Integrating proactive nutritional assessment in clinical practices to prevent complications and cost

Timely and appropriate nutritional interventions for patients with cancer and/or human immunodeficiency virus (HIV) infection require adoption of routine nutritional screening and comprehensive evaluations into clinical practice. Traditionally, the clinical skills necessary for comprehensive nutritional evaluation have not been a part of medical education. Likewise, the importance of nutritional screening and assessment has not been fully appreciated. In the context of current health care, these skills are increasingly important in maintaining or improving patient care and improving clinical and economic outcomes. It is imperative that nutritional screening be routinely implemented in all clinical settings (eg, office practices, clinics, preadmission units, homecare) to offset the impact of decreased rates of hospital admission. Hospitals have traditionally been the setting for dietetic screening and intervention and nutritional support services. Therapy for patients with cancer or HIV infection is increasingly being managed primarily or entirely in an outpatient setting. When nutritional risk or deficit is identified on screening, it is important to carry out sequential reassessment after intervention. This article reviews the principles of nutritional screening and comprehensive assessment. It includes a detailed overview of an instrument that can be used for either nutritional screening or assessment in patients with either malignancy or HIV infection.

Clinic-based interventions to promote breast and cervical cancer screening

BACKGROUND

Breast and cervical cancer continue to claim the lives of women. Early detection modalities for these cancers are available; however, utilization rates are far from optimal. Studies have documented the motivating effect that physician recommendations have on compliance with preventive health behaviors. The goal of this study was to develop and implement strategies to improve the use of cervical and breast cancer screening among African-American women age 40 and older who resided in low-income housing communities.

METHODS

Baseline surveys among clinic providers and a random sample of women in the target population indicated areas to be included in intervention material. Community health center-based strategies included educational interventions for providers and patients, follow-up interventions for abnormal screening tests, and the implementation of a computer tracking system. Pap smear and mammogram utilization rates at the health center were tracked throughout the project period to assess the effect of the clinic-based interventions.

RESULTS

Both Pap smear and mammography rates increased over time. Fifteen cases of breast cancer and 1 case of invasive cervical cancer have been detected. Compliance rates for follow-up for cervical dysplasia have increased from 50 to 90%.

CONCLUSIONS

These results suggest that clinic-based interventions can improve the use of breast and cervical cancer screening and follow-up among low-income women.

Effects of ethanol on nonspatial working memory and attention in rats

Investigation into the neural basis for ethanol-induced cognitive dysfunction requires the use of valid animal models. An operant signal detection procedure was developed to assess simultaneously the processes of sustained attention and working memory in rats, and to determine the effects of ethanol on these cognitive functions. Ethanol, at 0.75 g/kg ip, produced delay- and stimulus length-dependent decreases in choice accuracy, effects that are consistent with deficits in both working memory and sustained attention. Local infusion of ethanol directly into the medial septal area resulted in a selective loss of choice accuracy at the long delay. The impairment by intraseptal ethanol did not interact with stimulus length. Thus, the working memory impairment, but not the decrement in sustained attention, was mimicked by intraseptal ethanol. The current model provides a foundation for studying the neural basis of ethanol's cognitive effects.

Effects of ethanol on nonspatial working memory and attention in rats

Investigation into the neural basis for ethanol-induced cognitive dysfunction requires the use of valid animal models. An operant signal detection procedure was developed to assess simultaneously the processes of sustained attention and working memory in rats, and to determine the effects of ethanol on these cognitive functions. Ethanol, at 0.75 g/kg ip, produced delay- and stimulus length-dependent decreases in choice accuracy, effects that are consistent with deficits in both working memory and sustained attention. Local infusion of ethanol directly into the medial septal area resulted in a selective loss of choice accuracy at the long delay. The impairment by intraseptal ethanol did not interact with stimulus length. Thus, the working memory impairment, but not the decrement in sustained attention, was mimicked by intraseptal ethanol. The current model provides a foundation for studying the neural basis of ethanol's cognitive effects.

Neuronal mechanisms mediating drug-induced cognition enhancement: cognitive activity as a necessary intervening variable

The conceptual foundations of a research aimed at the determination of potential neuronal, neuropharmacological, and behavioral/cognitive mechanisms mediating drug-induced cognition enhancement are discussed. The available evidence justifies a focus on attentional processes as a target for drug-induced cognition enhancement. Neuropharmacological mechanisms that may mediate drug-induced enhancement of attentional functions are proposed to interact necessarily with attention-associated neuronal activity. The elements of a transsynaptic approach to increase the excitability of basal forebrain cholinergic neurons and hence, attentional functions are discussed. Experimental tests of this hypothesis require the demonstration of interactions between cognition-induced increases in the activity of cortical cholinergic afferents and the effects of putative cognition enhancers. The available data illustrate that the effects of benzodiazepine receptor (BZR) agonists and inverse agonists on cortical acetylcholine (ACh) efflux interact with the state of activity in this system. The feasibility, potential heuristic power, and the experimental and conceptual problems of studies attempting to simultaneously assess drug effects on behavioral/cognitive abilities, ACh efflux, and neuronal activity have been revealed by an experiment intended to correlate performance in a task measuring sustained attention with medial prefrontal ACh efflux and medial prefrontal single-unit activity. The rational development of a psychopharmacology of cognition enhancers requires a union among behavioral/cognitive pharmacology, neuropharmacological and electrophysiological approaches.

Finding a "healthy" medium

Home health care is an integral part of the health care system. As home care grows--a natural outcome with a growing elderly population and earlier discharges from the hospital under DRGs--so do the many challenges. Proposed Medicare budget cuts, managed care and Medicaid block grants are just a few of the pressing issues faces by not only home care, but the entire health care industry.

Multiple organ failure: the final complication of critical illness

The exact mechanisms responsible for the development and perpetuation of MOF are just beginning to be unraveled. Nurses must have an understanding of the progression of MOF and the physiologic and psychologic responses of the patient. Although caring for patients with MOF is not an easy task, the critical care nurse is in a pivotal role to make a difference in the outcome of these patients.

Utilizing volunteer research assistants in epidemiologic studies

Utilizing volunteers in research-assistant roles can provide a new model for extending research dollars in epidemiologic studies of the elderly. This is increasingly important with a rapidly growing older population suffering from an increasing prevalence of disability, disease, and the related medical costs. During a two-year cross-sectional study of factors that predict health aging conducted by the Buck Center for Research in Aging in Marin County, California, 82 volunteers were recruited and trained to fill roles often held by paid research assistants. The key activities of telephone screening, interviewing, coding, and data entry were successfully completed by trained volunteers following standards and within a time frame comparable to similar studies. Volunteer research assistants contributed approximately 13,600 hours that resulted in a savings in personnel costs of over $100,000. Many of the people recruited and trained as volunteer research assistants were healthy older adults and retired workers. The project utilized their transferable skills and talents in an interesting and productive capacity.

Multiple organ failure: the final complication of critical illness

The exact mechanisms responsible for the development and perpetuation of MOF are just beginning to be unraveled. Nurses must have an understanding of the progression of MOF and the physiologic and psychologic responses of the patient. Although caring for patients with MOF is not an easy task, the critical care nurse is in a pivotal role to make a difference in the outcome of these patients.

Ethanol suppresses the induction of long-term potentiation in vivo

Long-term potentiation (LTP), a leading neural mechanism of memory, is profoundly affected by ethanol in vitro, but ethanol's effect on LTP in vivo has not been studied at doses known to impair memory. In this study, LTP was induced in the dentate hilus by theta-pattern stimulation of the perforant path. Dentate evoked responses were recorded during a 3 h session in which rats pressed a lever on a fixed interval (30 s) schedule of reinforcement. Following theta-pattern stimulation, rats pretreated with saline had significant LTP that was present throughout the session. LTP was measured as an increase in the initial slope and the population spike of the evoked response. The potentiation was no longer present 24 h after stimulation. Ethanol (0.5 g/kg and 1.0 g/kg) blocked LTP and attenuated short-term frequency potentiation in a dose-dependent fashion. Although ethanol produced a decrease in rewarded lever pressing, lever pressing was not correlated to any measure of the evoked response. Ethanol, when given 60 min after theta-pattern stimulation, did not alter the expression of LTP. The results demonstrate that low doses of ethanol selectively blocked the induction of LTP in vivo, an effect that may underlie ethanol's impairment of memory.

Health and functioning among the elderly of Marin County, California: a glimpse of the future

BACKGROUND

The purpose of this study was to obtain information concerning the health status of the theoretically advantaged elderly population of Marin County, California, and to compare these data with those from other populations with different levels of socioeconomic status.

METHODS

An age-stratified sample of 2,018 community-dwelling elderly residents of Marin was selected, and these participants were interviewed between 1989 and 1991. Interview items included medical history of life-threatening diseases and chronic conditions, reported and observed disabilities, and life-style characteristics.

RESULTS

While the residents of Marin had lower mortality rates than the total U.S. population, there were few meaningful differences in measures of health and function in comparison to other elderly populations with substantially lower levels of socioeconomic status. The main exceptions were better memory performance and lower depressive symptomatology in Marin. Because of the many methodological differences, these comparisons must be viewed with caution.

CONCLUSION

The general pattern of findings in this study indicates that while death has been postponed in this socioeconomically advantaged population, the prevalence of disease and disability has not. If true, this implies that residents of an affluent community can spend a longer rather than shorter period of their late life in a state of infirmity and in need of medical care. This appears to be especially true for women.

Evaluation of the use and usefulness of telephone consultations in one general practice

In one practice with 14,000 patients an advice line was set aside at designated times to enable patients to speak directly to a doctor on the telephone. The aim of this study was to determine who used the line, why they called, the conditions callers presented with, the action taken by the doctor and whether patients and doctors thought the service was a good idea. A total of 277 calls were made during the five month study period. Responses to a questionnaire were received from doctors for all 277 calls and from 152 patients. It was found that most calls lasted about three minutes. Most of the callers (59%) were known to the doctor taking the call. Users of the advice line were most likely to be women, married people and people with children. Equal numbers of calls were received about new and existing problems. The most frequent reason for calling was to obtain the result of a test (21% of calls). The most frequent diagnosis by the doctors was chronic complaints for which the patient was already receiving treatment (19%). The data from patients and doctors were similar. In 30% of cases callers were advised to take medicine, mostly a prescription to be collected (16%), while a few callers received a home visit (7%). Doctors thought they provided reassurance in 26% of cases while callers thought they had received reassurance in 43% of cases. If the advice line had not been available three quarters of the respondents would have made an appointment and 13% would have asked the doctor to make a home visit.(ABSTRACT TRUNCATED AT 250 WORDS)

The accuracy of selective magnetic resonance imaging compared with the findings of arthroscopy of the knee

The results of selective magnetic resonance imaging of the knee were compared with those of arthroscopy in a prospective series of fifty patients. A specifically designed protocol for imaging, producing T1 sagittal images interleaved at four millimeters while the patient's foot was in 20 degrees of external rotation, was utilized. This technique, called selective magnetic resonance imaging, yielded excellent visualization of the posterior cruciate ligament, medial meniscus, and lateral meniscus in all patients. However, in only 76 per cent of the patients was the anterior cruciate ligament well visualized. Compared with arthroscopy, the sensitivity, specificity, and accuracy of selective magnetic resonance imaging were, respectively, 95.8, 100, and 98 per cent for tears of the medial meniscus; 66.7, 95.1, and 90 per cent for tears of the lateral meniscus; undefined, 100, and 100 per cent for tears of the posterior cruciate ligament; and 100, 96.9, and 97.3 per cent for tears of the anterior cruciate ligament, when that ligament was well visualized. Our selective sequence can be performed in fifteen minutes at a cost that is comparable with that of arthrography. It is totally non-invasive and requires no exposure to ionizing radiation. Selective magnetic resonance imaging can be a safe and valuable adjunct to the clinical evaluation of the knee and an aid to efficient preoperative planning.