alone (n=36). Fasting altered the gut microbiome, impacting bacterial taxa and gene modules associated with short-chain fatty acid production. Cross-system analyses revealed a positive correlation of circulating mucosa-associated invariant T (MAIT) cells, non-classical monocytes and CD4+ effector T cells with SBP. Furthermore, regulatory T cells (Tregs) positively correlated with BMI and weight. Machine learning could predict sustained SBP-responsiveness within the fasting group from baseline immunome data, identifying CD8+ effector T cells, Th17 cells and Tregs as important contributors to the model. The high-resolution multi-omics data highlights fasting as a promising non-pharmacological intervention in MetS.

The obesity epidemic is dynamic with varying secular trends and differences between countries and ethnic groups. The objective of this study was to describe the age- and sex-specific longitudinal changes in weight and waist circumference in a rural Norwegian population with a high proportion of the indigenous Sami population. Based on two population-based surveys, SAMINOR 1 (2003–2004) and SAMINOR 2 (2012–2014), we present longitudinal changes in weight and waist circumference according to age at baseline in the SAMINOR 1 Survey and sex during the 10-year period. The analyses included 1538 men and 1958 women aged 36 to 69 at baseline (birth year 1934 to 1967). Forty-one percent of the population were Sami. Both weight and waist circumference were measured. The mean weight increased 0.8 kg (95% confidence interval: 0.5, 1.1) in men and 0.3 kg (95% confidence interval: 0, 0.5) in women. In both men and women, younger individuals gained significantly more weight during the 10-year follow-up than older participants (p < 0.001). The mean weight showed a statistically significant increase in men aged 36–54 and women aged 36–49 at baseline and was statistically significantly reduced in men and women aged 60–69. The mean waist circumference increased by 6.3 cm (95% confidence interval: 6.0, 6.6) in men and 8.4 cm (95% confidence interval 8.1, 8.8) in women. The mean waist circumference increased statistically significantly from SAMINOR 1 to SAMINOR 2 in all age groups, and there was an inverse relationship between age at baseline and change in waist circumference (p < 0.001). Waist circumference increased more than can be explained by changes in weight and age during the 10-year period. The inverse relationships between age at baseline in SAMINOR 1 and the 10-year change in weight and waist circumference were found in both Sami and non-Sami participants. The findings underline the need for prevention of obesity, particularly in younger people, as it is difficult to achieve permanent weight loss. Copyright: © 2020 Jacobsen et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Background: During the COVID-19 pandemic people are facing risks of adverse health effects due to the restrictions implemented such as quarantine measures, reduced social contact, and self-isolation. In this qualitative review, we collected data on potential preventive and therapeutic health benefits of Complementary and Integrative Medicine (CIM) that might be useful during the COVID-19 pandemic. We have reviewed the scientific literature to summarize CIM practices that could be beneficial for improving physical and mental health and well-being of the population under the current pandemic circumstances. It must be noted that this review is not SARS-CoV-2 specific and we explicitly do not intend to make any SARS-CoV-2 specific health claims in this article. Methods and Findings: A qualitative, non-systematic literature review was conducted in Medline to identify literature describing preventive and therapeutic CIM approaches for strengthening mental and physical health. For a variety of CIM approaches clinical evidence was identified, indicating beneficial effects. CIM approaches include specific dietary measures and selected micronutrients, physical activity, techniques from Mind-Body Medicine, single botanicals or botanical compounds, and spending time in nature among others. The effects of CIM measures on conditions like obesity and hypertension are of special relevance here, as these conditions are considered as risk factors for a severe course of COVID-19. Moreover, a possibly direct effect of CIM approaches on immune functions and clinical parameters in respiratory tract infections, such as influenza, were identified. The findings of this review could be helpful for clinicians, patients, and the general population during the current pandemic when discussing and/or considering CIM options. Conclusions: CIM offers a variety of preventive and therapeutic options for strengthening physical and mental resilience, which could also be useful in the current COVID-19 pandemic. The evidence of CIM approaches with a potential benefit in the COVID-19 pandemic in different areas is worth to be analyzed. While this qualitative review has several obvious limitations, it might serve as useful starting point for further research on this topic. CA extern

BackgroundPrevious studies have suggested that Sami have a similar risk of myocardial infarction and a higher risk of stroke compared with non-Sami living in the same geographical area.DesignParticipants in the SAMINOR 1 Survey (2003–2004) aged 30 and 36–79 years were followed to the 31 December 2016 for observation of fatal or non-fatal events of acute myocardial infarction (AMI), coronary heart disease (CHD), ischaemic stroke (IS), stroke and a composite endpoint (fatal or non-fatal AMI or stroke).AimCompare the risk of AMI, CHD, IS, stroke and the composite endpoint in Sami and non-Sami populations, and identify intermediate factors if ethnic differences in risks are observed.MethodsCox regression models.ResultsThe sex-adjusted and age-adjusted risks of AMI (HR for Sami versus non-Sami 0.99, 95% CI: 0.83 to 1.17), CHD (HR 1.03, 95% CI: 0.93 to 1.15) and of the composite endpoint (HR 1.09, 95% CI: 0.95 to 1.24) were similar in Sami and non-Sami populations. Sami ethnicity was, however, associated with increased risk of IS (HR 1.36, 95% CI: 1.10 to 1.68) and stroke (HR 1.31, 95% CI: 1.08 to 1.58). Height explained more of the excess risk observed in Sami than conventional risk factors.ConclusionsThe risk of IS and stroke were higher in Sami and height was identified as an important intermediate factor as it explained a considerable proportion of the ethnic differences in IS and stroke. The risk of AMI, CHD and the composite endpoint was similar in Sami and non-Sami populations.

Introduction:Prehospital blood component therapy poses a possible treatment option among patients with severe bleeding. The aim of this paper was to characterize patients receiving prehospital blood component therapy by a paramedic-doctor-staffed, ground-based prehospital critical care (PHCC) service.Methods:Bleeding patients with a clinical need for prehospital blood transfusion were included prospectively. The following data were collected: indication for transfusion, mechanism of injury, vital parameters, units of red blood cells (RBCs)/plasma transfused, degree of shock, demographics, and mortality.Results:Twenty-one patients received blood products: 12 (57%) traumatic injuries and nine (43%) non-traumatic bleeds, with a median of 1.5 (range 1.0-2.0) units of RBCs and 1.0 (range 0.0-2.0) unit of plasma. The most frequent trigger to initiate transfusion was on-going excessive bleeding and hypotension. Improved systolic blood pressure (SBP) and milder degrees of shock were observed after transfusion. Mean time from initiation of transfusion to hospital arrival was 24 minutes. In-hospital, 11 patients (61%) received further transfusion and 13 (72%) had urgent surgery within 24 hours. Overall, 28-day mortality was 29% at 24-hours and 33% at 28-days.Conclusion:Prehospital blood component therapy is feasible in a ground-based prehospital service in a medium-sized Scandinavian city. Following transfusion, patient physiology and degree of shock were significantly improved.

Background The relationships between metabolic markers and obesity measures may differ by ethnicity, sex, and height. Questions have been posed whether these relationships differ by ethnicity in the population in Northern Norway, but this has not been explored yet. Objectives Investigate the relationships between metabolic markers and obesity measures in Sami and non‐Sami and explore the impact of stature. Methods In total, 13 921 men and women aged 30 and 36 to 79 years (22.0% Sami) from a population‐based cross‐sectional survey in Norway, the SAMINOR 1 Survey (2003‐2004, 57.2% attendance), were included. Relationships between triglycerides, high‐density lipoprotein cholesterol, glucose, systolic/diastolic blood pressure (BP), metabolic syndrome and diabetes mellitus as outcomes, and body mass index (BMI), waist circumference (WC), and waist‐to‐height ratio (WHtR), respectively, were modelled using fractional polynomial regression. Appropriate interaction analyses and adjustments were made. Results The non‐Sami were approximately 6 cm taller than the Sami. No interactions were found between ethnicity and obesity. At the same levels of WC, BMI, or WHtR, levels of lipids and BP differed marginally between Sami and non‐Sami, but these were eliminated by height adjustment, with one exception: At any given WC, BMI, or WHtR, Sami had approximately 1.4 mmHg (95% CI, −2.1 to −0.7) lower systolic BP than non‐Sami (P values < .001). Conclusions Height explained the marginal ethnic differences in metabolic markers at the same level of obesity, except for systolic BP, which was lower in Sami than in non‐Sami at any given BMI, WC, or WHtR. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

In many critically ill patients, it is uncertain whether the chance of survival and recovery justifies the suffering that is associated with (prolonged) life support. This chapter discusses the circumstances when limiting life-sustaining therapies may be permissible, advisable, or even imperative. Differences between withholding and withdrawing are commented on as well as the role of intensity- or time-limited treatment trials. We discuss strategies to make careful decisions on limiting life-sustaining therapies and suggest how withdrawal of life support can be implemented.

Background People with intellectual disabilities (ID) have lower levels of physical activity than the general population. The aim of this study was to understand the motivational factors of participation in physical activity for people with ID from the perspectives of the family members and staff. Method An abductive qualitative design was used. Social Cognitive Theory constituted the theoretical frame of reference of the study. Two focus group interviews with health care workers and family members and two individual interviews with health care workers were conducted at their workplace. A thematic analysis was performed. Results Three main themes were identified. According to support persons, motivation could be promoted at the individual level by fun, mastery, social setting, technology and knowledge about health behaviours. At a contextual level, physical activity was mediated by engagement with support individuals and available resources. At an interactional level, individuals were more motivated if the interaction was featured by joint activities, predictability and the use of rewards. Conclusions Motivation for participation in physical activity might be promoted at the individual, contextual and interactional levels. The interactions between individuals with ID and their support persons should work in a supportive way and strengthen mastery experiences. Support and engagement in the context could serve as a prerequisite for motivation and participation in physical activity and should be considered when developing interventions for physical activity for individuals with ID. © 2020 The Authors. Journal of Intellectual Disability Research published by MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disibilities and John Wiley & Sons Ltd This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Compared with the general population, people with intellectual disabilities have worse health, lower levels of activity, and greater barriers to participating in fitness activities. Regular physical activity has positive effects on cardiovascular and psychosocial health and thus it is important to identify effective interventions for people with intellectual disabilities in everyday settings. In this position paper we present the design and development of prototypes of game-based eHealth solutions for behaviour change and health promotion by influencing physical activity. Participatory design and agile development have been applied in this project to deliver a system based on three solutions to promote, motivate and maintain physical activity in people with intellectual disabilities: Guided in-door bicycle exercise, guided out-door exercise and guided mild workouts. All the solutions provide virtual environments and motivation features adapted to people with intellectual disabilities for better engagement.