Publications
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Fallowfield JL, Delves SK, Hill NE, et al., 2019, Serum 25-hydroxyvitamin D fluctuations in military personnel during 6-month summer operational deployments in Afghanistan, British Journal of Nutrition, Vol: 121, Pages: 384-392, ISSN: 0007-1145
<jats:title>Abstract</jats:title><jats:p>Soldier operational performance is determined by their fitness, nutritional status, quality of rest/recovery, and remaining injury/illness free. Understanding large fluctuations in nutritional status during operations is critical to safeguarding health and well-being. There are limited data world-wide describing the effect of extreme climate change on nutrient profiles. This study investigated the effect of hot-dry deployments on vitamin D status (assessed from 25-hydroxyvitamin D (25(OH)D) concentration) of young, male, military volunteers. Two data sets are presented (pilot study, <jats:italic>n</jats:italic> 37; main study, <jats:italic>n</jats:italic> 98), examining serum 25(OH)D concentrations before and during 6-month summer operational deployments to Afghanistan (March to October/November). Body mass, percentage of body fat, dietary intake and serum 25(OH)D concentrations were measured. In addition, parathyroid hormone (PTH), adjusted Ca and albumin concentrations were measured in the main study to better understand 25(OH)D fluctuations. Body mass and fat mass (FM) losses were greater for early (pre- to mid-) deployment compared with late (mid- to post<jats:italic>-</jats:italic>) deployment (<jats:italic>P</jats:italic><0·05). Dietary intake was well-maintained despite high rates of energy expenditure. A pronounced increase in 25(OH)D was observed between pre- (March) and mid-deployment (June) (pilot study: 51 (<jats:sc>sd</jats:sc> 20) <jats:italic>v.</jats:italic> 212 (<jats:sc>sd</jats:sc> 85) nmol/l, <jats:italic>P</jats:italic><0·05; main study: 55 (<jats:sc>sd</jats:sc> 22) <jats:italic>v.</jats:italic> 167 (<jats:sc>sd</jats:sc> 71) nmol/l, <jats:italic>P</jats:italic><0·05) and remained elevated post-deploymen
Hill NE, Rilstone S, Stacey M, et al., 2018, Changes in northern hemisphere male international rugby union players body mass and height between 1955 and 2015, BMJ Open Sport and Exercise Medicine, Vol: 4, ISSN: 2055-7647
Objectives We sought to establish the effects of professionalism, which officially began in 1995, on the body mass and height of northern hemisphere male international rugby union (RU) players. We hypothesised that mass would significantly increase following professionalism. We also investigated the changes in size of players according to their playing position, and we compared changes to rugby league (RL) players and the public.Methods The body mass and height of players representing their international team for that country’s first game of the Five Nations in 1955, 1965, 1975, 1985 and 1995 and, for 2005 and 2015, the Six Nations, were collected from matchday programmes. RL players’ data were collected from the Challenge Cup final games played in the same years.Results International RU player body mass has significantly increased since 1995. In 1955 mean (±SD) player body mass was 84.8 kg (±8.2); in 2015, it was 105.4 kg (±12.1), an increase of 24.3%. Between 1955 and 2015, the body mass of forwards increased steadily, whereas that of backs has mostly gone up since 1995. RU player body mass gain has exceeded that of RL, but the age-matched difference between RU players and the public has remained relatively constant.Conclusions The factors influencing the gain in body mass of rugby players are legion; however, we believe that the interpretation of the law relating to the scrum put-in and changes allowing substitutions have, at least in part, contributed to the observed changes. Injury severity is increasing, and this may be linked to greater forces (caused by greater body mass) occurring in contact. RU law makers should adjust the rules to encourage speed and skill at the expense of mass.
Hill NE, Deighton K, Matu J, et al., 2018, Continuous Glucose Monitoring at High Altitude-Effects on Glucose Homeostasis., Med Sci Sports Exerc, Vol: 50, Pages: 1679-1686
PURPOSE: Exposure to high altitude has been shown to enhance both glucose and lipid utilization depending on experimental protocol. In addition, high and low blood glucose levels have been reported at high altitude. We hypothesized that gradual ascent to high altitude results in changes in glucose levels in healthy young adults. METHODS: Twenty-five adult volunteers, split into two teams, took part in the British Services Dhaulagiri Medical Research Expedition completing 14 d of trekking around the Dhaulagiri circuit in Nepal reaching a peak altitude of 5300 m on day 11 of the trek. Participants wore blinded continuous glucose monitors (CGM) throughout. Blood samples for C-peptide, proinsulin, and triacylglycerides were taken at sea level (United Kingdom) and in acclimatization camps at 3600, 4650, and 5120 m. Energy intake was determined from food diaries. RESULTS: There was no difference in time spent in hypoglycemia stratified by altitude. Nocturnal CGM readings (2200-0600 h) were chosen to reduce the short-term effect of physical activity and food intake and showed a significant (P < 0.0001) increase at 3600 m (5.53 ± 0.22 mmol·L), 4650 m (4.77 ± 0.30 mmol·L), and 5120 m (4.78 ± 0.24 mmol·L) compared with baseline altitude 1100 m (vs 4.61 ± 0.25 mmol·L). Energy intake did not differ by altitude. Insulin resistance and beta-cell function, calculated by homeostatic model assessment, were reduced at 3600 m compared with sea level. CONCLUSIONS: We observed a significant increase in nocturnal CGM glucose at 3600 m and greater despite gradual ascent from 1100 m. Taken with the changes in insulin resistance and beta-cell function, it is possible that the stress response to high altitude dominates exercise-enhanced insulin sensitivity, resulting in relative hyperglycemia.
Hill NE, 2018, Response to Howard et al (Howard M, Bakker-Dyos J, Gallagher L, et al Power supplies and equipment for military field research: lessons from the British Service Dhaulagiri Research Expedition 2016 Journal of the Royal Army Medical Corps 2018;164:41-45), Journal of the Royal Army Medical Corps
Hill NE, Rilstone S, Jairam C, et al., 2018, Establishing the multidisciplinary Imperial Physical Activity and Diabetes clinic, Practical Diabetes, Vol: 35, Pages: 11-15, ISSN: 2047-2897
Increasing numbers of people with diabetes are adopting exercise programmes. Fear of hypoglycaemia, and hypoglycaemia itself, are major issues for many people with diabetes undertaking physical activity. The risk of hypoglycaemia is exacerbated by endurance exercise. In addition, soft tissue injuries are more common in people with diabetes. We have established a multidisciplinary physical activity and diabetes clinic with the aim of empowering, educating and enabling people with diabetes to enjoy sport and exercise without fear of hypoglycaemia or frustration at glycaemic variability or soft tissue injuries. The multidisciplinary team (MDT) includes a diabetologist, sports and exercise physician, radiologist, dietitian, diabetes specialist nurse, and psychologist. Between October 2015 and September 2017, we undertook 19 clinics and saw 66 patients (48 new and 18 follow-up). Of the 48 new referrals (median age 35; range 20–72) 47 had type 1 diabetes and 27 (56%) used an insulin pump. Attendees had a median 18 years of diabetes (range 1–50). Diabetes distress was variable (median PAID score 18; range 0–64). Twenty-five patients attended for glycaemic management, 15 for musculoskeletal issues and eight for both. Sixteen (33%) required physiotherapy and nine (19%) were referred for joint imaging. It is possible to establish a new service to support physical activity in diabetes. To meet demand and enhance the MDT, physiotherapy will be added. A means of assessing the effects of diabetes on physical activity and outcome measures that matter to people with diabetes must be developed. Copyright © 2018 John Wiley & Sons.
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Mellor A, Bakker-Dyos J, Howard M, et al., 2017, The British Services Dhaulagiri Medical Research Expedition 2016: a unique military and civilian research collaboration, Journal of the Royal Army Medical Corps, Vol: 163, Pages: 371-375, ISSN: 0035-8665
Stacey M, Hill NE, woods D, 2017, Physiological monitoring for healthy military personnel, Journal of the Royal Army Medical Corps, Pages: 290-292
Khoo B, Boshier PR, Freethy A, et al., 2017, Redefining the stress cortisol response to surgery., Clin Endocrinol (Oxf), Vol: 87, Pages: 451-458
BACKGROUND: Cortisol levels rise with the physiological stress of surgery. Previous studies have used older, less-specific assays, have not differentiated by severity or only studied procedures of a defined type. The aim of this study was to examine this phenomenon in surgeries of varying severity using a widely used cortisol immunoassay. METHODS: Euadrenal patients undergoing elective surgery were enrolled prospectively. Serum samples were taken at 8 am on surgical day, induction and 1 hour, 2 hour, 4 hour and 8 hour after. Subsequent samples were taken daily at 8 am until postoperative day 5 or hospital discharge. Total cortisol was measured using an Abbott Architect immunoassay, and cortisol-binding globulin (CBG) using a radioimmunoassay. Surgical severity was classified by POSSUM operative severity score. RESULTS: Ninety-three patients underwent surgery: Major/Major+ (n = 37), Moderate (n = 33) and Minor (n = 23). Peak cortisol positively correlated to severity: Major/Major+ median 680 [range 375-1452], Moderate 581 [270-1009] and Minor 574 [272-1066] nmol/L (Kruskal-Wallis test, P = .0031). CBG fell by 23%; the magnitude of the drop positively correlated to severity. CONCLUSIONS: The range in baseline and peak cortisol response to surgery is wide, and peak cortisol levels are lower than previously appreciated. Improvements in surgery, anaesthetic techniques and cortisol assays might explain our observed lower peak cortisols. The criteria for the dynamic testing of cortisol response may need to be reduced to take account of these factors. Our data also support a lower-dose, stratified approach to dosing of steroid replacement in hypoadrenal patients, to minimize the deleterious effects of over-replacement.
Matu J, O'Hara J, Hill N, et al., 2017, Changes in appetite, energy intake, body composition, and circulating ghrelin constituents during an incremental trekking ascent to high altitude., Eur J Appl Physiol, Vol: 117, Pages: 1917-1928
PURPOSE: Circulating acylated ghrelin concentrations are associated with altitude-induced anorexia in laboratory environments, but have never been measured at terrestrial altitude. This study examined time course changes in appetite, energy intake, body composition, and ghrelin constituents during a high-altitude trek. METHODS: Twelve participants [age: 28(4) years, BMI 23.0(2.1) kg m-2] completed a 14-day trek in the Himalayas. Energy intake, appetite perceptions, body composition, and circulating acylated, des-acylated, and total ghrelin concentrations were assessed at baseline (113 m, 12 days prior to departure) and at three fixed research camps during the trek (3619 m, day 7; 4600 m, day 10; 5140 m, day 12). RESULTS: Relative to baseline, energy intake was lower at 3619 m (P = 0.038) and 5140 m (P = 0.016) and tended to be lower at 4600 m (P = 0.056). Appetite perceptions were lower at 5140 m (P = 0.027) compared with baseline. Acylated ghrelin concentrations were lower at 3619 m (P = 0.046) and 4600 m (P = 0.038), and tended to be lower at 5140 m (P = 0.070), compared with baseline. Des-acylated ghrelin concentrations did not significantly change during the trek (P = 0.177). Total ghrelin concentrations decreased from baseline to 4600 m (P = 0.045). Skinfold thickness was lower at all points during the trek compared with baseline (P ≤ 0.001) and calf girth decreased incrementally during the trek (P = 0.010). CONCLUSIONS: Changes in plasma acylated and total ghrelin concentrations may contribute to the suppression of appetite and energy intake at altitude, but differences in the time course of these responses suggest that additional factors are also involved. Interventions are required to maintain appetite and energy balance during trekking at terrestrial altitudes.
Malcolm G, Rilstone S, Sivasubramaniyam S, et al., 2017, Managing diabetes at high altitude: Personal experience with support from a Multidisciplinary Physical Activity and Diabetes Clinic, BMJ Open Sport and Exercise Medicine, Vol: 3, ISSN: 2055-7647
Objective Physical activity is important for well-being but can be challenging for people with diabetes. Data informing support of specialist activities such as climbing and high-altitude trekking are limited. A 42-year-old man with type 1 diabetes (duration 30 years) attended a Multidisciplinary Physical Activity and Diabetes Clinic planning to climb Mont Blanc during the summer and trek to Everest Base Camp in the autumn. His aims were to complete these adventures without his diabetes impacting on their success. Methods We report the information provided that enabled him to safely facilitate his objectives, in particular, the requirement for frequent checking of blood glucose levels, the effects of altitude on insulin dose requirements, and recognition that acute mountain sickness may mimic the symptoms of hypoglycaemia and vice versa. Real-time continuous glucose monitoring was made available for his treks. Results The effects of high altitude on blood glucose results and glycaemic variability while treated on multiple daily injections of insulin are reported. In addition, we present a first-person account of his experience and lessons learnt from managing diabetes at high altitude. Conclusions A dedicated Multidisciplinary Physical Activity and Diabetes Clinic delivering individualised, evidence-based, patient-focused advice on the effects of altitude on blood glucose levels, and provision of real-time continuous glucose monitoring enabled uneventful completion of a trek to Everest Base Camp in a person with type 1 diabetes.
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Woods DR, O'Hara JP, Boos CJ, et al., 2017, Markers of physiological stress during exercise under conditions of normoxia, normobaric hypoxia, hypobaric hypoxia, and genuine high altitude., Eur J Appl Physiol, Vol: 117, Pages: 893-900
PURPOSE: To investigate whether there is a differential response at rest and following exercise to conditions of genuine high altitude (GHA), normobaric hypoxia (NH), hypobaric hypoxia (HH), and normobaric normoxia (NN). METHOD: Markers of sympathoadrenal and adrenocortical function [plasma normetanephrine (PNORMET), metanephrine (PMET), cortisol], myocardial injury [highly sensitive cardiac troponin T (hscTnT)], and function [N-terminal brain natriuretic peptide (NT-proBNP)] were evaluated at rest and with exercise under NN, at 3375 m in the Alps (GHA) and at equivalent simulated altitude under NH and HH. Participants cycled for 2 h [15-min warm-up, 105 min at 55% Wmax (maximal workload)] with venous blood samples taken prior (T0), immediately following (T120) and 2-h post-exercise (T240). RESULTS: Exercise in the three hypoxic environments produced a similar pattern of response with the only difference between environments being in relation to PNORMET. Exercise in NN only induced a rise in PNORMET and PMET. CONCLUSION: Biochemical markers that reflect sympathoadrenal, adrenocortical, and myocardial responses to physiological stress demonstrate significant differences in the response to exercise under conditions of normoxia versus hypoxia, while NH and HH appear to induce broadly similar responses to GHA and may, therefore, be reasonable surrogates.
Hill NE, Campbell C, Buchanan P, et al., 2017, Biochemical, Physiological and Psychological Changes During Endurance Exercise in People With Type 1 Diabetes., J Diabetes Sci Technol, Vol: 11, Pages: 529-536
BACKGROUND: Increasing numbers of people with diabetes are adopting exercise programs. Fear of hypoglycemia, hypoglycemia itself, and injuries are major issues for many people with diabetes undertaking physical activity. The purpose of this study was to investigate the effects of type 1 diabetes mellitus on the risk of hypoglycemia, glycemic variability, exercise performance, changes in body composition, changes in insulin dosage, and psychosocial well-being during a multiday endurance exercise event. METHODS: Eleven participants (7 with type 1 diabetes, 4 with normal glucose tolerance) undertook a 15-day, 2300 km cycling tour from Barcelona to Vienna. Data were prospectively collected using bike computers, continuous glucose monitors, body composition analyzers, and mood questionnaires. RESULTS: Mean blood glucose in riders with and without diabetes significantly reduced as the event progressed. Glycemic variability and time spent in hypoglycemia did not change throughout the ride for either set of riders. Riders with diabetes in the lowest quartile of sensor glucose values had significantly reduced power output. Percentage body fat also significantly fell. Hypo- and hyperglycemia provoked feelings of anxiety and worry. CONCLUSIONS: This is the first study to describe a real-time endurance event in type 1 diabetes, and provides important new data that cannot be studied in laboratory conditions. Hypoglycemia continues to occurs in spite of peer support and large reductions in insulin dose. Glycemic variability is shown as a potential barrier to participation in physical activity through effects on mood and psychological well-being.
Hill NE, Murphy KG, Saeed S, et al., 2017, Impact of ghrelin on body composition and muscle function in a long-term rodent model of critical illness., PLoS One, Vol: 12
BACKGROUND: Patients with multiple injuries or sepsis requiring intensive care treatment invariably develop a catabolic state with resultant loss of lean body mass, for which there are currently no effective treatments. Recovery can take months and mortality is high. We hypothesise that treatment with the orexigenic and anti-inflammatory gastric hormone, ghrelin may attenuate the loss of body mass following critical illness and improve recovery. METHODS: Male Wistar rats received an intraperitoneal injection of the fungal cell wall derivative zymosan to induce a prolonged peritonitis and consequent critical illness. Commencing at 48h after zymosan, animals were randomised to receive a continuous infusion of ghrelin or vehicle control using a pre-implanted subcutaneous osmotic mini-pump, and continued for 10 days. RESULTS: Zymosan peritonitis induced significant weight loss and reduced food intake with a nadir at Day 2 and gradual recovery thereafter. Supra-physiologic plasma ghrelin levels were achieved in the treated animals. Ghrelin-treated rats ate more food and gained more body mass than controls. Ghrelin increased adiposity and promoted carbohydrate over fat metabolism, but did not alter total body protein, muscle strength nor muscle morphology. Muscle mass and strength remained significantly reduced in all zymosan-treated animals, even at ten days post-insult. CONCLUSIONS: Continuous infusion of ghrelin increased body mass and food intake, but did not increase muscle mass nor improve muscle function, in a long-term critical illness recovery model. Further studies with pulsatile ghrelin delivery or additional anabolic stimuli may further clarify the utility of ghrelin in survivors of critical illness.
Woods D, Hill NE, Neely D, et al., 2017, Hematopoiesis Shows Closer Correlation with Calculated Free Testosterone in Men than Total Testosterone, Journal of Applied Laboratory Medicine, Vol: 1, Pages: 441-444
Hill NE, Fallowfield JL, Wilson DR, 2016, Commentary: The use of creatine supplements in the military, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 162, Pages: 249-249, ISSN: 0035-8665
Daniel E, Aylwin S, Mustafa O, et al., 2015, Effectiveness of Metyrapone in Treating Cushing's Syndrome: A Retrospective Multicenter Study in 195 Patients., J Clin Endocrinol Metab, Vol: 100, Pages: 4146-4154
BACKGROUND: Cushing's syndrome (CS) is a severe condition with excess mortality and significant morbidity necessitating control of hypercortisolemia. There are few data documenting use of the steroidogenesis inhibitor metyrapone for this purpose. OBJECTIVE: The objective was to assess the effectiveness of metyrapone in controlling cortisol excess in a contemporary series of patients with CS. DESIGN: This was designed as a retrospective, multicenter study. SETTING: Thirteen University hospitals were studied. PATIENTS: We studied a total of 195 patients with proven CS: 115 Cushing's disease, 37 ectopic ACTH syndrome, 43 ACTH-independent disease (adrenocortical carcinoma 10, adrenal adenoma 30, and ACTH-independent adrenal hyperplasia 3). MEASUREMENTS: Measurements included biochemical parameters of activity of CS: mean serum cortisol "day-curve" (CDC) (target 150-300 nmol/L); 9 am serum cortisol; 24-hour urinary free cortisol (UFC). RESULTS: A total of 164/195 received metyrapone monotherapy. Mean age was 49.6 ± 15.7 years; mean duration of therapy 8 months (median 3 mo, range 3 d to 11.6 y). There were significant improvements on metyrapone, first evaluation to last review: CDC (91 patients, 722.9 nmol/L [26.2 μg/dL] vs 348.6 nmol/L [12.6 μg/dL]; P < .0001); 9 am cortisol (123 patients, 882.9 nmol/L [32.0 μg/dL] vs 491.1 nmol/L [17.8 μg/dL]; P < .0001); and UFC (37 patients, 1483 nmol/24 h [537 μg/24 h] vs 452.6 nmol/24 h [164 μg/24 h]; P = .003). Overall, control at last review: 55%, 43%, 46%, and 76% of patients who had CDCs, UFCs, 9 am cortisol less than 331 nmol/L (12.0 μg/dL), and 9 am cortisol less than upper limit of normal/600 nmol/L (21.7 μg/dL). Median final dose: Cushing's disease 1375 mg; ectopic ACTH syndrome 1500 mg; benign adrenal disease 750 mg; and adrenocortical carcinoma 1250 mg. Adverse events occurred in 25% of patients, mostly mild gastrointestinal upset and dizziness, usually within 2 weeks of init
Carter NJ, Hill NE, Nicol ED, et al., 2015, Dyslipidaemia and the military patient., J R Army Med Corps, Vol: 161, Pages: 206-210, ISSN: 0035-8665
Dyslipidaemias refer to abnormal levels of circulating lipids and high cholesterol and is related to cardiovascular death. This paper examines the types and prevalence of dyslipidaemia with specific reference to a military population and describes who to target in screening strategies used to detect people with abnormal lipid profiles. The diagnostic limits for a diagnosis of dyslipidaemia are explored. Finally, medical management of hyperlipidaemia is discussed and how this may affect military medical grading.
Hill NE, Fallowfield JL, Delves SK, et al., 2015, Changes in gut hormones and leptin in military personnel during operational deployment in Afghanistan., Obesity (Silver Spring), Vol: 23, Pages: 608-614
OBJECTIVE: Understanding the mechanisms that drive weight loss in a lean population may elucidate systems that regulate normal energy homeostasis. This prospective study of British military volunteers investigated the effects of a 6-month deployment to Afghanistan on energy balance and circulating concentrations of specific appetite-regulating hormones. METHODS: Measurements were obtained twice in the UK (during the Pre-deployment period) and once in Afghanistan, at Mid-deployment. Body mass, body composition, food intake, and appetite-regulatory hormones (leptin, active and total ghrelin, PYY, PP, GLP-1) were measured. RESULTS: Repeated measures analysis of 105 volunteers showed body mass decreased by 4.9% ± 3.7% (P < 0.0001) during the first half of the deployment. Leptin concentrations were significantly correlated with percentage body fat at each time point. The reduction in percentage body fat between Pre-deployment and Mid-deployment was 8.6%, with a corresponding 48% decrease in mean circulating leptin. Pre-deployment leptin and total and active ghrelin levels correlated with subsequent change in body mass; however. no changes were observed in the anorectic gut hormones GLP-1, PP, or PYY. CONCLUSIONS: These data suggest that changes in appetite-regulating hormones in front line military personnel occur in response to, but do not drive, reductions in body mass.
Hill NE, Woods DR, Delves SK, et al., 2015, The gonadotrophic response of Royal Marines during an operational deployment in Afghanistan., Andrology, Vol: 3, Pages: 293-297
Military training has been associated with changes in the hypothalamic-pituitary-gonadal axis consistent with central hypogonadism. Often such changes have been associated with body mass loss, though sleep deprivation and other psychological stress may also contribute. The effects of deployment in a combat zone on the hypothalamic-pituitary-gonadal axis in military personnel are not known. The objective was to investigate the hypothalamic-pituitary-gonadal axis in male military personnel deployed in Afghanistan. Eighty-nine Royal Marines were investigated pre-deployment, following 3 months in Afghanistan and following 2 weeks mid-tour leave. Testosterone, sex hormone-binding globulin (SHBG), follicle-stimulating hormone (FSH), luteinising hormone (LH), 17-hydroxyprogesterone, androstenedione (AD) and insulin were assayed and body mass recorded. The results showed that body mass (kg) dropped from 83.2 ± 9.2 to 79.2 ± 8.2 kg during the first 3 months of deployment (p < 0.001). Total testosterone did not change, but SHBG increased (30.7 ± 9.7 vs. 42.3 ± 14.1 nmol/L, p < 0.001), resulting in a significant (p < 0.001) fall in calculated free testosterone (435.2 ± 138 vs. 375.1 ± 98 pmol/L). Luteinising hormone and FSH increased by 14.3% (p < 0.001) and 4.9% (p = 0.003) respectively. Free testosterone, SHBG, LH and FSH returned to baseline following 2 weeks of mid-tour leave. Androstenedione (AD) decreased by 14.5% (p = 0.024), and insulin decreased by 26% (p = 0.039), over the course of deployment. In this study of lean Royal Marines, free testosterone decreased during operational deployment to Afghanistan. There was no evidence to suggest major stress-induced central hypogonadism. We postulate that reduced body mass, accompanied by a decrease in insulin and AD synthesis, may have contributed to an elevated SHBG, leading to a decrease in free testosterone.
Hill NE, Saeed S, Phadke R, et al., 2015, Detailed characterization of a long-term rodent model of critical illness and recovery., Crit Care Med, Vol: 43, Pages: e84-e96
OBJECTIVE: To characterize a long-term model of recovery from critical illness, with particular emphasis on cardiorespiratory, metabolic, and muscle function. DESIGN: Randomized controlled animal study. SETTING: University research laboratory. SUBJECTS: Male Wistar rats. INTERVENTIONS: Intraperitoneal injection of the fungal cell wall constituent, zymosan or n-saline. MEASUREMENTS AND MAIN RESULTS: Following intervention, rats were followed for up to 2 weeks. Animals with zymosan peritonitis reached a clinical and biochemical nadir on day 2. Initial reductions were seen in body weight, total body protein and fat, and muscle mass. Leg muscle fiber diameter remained subnormal at 14 days with evidence of persisting myonecrosis, even though gene expression of regulators of muscle mass (e.g., MAFbx, MURF1, and myostatin) had peaked on days 2-4 but normalized by day 7. Treadmill exercise capacity, forelimb grip strength, and in vivo maximum tetanic force were also reduced. Food intake was minimal until day 4 but increased thereafter. This did not relate to appetite hormone levels with early (6 hr) rises in plasma insulin and leptin followed by persisting subnormal levels; ghrelin levels did not change. Serum interleukin-6 level peaked at 6 hours but had normalized by day 2, whereas interleukin-10 remained persistently elevated and high-density lipoprotein cholesterol persistently depressed. There was an early myocardial depression and rise in core temperature, yet reduced oxygen consumption and respiratory exchange ratio with a loss of diurnal rhythmicity that showed a gradual but incomplete recovery by day 7. CONCLUSIONS: This detailed physiological, metabolic, hormonal, functional, and histological muscle characterization of a model of critical illness and recovery reproduces many of the findings reported in human critical illness. It can be used to assess putative therapies that may attenuate loss, or enhance recovery, of muscle mass and function.
Carter N, Hill NE, 2014, The discovery of a bullet lost in the wrist by means of roentgen rays: Robert Jones, Grand Rounds, Vol: 14, Pages: L3-L4
Fallowfield JL, Delves SK, Hill NE, et al., 2014, Energy expenditure, nutritional status, body composition and physical fitness of Royal Marines during a 6-month operational deployment in Afghanistan., Br J Nutr, Vol: 112, Pages: 821-829
Understanding the nutritional demands on serving military personnel is critical to inform training schedules and dietary provision. Troops deployed to Afghanistan face austere living and working environments. Observations from the military and those reported in the British and US media indicated possible physical degradation of personnel deployed to Afghanistan. Therefore, the present study aimed to investigate the changes in body composition and nutritional status of military personnel deployed to Afghanistan and how these were related to physical fitness. In a cohort of British Royal Marines (n 249) deployed to Afghanistan for 6 months, body size and body composition were estimated from body mass, height, girth and skinfold measurements. Energy intake (EI) was estimated from food diaries and energy expenditure measured using the doubly labelled water method in a representative subgroup. Strength and aerobic fitness were assessed. The mean body mass of volunteers decreased over the first half of the deployment ( - 4·6 (sd 3·7) %), predominately reflecting fat loss. Body mass partially recovered (mean +2·2 (sd 2·9) %) between the mid- and post-deployment periods (P< 0·05). Daily EI (mean 10 590 (sd 3339) kJ) was significantly lower than the estimated daily energy expenditure (mean 15 167 (sd 1883) kJ) measured in a subgroup of volunteers. However, despite the body mass loss, aerobic fitness and strength were well maintained. Nutritional provision for British military personnel in Afghanistan appeared sufficient to maintain physical capability and micronutrient status, but providing appropriate nutrition in harsh operational environments must remain a priority.
Hill NE, Fallowfield JL, Delves SK, et al., 2014, Nutrition research in the military, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 160, Pages: 99-101, ISSN: 0035-8665
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Hill N, Meeran K, 2014, The dark truth about vitamin D licensing: food or drug?, BMJ, Vol: 348
Hill NE, Murphy KG, Singer M, 2012, Ghrelin, appetite and critical illness., Curr Opin Crit Care, Vol: 18, Pages: 199-205
PURPOSE OF REVIEW: Recovery and rehabilitation after critical illness is a vital part of intensive care management. The role of feeding and nutritional intervention is the subject of many recent studies. The gastric hormone ghrelin has effects on appetite and food intake and on immunomodulatory functions. Here we review the interactions between critical illness, appetite regulation, nutrition and ghrelin. RECENT FINDINGS: Critical illness results in significant loss of lean body mass; strategies to prevent this have so far proven unsuccessful. Ghrelin has been shown to reduce catabolic protein loss in animal models of critical illness and improve body composition in chronic cachectic illnesses in humans. SUMMARY: Enhancing recovery from critical illness will improve both short-term and long-term outcomes. Ghrelin may offer an important means of improving appetite, muscle mass and rehabilitation in the period after critical illness, although studies are needed to see whether this potential is realized.
Woods DR, Stacey M, Hill N, et al., 2011, Endocrine Aspects of High Altitude Acclimatization and Acute Mountain Sickness, JOURNAL OF THE ROYAL ARMY MEDICAL CORPS, Vol: 157, Pages: 33-37, ISSN: 0035-8665
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Hill NE, Stacey MJ, Woods DR, 2011, Energy at high altitude., J R Army Med Corps, Vol: 157, Pages: 43-48, ISSN: 0035-8665
For the military doctor, an understanding of the metabolic effects of high altitude (HA) exposure is highly relevant. This review examines the acute metabolic challenge and subsequent changes in nutritional homeostasis that occur when troops deploy rapidly to HA. Key factors that impact on metabolism include the hypoxic-hypobaric environment, physical exercise and diet. Expected metabolic changes include augmentation of basal metabolic rate (BMR), decreased availability of oxygen in peripheral metabolic tissues, reduction in VO2 max, increased glucose dependency and lactate accumulation during exercise. The metabolic demands of exercise at HA are crucial. Equivalent activity requires greater effort and more energy than it does at sea level. Soldiers working at HA show high energy expenditure and this may exceed energy intake significantly. Energy intake at HA is affected adversely by reduced availability, reduced appetite and changes in endocrine parameters. Energy imbalance and loss of body water result in weight loss, which is extremely common at HA. Loss of fat predominates over loss of fat-free mass. This state resembles starvation and the preferential primary fuel source shifts from carbohydrate towards fat, reducing performance efficiency. However, these adverse effects can be mitigated by increasing energy intake in association with a high carbohydrate ration. Commanders must ensure that individuals are motivated, educated, strongly encouraged and empowered to meet their energy needs in order to maximise mission-effectiveness.
Hill N, Fallowfield J, Price S, et al., 2011, Military nutrition: maintaining health and rebuilding injured tissue., Philos Trans R Soc Lond B Biol Sci, Vol: 366, Pages: 231-240
Food and nutrition are fundamental to military capability. Historical examples demonstrate that a failure to supply adequate nutrition to armies inevitably leads to disaster; however, innovative measures to overcome difficulties in feeding reap benefits, and save lives. In barracks, UK Armed Forces are currently fed according to the relatively new Pay As You Dine policy, which has attracted criticism from some quarters. The recently introduced Multi-Climate Ration has been developed specifically to deal with issues arising from Iraq and the current conflict in Afghanistan. Severely wounded military personnel are likely to lose a significant amount of their muscle mass, in spite of the best medical care. Nutritional support is unable to prevent this, but can ameliorate the effects of the catabolic process. Measuring and quantifying nutritional status during critical illness is difficult. A consensus is beginning to emerge from studies investigating the effects of nutritional interventions on how, what and when to feed patients with critical illness. The Ministry of Defence is currently undertaking research to address specific concerns related to nutrition as well as seeking to promote healthy eating in military personnel.
Bastin AJ, Starling L, Ahmed R, et al., 2010, High prevalence of undiagnosed and severe chronic obstructive pulmonary disease at first hospital admission with acute exacerbation., Chron Respir Dis, Vol: 7, Pages: 91-97
Chronic obstructive pulmonary disease (COPD) is a common cause of acute medical hospital admission, and the prevalence of undiagnosed COPD in the community is high. The impact of undiagnosed COPD on presentation to secondary care services is not currently known. We therefore set out to characterise patients at first admission with an acute exacerbation of COPD, and to identify potential areas for improvement in earlier diagnosis and further management. A retrospective case review of patients first admitted to a district teaching hospital with an acute exacerbation of COPD over a 1-year period was carried out. Forty-one patients with a first admission with an acute exacerbation of COPD were identified, 14 (34%) of whom had not been previously diagnosed and were diagnosed with COPD as a result of the admission. At presentation, this group of patients had severe disease, with mean (SD) FEV(1) 1.02 (0.32) L, and a respiratory acidosis in eight (20%) patients, even though this was their first admission for an acute exacerbation of COPD. Missed potential opportunities to intervene in community and inpatient management were identified, including earlier diagnosis, pre-hospital corticosteroid therapy, inpatient respiratory team input, provision of smoking cessation advice and consideration of pulmonary rehabilitation. Patients with a first hospital admission with an acute exacerbation of COPD frequently have severe disease at presentation. Despite having severe disease, a diagnosis of COPD had not been made in the community prior to admission in one-third of patients. Future work should be directed at earlier identification of patients who are symptomatic from COPD and ensuring that the interventions of proven benefit in COPD are systematically offered to patients in both primary and secondary care.
Hill N, Davis P, 2000, Nursing care of total joint replacement, Journal of Orthopaedic Nursing, Vol: 4, Pages: 41-45, ISSN: 1361-3111
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