Bigelow, Maureen L.

Background: Music therapy (MT) offers benefits of improved symptom relief and quality of life at the end of life, but its impact on hospice patients and caregivers needs more research. Objective: To assess the impact of MT intervention on symptom burden and well-being of hospice patients and caregivers. Methods: A total of 18 hospice patients, selected based on scores ≥4 on the revised Edmonton Symptom Assessment System (ESAS-r) items on pain, depression, anxiety, or well-being, participated in MT sessions provided by a board-certified music therapist. Over a period of 2-3 weeks, 3-4 MT sessions were conducted for each. Patient Quality of life (QOL) was assessed using the Linear Analogue Self-Assessment (LASA). Depression and anxiety were measured with the Patient Health Questionnaire-4 (PHQ-4). For the 7 caregivers enrolled, stress levels were measured using the Pearlin role overload measure and LASA. Results: Patients reported a reduction in symptom severity and emotional distress and an increase in QOL. All patients endorsed satisfaction with music therapy, describing it as particularly beneficial for stress relief, relaxation, spiritual support, emotional support, and well-being. Scores on overall QOL and stress were worse for caregivers. Conclusion: This study provides evidence that MT reduces symptom burden and enhances the quality of life for hospice patients. Hospice patients and their caregivers endorsed satisfaction with MT. Given the benefits observed, integrating MT into hospice care regimens could potentially improve patient and caregiver outcomes. Larger studies should be conducted to better assess the impact of MT in this population.

Insulin resistance increase with age but it is uncertain whether it is related to age or other factors. We measured insulin sensitivity by hyperinsulinemic euglycemic clamp in 48 men and women −12 each of young lean (YL) and obese (YO) as well as old lean (OL) and obese (OO) groups. OL (69.9±1.4 years), OO (71.0±1.5 years), YL (22.8±1.0 years) and YO (24.2±0.6 years) were matched for BMI. Older groups had lower peak VO 2 (32.4±1.3 ml/kg FFM) than young (46.9±1.0)(p<0.01) but no differences noted among the two older and younger groups. Similar glucose levels (90.4 to 91.4 mg/dL) were maintained during the glucose clamp. The glucose infusion rate (GIR) at steady state, was similar in the YO (38.7±5.4 mmol/kgFFM/min) and OO (43.0±2.4) where as YL (55.5±3.7) and OL (54.2±3.4) were higher (p<0.02) than obese groups. GIR was significantly correlated to fasting insulin levels (R 2 =0.32, p<0.001). Energy expenditure per FFM, was not different amongst the 4 groups. Adiponectin levels were higher in the older groups (12526±1109 ng/mL) than in the younger (8640±392, p<0.01). A trend toward lower adiponectin levels was seen in OO (10394 ± 1187 ng/ml) than OL (14657 ±1705, p=0.05). A similar trend was not seen comparing the YO to YL. However, the OL had a significantly higher adiponectin level than the YL (9023.8 ± 595 ng/mL, p<0.01). GIR was not significantly correlated to age (R 2 =0.00005, p=NS) nor to peak VO2 (R 2 =0.007, p=NS) but was significantly correlated to truncal fat (R 2 =0.17, p<0.01) and BMI (R 2 =0.25, p<0.001). The age‐related decline in insulin sensitivity is not accounted for by fitness levels or age per se. The results demonstrated that insulin resistance in aging is explained by change in body composition rather than age.

Age‐related mitochondrial dysfunction is paralleled by reductions in gene transcripts and expression of proteins involved in cellular ATP production. Short‐term endurance exercise has been shown to enhance muscle protein synthesis in the elderly. We determined the impact of long‐term endurance exercise on gene expression and protein abundance of numerous proteins involved in cellular energetics. Vastus lateralis tissue was biopsied from 11 young sedentary (YS), 10 old sedentary (OS), 11 young trained (YT), and 11 old trained (OT) subjects. Trained subjects vigorously exercised ¡Ý 1 hr/d, ¡Ý five d/wk for ¡Ý 4 years. Large‐scale measurement of relative protein abundance was performed using isobaric tags for relative and absolute quantitation (iTRAQ) reagents and tandem mass spectrometry. Gene transcript levels were measured by high‐density oligonucleotide microarrays. Ingenuity Pathway Analysis was used to determine canonical pathways that were altered by age. Of the 33 proteins involved in cellular ATP production 27 were less abundant in OS vs. YS, while only 4 of these proteins were less abundant in OT vs. YT. Genes involved in glycolysis and oxidative phosphorylation were underexpressed in OS vs. YS, with no effects of age in OT vs. YT. CONCLUSIONS: Long‐term vigorous endurance exercise ameliorates the detrimental effects of old age on muscle gene and protein expression in humans.

Whole body and mixed muscle protein synthesis rate declines with age in healthy people. In response to a 4‐month aerobic exercise program we showed that mixed muscle protein synthesis rate increased 22%. Several gene transcripts that encode mitochondrial (mito) proteins increased in response to exercise but it remains to be determined whether these are translated to protein synthesis. In this study we tested the hypothesis that mito protein synthesis also increased in response to aerobic exercise training. Healthy men and women (N = 42) from 30–74 y were studied before and after a 4‐month program of stationary bicycle training (3d/wk, up to 40min/d at 80% HRmax) or control activity. Muscle protein synthesis rate was measured using [ 15 N] phenylalanine as a tracer. Mito and sarcoplasmic (sarco) proteins were separated from muscle biopsies for analysis. At baseline there was a decline with age (p<0.05) in both mito (6%/decade, r= −0.32) and sarco (5.5%/decade, r= −0.42) protein synthesis rate. Muscle protein synthesis rates did not change in control subjects, but in the exercise group mito synthesis increased 27% (0.046 ± 0.003 %/h pre vs. 0.058 ± 0.005 post, p=0.017, N=25) and there was a trend for 10% higher sarco protein synthesis (0.036 ± 0.002 %/h pre vs. 0.040 ± 0.003 post, p=0.066, N=33). These effects of exercise did not vary with age. We conclude that despite a decline in mito protein synthesis and function with advancing age, the potential for mito biogenesis in response to aerobic exercise remains robust in older muscle, as demonstrated by enhanced mito protein synthesis, gene expression, and enzyme action. Support: NIH RO1DK41973, MO1RR00585.

Hypoxia during exercise augments vasodilation and blood flow to ensure adequate delivery of O 2 to active muscles. However, the impact of hyperoxia on skeletal muscle blood flow during exercise is poorly understood. Therefore, we tested the hypothesis that the hyperemic response to exercise with hyperbaric hyperoxia would be blunted compared to exercise during normoxia. Seven subjects (6M/1F; 26 ± 2 years) performed forearm exercise (20% of maximum) under normoxic and hyperoxic conditions. Forearm blood flow (FBF; ml/min) was measured using Doppler ultrasound. Forearm vascular conductance (FVC; ml/min/100mmHg) was calculated from FBF and blood pressure (mmHg; brachial arterial catheter). Studies were performed in a hyperbaric chamber with the subjects supine at 1 ATA (sea level) and 2.8 ATA while breathing normoxic (21% O 2 , 1 ATA; F I O 2 ≈ 150 mmHg), hyperbaric normoxic (7% O 2 , 2.8 ATA, F I O 2 ≈ 150 mmHg) and hyperoxic (7% O 2 , 2.8 ATA, F I O 2 ≈ 2100 mmHg) gas. The change in FBF and FVC (Δ from rest) during exercise under normoxia and hyperbaric normoxia did not differ (P > 0.05). However, the ΔFBF and ΔFVC during exercise under hyperoxia were attenuated by ~18–29% compared to both normoxic conditions (P ≤ 0.01). Our data suggest that exercise hyperemia in skeletal muscle is highly dependent on oxygen availability during hyperoxia as well as hypoxia. NIH HL46493 (MJJ), AR55819 (DPC) and RR‐024150.

Evidence for massage therapy (MT) in hospice patients remains limited. We conducted a prospective pilot study on MTs impact on quality of life of hospice patients and caregivers. Patient-caregiver dyads were enrolled if patients scored ≥5 on pain, depression, anxiety, or well-being using the revised Edmonton Symptom Assessment System Revised (ESAS-r). The patient received MT weekly for up to 3 massages with assessments completed at baseline, after each massage, and 1 week after the final massage for patients and at baseline and 1 week after final massage for caregivers. A satisfaction survey was completed at study completion. A pro-rated area under the curve (AUC) was utilized to assess the primary endpoints of change in ESAS-r for patient ratings of pain, depression and anxiety as well as the Linear Analogue Self-Assessment (LASA). Median difference scores (end of study value)-(baseline value) for each participant and caregiver were calculated. Of 27 patients and caregivers enrolled, 25 patients received MT. Fifteen patients completed all 3 MT sessions and were given the final symptom assessment and satisfaction survey and their caregivers completed final assessments. The proportion of patients considered success (AUC > baseline) in the primary endpoints were the following: pain 40.9%, depression 40.9%, anxiety 54.5%, LASA 54.5%. Median difference scores were largely zero indicating no significant temporal change in symptoms. Patients were highly satisfied with MT. This pilot study indicated that MT was a feasible and well-received intervention in our population of patients with inadequately controlled symptoms.

Insulin resistance is associated with skeletal muscle mitochondrial (mito) dysfunction in many conditions including type 2 diabetes (T2D). Poor glycemic control in T2D is associated with muscle mito gene transcript alterations. It is unknown whether muscle mito changes are related to reduced insulin action or vice versa. We obtained vastus lateralis muscle biopsies from 7 type 1 diabetic patients (T1D) following 8–12 hrs of insulin deprivation (I−) and replacement (I+) and measured skeletal muscle mito ATP production (MATP) and gene transcripts. I− and I+ changed glucose and glucagon levels (glucose=291±15mg/dl in I− vs 97±3 in I+ and glucagon=79.8±15.3 pg/mL in I− vs 47.3±5.9 in I+, p<0.04). Whole body O 2 consumption increased during I− by 15% (p<0.05) but maximal MATP decreased by 21.3–27.9% (p<0.05). Gene transcript profiling in skeletal muscle analyzed using Affymetrix GeneChip arrays showed alterations in 2355 transcripts. Pathway analysis showed down‐regulation of oxidative phosphorylation and arachidonic acid metabolism, and up‐regulation of VEGF and actin cytoskeleton signaling in I−. We conclude that the reduced insulin action that occurred during I− in T1D resulted in substantial changes in gene transcript levels of muscle mito genes and reduced maximal MATP, supporting that insulin is key regulator of muscle mito function by exerting its effect at various levels. Supported by NIHRO1DK41973.

It has been shown ingestion of whey protein (WP) results in rapid systemic appearance rates of amino acids (AA) but in higher amino acid (AA) oxidation and whole body protein synthesis than in with casein (cas) ingestion which inhibits protein breakdown. To determine whether combined ingestion of both cas and WP in a meal containing carbohydrate has any disparate effects on protein economy in splanchnic and muscle beds we studied 12 healthy volunteers who ingested intrinsically labeled WP and Cas protein fractions. Following ingestion of 0.625 g·kg FFM −1 each of [ 15 N]WP and [ 13 C]Cas and 0.9 g·kg FFM −1 of lactose; or 0.625 g·kg FFM −1 each of [ 13 C]WP and [ 15 N]CAS and 0.9 g·kg FFM −1 of lactose blood samples were collected from femoral artery and vein and hepatic vein at frequent intervals. At 80–120 min, the rate of appearance (PheRa) of Phe at hepatic vein from WP and Cas were similar (5.5 (0.9) vs 5.2 (0.7) μmol, min −1 , but at 220–260 min, PheRa from WP was slower than PheRa from Cas (2.4 (0.5) vs 5.3 (1.2) μmol, min −1 , P<0.05). Retention rates of Phe in muscle (PheRd) absorbed from WP and Cas were similar at 80–120 min (0.8 (0.1) vs 0.9 (0.2) μmol, min −1 , ns) but was significantly lower for WP than Cas at 220–260 min (0.5 (0.1) vs 1.1 (0.3) μmol, min −1 , P<0.05). In conclusion Cas has more sustained systemic effects and muscle protein accretion than WP. The different metabolic effects of co‐ingested protein fractions have potential implications in designing appropriate nutritional support.

Abstract Context: A reduction in maximal mitochondrial ATP production rate (MAPR) and mitochondrial DNA (mtDNA) abundance occurs with age in association with muscle weakness and reduced endurance in elderly people. Branched chain amino acids (BCAA) have been extensively used to improve physical performance. Objective: The objective was to determine whether an 8-h infusion of BCAA enhances MAPR equally in healthy young and elderly adults. Methods: Using a crossover study design, we compared the effect BCAA vs. saline infusion in 12 young (23.0 ± 0.8 yr) and 12 elderly (70.7 ± 1.1 yr) participants matched for sex and body mass index. Skeletal muscle MAPR and mtDNA abundance were measured in muscle biopsy samples obtained before and at the end of the 8-h infusion. Results: In young participants, MAPR with the substrates glutamate plus malate (supplying electrons to complex I) and succinate plus rotenone (complex II) increased in response to BCAA infusion, relative to a decline in MAPR in response to the saline infusion. In contrast, MAPR was unaffected by BCAA infusion in the elderly participants. Moreover, mtDNA abundance was lower in the elderly compared with the young participants but was unaffected by the BCAA infusion. Insulin and C-peptide concentrations declined over time during the saline infusion, but these declines were prevented by the BCAA infusion. Conclusions: BCAA increased skeletal muscle MAPR in the young participants in comparison with saline, but this effect was not seen in the elderly participants indicating, that unlike in the young, BCAA does not increase muscle mitochondrial function in the elderly.

Glucocorticoids cause muscle atrophy and weakness, but the mechanisms for these effects are unclear. The purpose of this study was to test a hypothesis that prednisone (Pred) counteracts insulin's anabolic effects on muscle. A randomized, double-blind cross-over design was used to test the effects of 6 days either Pred (0.8 mg·kg−1·day−1) or placebo use in seven healthy young volunteers. Protein dynamics were measured across the leg using stable isotope tracers of leucine (Leu) and phenylalanine (Phe) after overnight fast and during a hyperinsulinemic (1.5 μU·min−1·kg FFM−1) euglycemic clamp with amino acid replacement. Fasting glucose, amino acids, insulin, and glucagon were higher ( P < 0.01) on Pred vs. placebo, whereas leg blood flow was 18% lower. However, basal whole body and leg kinetics of Leu and Phe were unaltered by Pred. Insulin infusion increased leg glucose uptake in both trials but was 65% lower with Pred than with placebo. Insulin in both trials similarly suppressed whole body flux of Leu and Phe. Importantly, insulin increased net Leu and Phe balance across the leg and the balance between muscle protein synthesis and breakdown, but these changes were 45–140% lower ( P < 0.03) in Pred than in placebo. The present study demonstrates that short-term Pred use in healthy people does not alter whole body or leg muscle protein metabolism during the postaborptive state but causes muscle insulin resistance for both glucose and amino acid metabolism, with a blunted protein anabolism. This interactive effect may lead to muscle atrophy with continued use of glucocorticoids.