Exploring hospital mealtime experiences of older inpatients, caregivers and staff using photovoice methods

AIM

To gather and understand the experience of hospital mealtimes from the perspectives of those receiving and delivering mealtime care (older inpatients, caregivers and staff) using photovoice methods to identify touchpoints and themes to inform the co-design of new mealtime interventions.

METHODS

This study was undertaken on acute care wards within a single metropolitan hospital in Brisbane, Australia in 2019. Photovoice methods involved a researcher accompanying 21 participants (10 older patients, 5 caregivers, 4 nurses and 2 food service officers) during a mealtime and documenting meaningful elements using photographs and field notes. Photo-elicitation interviews were then undertaken with participants to gain insight into their experience. Data were analysed using inductive thematic analysis, involving a multidisciplinary research team including a consumer.

RESULTS

Themes were identified across the three touchpoints: (1) preparing for the meal (the juggle, the anticipation), (2) delivering/receiving the meal (the rush, the clutter and the wait) and (3) experiencing the meal (the ideal, pulled away and acceptance). Despite a shared understanding of the importance of meals and shared vision of 'the ideal' mealtime, generally this was a time of tension, missed cares and dissatisfaction for staff, patients and caregivers. There was stark contrast in some aspects of mealtime experience, with simultaneous experiences of 'the rush' (staff) and 'the wait' (patients and caregivers). There was an overwhelming sense of acceptance and lack of control over change from all.

CONCLUSIONS

This study identified themes during hospital mealtimes which have largely gone unaddressed in the design of mealtime interventions to date. This research may provide a framework to inform the future co-design of mealtime interventions involving patients, caregivers and multidisciplinary staff, centred around these key touchpoints.

PRACTICE IMPLICATIONS

Mealtimes are experienced differently by patients, caregivers, nurses and food service officers across three key touchpoints: preparing for, delivering/receiving and experiencing the meal. Improving mealtime experiences therefore necessitates a collaborative approach, with co-designed mealtime improvement programs that include specific interventions focusing each touchpoint. Our data suggest that improvements could focus on reducing clutter, clarifying mealtime roles and workflows and supporting caregiver involvement.

IMPACT

What problem did the study address? Mealtimes are the central mechanism to meet patients' nutritional needs in hospital; however, research consistently shows that many patients do not eat enough to meet their nutritional requirements and that they often do not receive the mealtime assistance they require. Interventions to improve hospital mealtimes have, at best, shown only modest improvements in nutritional intake and mealtime care practices. Gaining deeper insight into the mealtime experience from multiple perspectives may identify new opportunities for improvement. What were the main findings? Patients, caregivers and staff have shared ideals of comfort, autonomy and conviviality at mealtimes, but challenges of complex teamwork and re-prioritisation of mealtimes in the face of prevailing power hierarchies make it difficult to achieve this ideal. There are three discrete touchpoints (preparing for, delivering/receiving and experiencing the meal) that require different approaches to improvement. Our data suggests a need to focus improvement on reducing clutter, clarifying mealtime roles and workflows and supporting caregivers. Where and on whom will the research have an impact? The research provides a framework for multidisciplinary teams to begin co-designing improvements to mealtime care to benefit patients, caregivers and staff, while also providing a method for researchers to understand other complex care situations in hospital.

REPORTING METHOD

This manuscript is written in adherence with the Standards for Reporting Qualitative Research.

PATIENT OR PUBLIC CONTRIBUTION

Patients and caregivers were involved in the conception and design of the study through their membership of the hospital mealtime reference group. A consumer researcher (GP) was involved in the team to advise on study conduct (i.e. recruitment methods and information), data analysis (i.e. coding transcripts), data interpretation (i.e. review and refinement of themes) and manuscript writing (i.e. review and approval of final manuscript).

Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study

BACKGROUND

In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States.

METHODS

We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes.

RESULTS

Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration.

CONCLUSION

Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.

Incidence and outcomes of in-hospital nutritional decline: A prospective observational cohort study in adult patients

BACKGROUND AND AIMS

Hospital malnutrition is associated with higher healthcare costs and worse outcomes. Only a few prospective studies have evaluated trends in nutritional status during an acute stay, but these studies were limited by the short timeframe between nutrition assessments. The aim of this study was to investigate changes in nutritional status, incidence of hospital-acquired malnutrition (HAM), and the associated risk factors and outcomes in acute adult patients admitted for >14 days.

METHODS

A prospective observational cohort study was conducted in two medical and two surgical wards in a tertiary hospital in Brisbane, Australia. Nutrition assessments were performed using the Subjective Global Assessment at baseline (day eight) and weekly until discharge. Nutritional decline was defined as a change from well-nourished to moderate/severe malnutrition (HAM) or from moderate to severe malnutrition (further decline) >14 days after admission.

RESULTS

One hundred and thirty patients were included in this study (58.5% male; median age 67.0 years (IQR 24.4), median length of stay 23.5 days (IQR 14)). At baseline, 70.8% (92/130) of patients were well-nourished. Nutritional decline occurred in 23.8% (31/130), with 28.3% (26/92) experiencing HAM. Of the patients with moderate malnutrition on admission (n = 30), 16% (5/30) continued to decline to severe malnutrition. Improvement in nutritional status from moderate and severe malnutrition to well-nourished was 18.4% (7/38). Not being prescribed the correct nutrition care plan within the first week of admission was an independent predictor of in-hospital nutritional decline or remaining malnourished (OR 2.3 (95% CI 1.0-5.1), p = 0.039). In-hospital nutritional decline was significantly associated with other hospital-acquired complications (OR 3.07 (95% CI 1.1-8.9), p = 0.04) and longer length of stay (HR 0.63 (95% CI 0.4-0.9), p = 0.044).

CONCLUSION

This study found a high rate of nutritional decline in acute patients, highlighting the importance of repeated nutrition screening and assessments during hospital admission and proactive interdisciplinary nutrition care to treat or prevent further nutritional decline.

Mealtimes matter: Measuring the hospital mealtime environment and care practices to identify opportunities for multidisciplinary improvement

AIMS

Hospital inpatients often eat poorly and report barriers related to mealtime care. This study aimed to measure and describe the mealtime environment and care practices across 16 acute wards in a tertiary hospital to identify opportunities for improvement.

METHODS

A prospective cross-sectional audit was undertaken over a two-month period in 2021. A structured audit tool was used at one breakfast, lunch and dinner on each ward to observe the mealtime environment (competing priorities, lighting, tray table clutter) and care practices (positioning, tray within reach, mealtime assistance). Data were analysed descriptively (%, count), with analyses by meal period and ward to identify variation in practices.

RESULTS

A total of 892 observations were completed. Competing priorities (59%), poor lighting (43%) and cluttered tray tables (41%) were common. Mealtime assistance was required by 300 patients (33.6%; 5.9% eating assistance, 27.7% set-up assistance) and was provided within 10 min for 203 (66.7%) patients. A total of 54 patients (18.0%) did not receive the required assistance. We observed 447 (50.2%) patients lying in bed at meal delivery, with 188 patients (21.1%) sitting in a chair. Competing priorities, poor lighting, poor patient positioning and delayed assistance were worse at breakfast. Mealtime environments and practices varied between wards.

CONCLUSION

This audit demonstrates opportunities to improve mealtimes in our hospital. Variation between wards and meal periods suggest that improvements need to be tailored to the ward-specific barriers and enablers. Dietitians are ideally placed to lead a collaborative approach alongside the wider multidisciplinary team to improve mealtime care and optimise intake.

Enhancing or impeding? The influence of digital systems on interprofessional practice and person-centred care in nutrition care systems across rehabilitation units

AIMS

Digital health transformation may enhance or impede person-centred care and interprofessional practice, and thus the provision of high-quality rehabilitation and nutrition services. We aimed to understand how different elements and factors within existing digital nutrition and health systems in subacute rehabilitation units influence person-centred and/or interprofessional nutrition and mealtime care practices through the lens of complexity science.

METHODS

Our ethnographic study was completed through an interpretivist paradigm. Data were collected from observation and interviews with patients, support persons and staff. Overall, 58 h of ethnographic field work led to observing 125 participants and interviewing 77 participants, totalling 165 unique participants. We used reflexive thematic analysis to analyse the data with consideration of complexity science.

RESULTS

We developed four themes: (1) the interplay of local context and technology use in nutrition care systems; (2) digitalisation affects staff participation in nutrition and mealtime care; (3) embracing technology to support nutrition and food service flexibility; and (4) the (in)visibility of digitally enabled nutrition care systems.

CONCLUSIONS

While digital systems enhance the visibility and flexibility of nutrition care systems in some instances, they may also reduce the ability to customise nutrition and mealtime care and lead to siloing of nutrition-related activities. Our findings highlight that the introduction of digital systems alone may be insufficient to enable interprofessional practice and person-centred care within nutrition and mealtime care and thus should be accompanied by local processes and workflows to maximise digital potential.

An ethnographic study exploring person-centred nutrition care in rehabilitation units

PURPOSE

Person-centred care (PCC) is an essential component of high-quality healthcare across professions and care settings. While research is emerging in subacute nutrition services more broadly, there is limited literature exploring the person-centredness of nutrition care in rehabilitation. This study aimed to explore person-centred nutrition care (PCNC) in rehabilitation units, as described and actioned by patients, support persons and staff. Key factors influencing PCNC were also explored.

MATERIALS AND METHODS

An ethnographic study was undertaken across three rehabilitation units. Fifty-eight hours of field work were completed with 165 unique participants to explore PCNC. Field work consisted of observations and interviews with patients, support persons and staff. Data were analysed through the approach of reflexive thematic analysis, informed by PCC theory.

RESULTS

Themes generated were: (1) tensions between patient and staff goals; (2) disconnected moments of PCNC; (3) the necessity of interprofessional communication for PCNC; and (4) the opportunity for PCNC to enable the achievement of rehabilitation goals.

CONCLUSIONS

PCNC was deemed important to different stakeholders but was at times hindered by a focus on profession-specific objectives. Opportunities exist to enhance interprofessional practice to support PCNC in rehabilitation. Future research should consider the system-level factors influencing PCNC in rehabilitation settings.

Are Malnourished Inpatients Treated by Dietitians Active Participants in Their Nutrition Care? Findings of an Exploratory Study of Patient-Reported Measures across Nine Australian Hospitals

BACKGROUND

Inpatient malnutrition is a key determinant of adverse patient and healthcare outcomes. The engagement of patients as active participants in nutrition care processes that support informed consent, care planning and shared decision making is recommended and has expected benefits. This study applied patient-reported measures to identify the proportion of malnourished inpatients seen by dietitians that reported engagement in key nutrition care processes.

METHODS

A subset analysis of a multisite malnutrition audit limited to patients with diagnosed malnutrition who had at least one dietitian chart entry and were able to respond to patient-reported measurement questions.

RESULTS

Data were available for 71 patients across nine Queensland hospitals. Patients were predominantly older adults (median 81 years, IQR 15) and female (n = 46) with mild/moderate (n = 50) versus severe (n = 17) or unspecified severity (n = 4) malnutrition. The median length of stay at the time of audit was 7 days (IQR 13). More than half of the patients included had two or more documented dietitian reviews. Nearly all patients (n = 68) received at least one form of nutrition support. A substantial number of patients reported not receiving a malnutrition diagnosis (n = 37), not being provided information about malnutrition (n = 30), or not having a plan for ongoing nutrition care or follow-up (n = 31). There were no clinically relevant trends between patient-reported measures and the number of dietitian reviews or severity of malnutrition.

CONCLUSIONS

Malnourished inpatients seen by dietitians across multiple hospitals almost always receive nutritional support. Urgent attention is required to identify why these same patients do not routinely report receiving malnutrition diagnostic advice, receiving information about being at risk of malnutrition, and having a plan for ongoing nutrition care, regardless of how many times they are seen by dietitians.

Using Implementation Science in Nursing Research

OBJECTIVES

Clinical research continues to build knowledge that can potentially improve clinical and health service outcomes; however, integrating evidence into routine care is challenging, resulting in a knowledge practice gap. The field of implementation science is a resource available for nurses to translate evidence into their practice. This article aims to provide nurses with an overview of implementation science, illustrate its value integrating evidence into practice, and show how it can be applied with high rigor in nursing research practice.

DATA SOURCES

A narrative synthesis of the implementation science literature was conducted. A series of case studies were purposively selected to demonstrate the application of commonly used implementation theories, models, and frameworks across health care settings relevant to nursing. These case studies demonstrate how the theoretical framework was applied and how the outcomes of the work reduced the knowledge practice gap.

CONCLUSION

Implementation science theoretical approaches have been used by nurses and multidisciplinary teams to better understand the gap between knowledge and practice for better informed implementation. These can be used to understand the processes involved, identify the determinants at play, and undertake an effective evaluation.

IMPLICATIONS FOR NURSING PRACTICE

By using implementation science research practice, nurses can also build a strong foundation of evidence about nursing clinical practice. As an approach, implementation science is practical and can optimize the valuable nursing resource.

A qualitative analysis of rural syringe service program fidelity in Appalachian Kentucky: Staff and participant perspectives

PURPOSE

As drug-related epidemics have expanded from cities to rural areas, syringe service programs (SSPs) and other harm reduction programs have been slow to follow. The recent implementation of SSPs in rural areas demands attention to program fidelity based on core components of SSP success.

METHODS

Semistructured interviews conducted with clients and staff at 5 SSPs in 5 counties within 2 Central Appalachian health districts. Interviews covered fidelity of SSP implementation to 6 core components: (1) meet needs for harm reduction supplies; (2) education and counseling for sexual, injection, and overdose risks; (3) cooperation between SSPs and local law enforcement; (4) provide other health and social services; (5) ensure low threshold access to services; and (6) promote dignity, the impact of poor fidelity on vulnerability to drug-related harms, and the risk environment's influence on program fidelity. We applied thematic methods to analyze the data.

FINDINGS

Rural SSPs were mostly faithful to the 6 core components. Deviations from core components can be attributed to certain characteristics of the local rural risk environment outlined in the risk environment model, including geographic remoteness, lack of resources and underdeveloped infrastructure, and stigma against people who inject drugs (PWID) CONCLUSIONS: As drug-related epidemics continue to expand outside cities, scaling up SSPs to serve rural PWID is essential. Future research should explore whether the risk environment features identified also influence SSP fidelity in other rural areas and develop and test strategies to strengthen core components in these vulnerable areas.

What is 'successful rehabilitation'? A multi-stakeholder nominal group technique study to inform rehabilitation outcome measurement

OBJECTIVE

To explore how stakeholders in rehabilitation conceptualise 'successful rehabilitation', to inform the development of a minimum dataset and core outcomes for sub-acute rehabilitation.

DESIGN

Qualitative consensus study using the nominal group technique.

SETTING

Online focus groups.

PARTICIPANTS

Consumer representatives (n = 7), clinicians (n = 15), and health service managers (n = 9) from Australia.

INTERVENTION

Participants responded to the question, 'What does successful rehabilitation look like?'. Following item generation, they prioritised their top five responses, allocating 100 points across items to denote relative importance.

MAIN MEASURES

Prioritised responses were analysed across stakeholder groups using qualitative content analysis.

RESULTS

Ten themes were identified. 'Successful rehabilitation' is: (1) person and family centred; (2) effective; (3) inter-professional; (4) accessible; (5) goal oriented with meaningful outcomes; (6) connected to the continuum of care; (7) evidence-based and supportive of innovation and research; (8) appropriately funded and skilled; (9) satisfying and engaging; and (10) safe.

CONCLUSIONS

Stakeholder-defined 'successful rehabilitation' aligned with principles of value-based care and evidence-based rehabilitation. Provision and receipt of person and family centred care was the most important indicator of successful rehabilitation. Measures of success should include indicators of structure, process, outcome, and experience, and be conducted at multiple time-points.

Developing a knowledge translation program for health practitioners: Allied Health Translating Research into Practice

Background

Front-line health practitioners lack confidence in knowledge translation, yet they are often required to undertake projects to bridge the knowledge-practice gap. There are few initiatives focused on building the capacity of the health practitioner workforce to undertake knowledge translation, with most programs focusing on developing the skills of researchers. This paper reports the development and evaluation of a knowledge translation capacity building program for allied health practitioners located over geographically dispersed locations in Queensland, Australia.

Methods

Allied Health Translating Research into Practice (AH-TRIP) was developed over five years with consideration of theory, research evidence and local needs assessment. AH-TRIP includes five components: training and education; support and networks (including champions and mentoring); showcase and recognition; TRIP projects and implementation; evaluation. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation Maintenance) guided the evaluation plan, with this paper reporting on the reach (number, discipline, geographical location), adoption by health services, and participant satisfaction between 2019 and 2021.

Results

A total of 986 allied health practitioners participated in at least one component of AH-TRIP, with a quarter of participants located in regional areas of Queensland. Online training materials received an average of 944 unique page views each month. A total of 148 allied health practitioners have received mentoring to undertake their project, including a range of allied health disciplines and clinical areas. Very high satisfaction was reported by those receiving mentoring and attending the annual showcase event. Nine of sixteen public hospital and health service districts have adopted AH-TRIP.

Conclusion

AH-TRIP is a low-cost knowledge translation capacity building initiative which can be delivered at scale to support allied health practitioners across geographically dispersed locations. Higher adoption in metropolitan areas suggests that further investment and targeted strategies are needed to reach health practitioners working in regional areas. Future evaluation should focus on exploring the impact on individual participants and the health service.

Incidence and criteria used in the diagnosis of hospital-acquired malnutrition in adults: a systematic review and pooled incidence analysis

Despite advances in identifying malnutrition at hospital admission, decline in nutritional status of well-nourished patients can be overlooked. The aim of this systematic review was to investigate the incidence of hospital-acquired malnutrition (HAM), diagnostic criteria and health-related outcomes. PubMed, CINAHL, Embase and Cochrane Library were searched up to July 2021. Studies were included if changes in nutritional status was assessed with a validated nutrition assessment tool in acute and subacute adult (≥18 yrs) hospitalised patients. A random-effects method was used to pool the incidence proportion of HAM in prospective studies. The certainty of evidence was appraised using the Grading of Recommendation Assessment, Development and Evaluation system. We identified 12 observational cohort studies (10 prospective and 2 retrospective), involving 35,324 participants from acute (9 studies) and subacute settings (3 studies). Retrospective studies reported a lower incidence of HAM (<1.4%) than prospective studies (acute: 9-38%; subacute: 0-7%). The pooled incidence of HAM in acute care was 25.9% (95% confidence interval (CI): 17.3-34.6). Diagnostic criteria varied, with use of different nutrition assessment tools and timeframes for assessment (retrospective studies: >14 days; prospective studies: ≥7 days). Nutritional decline is probably associated with longer length of stay and higher 6-month readmission (moderate certainty of evidence) and may be association with higher complications and infections (low certainty of evidence). The higher incidence of HAM in the acute setting, where nutritional assessments are conducted prospectively, highlights the need for consensus regarding diagnostic criteria and further studies to understand the impact of HAM.

A systematic review of frailty education programs for health care professionals

OBJECTIVES

To identify and examine the reported effectiveness of education programs for health professionals on frailty.

METHODS

A systematic review was conducted of articles published up to June 2021, examining the evaluation of frailty training or education programs targeting health professionals/students. The participant demographics, program content and structure, effectiveness assessment methodology and outcomes, as well as participant feedback, were recorded with narrative synthesis of results.

RESULTS

There were nine programs that have evaluated training of health professionals in frailty. These programs varied with respect to intensity, duration, and delivery modality, and targeted a range of health professionals and students. The programs were well-received and found to be effective in increasing frailty knowledge and self-perceived competence in frailty assessment. Common features of successful programs included having multidisciplinary participants, delivering a clinically tailored program and using flexible teaching modalities. Of note, many programs assessed self-perceived efficacy rather than objective changes in patient outcomes.

CONCLUSIONS

Despite increasing attention on frailty in clinical practice, this systematic review found that there continues to be limited reporting of frailty training programs.

Development of a minimum dataset for subacute rehabilitation: a three-round e-Delphi consensus study

OBJECTIVES

To develop a minimum dataset to be routinely collected across a heterogenous population within a subacute rehabilitation service to guide best care and outcomes for patients, and value for the health service.

DESIGN

Three-round e-Delphi exercise, followed by consensus meetings.

SETTING

Multicentre study in Brisbane, Australia.

PARTICIPANTS

Rehabilitation decision-makers, researchers and clinicians were invited to participate in the e-Delphi exercise. A multidisciplinary project steering committee (rehabilitation decision makers, researchers, clinicians and consumers) participated in consensus meetings.

METHODS

In round 1 of the e-Delphi, participants responded to an open-ended question, generating data and outcomes that should be routinely collected in rehabilitation. In rounds 2 and 3, participants rated the importance of collecting each item on a nine-point scale. Consensus was defined a priori, as items rated as 'essential' by at least 70%, and of 'limited importance' by less than 15%, of respondents. Consensus meetings were held to further refine and define the dataset for implementation.

RESULTS

In total, 38 participants completed round 1 of the e-Delphi. Qualitative content analysis of their responses generated 1072 codes, which were condensed into 39 categories and 209 subcategories. Following two rounds of rating (round 2: n=32 participants; round 3: n=28 participants), consensus was reached for 124 items. Four consensus meetings (n=14 participants) resulted in the final dataset which included 42 items across six domains: (1) patient demographics, (2) premorbid health and psychosocial information, (3) admission information, (4) service delivery and interventions, (5) outcomes and (6) caregiver information and outcomes.

CONCLUSIONS

We identified 42 items that reflect the values and experiences of rehabilitation stakeholders. Items unique to this dataset include caregiver information and outcomes, and detailed service delivery and intervention data. Future research will establish the feasibility of collection in practice.

Minimally Invasive Surgical Approach for Esophageal Adenocarcinoma in a Patient with Previous Belsey Mark IV Fundoplication: A Case Report

Background: Historically, the management for recurrent or persistent Gastro-esophageal reflux disease included selective vagotomy and fundoplication. Despite these surgical interventions, the risk of Barrett’s esophagus (BE) and subsequent malignant transformation remains, requiring cancer resection surgery. We present a case of a patient with a gastro-esophageal junction (GEJ) adenocarcinoma, who underwent a pediatric thoracotomy and Belsey Mark IV fundoplication, and was successfully treated by Laparoscopic Ivor-Lewis Esophagectomy (LILE). Case Presentation: This 64-year-old gentleman with BE and GEJ adenocarcinoma was previously deemed unsuitable for curative surgery due to clinical staging indicating a tumor length of 10cm and suspected invasion of the left pleura. Further staging by Endoscopic ultrasound indicated no evidence of pleural invasion with the distal esophageal thickening in keeping with his previous Belsey Mark IV fundoplication. He underwent neo-adjuvant chemotherapy and a subsequent LILE with complete laparoscopic reversion of the gastric fundoplication without injury to the gastroepiploic artery or fundus. There was sufficient preservation of conduit length to enable a tension free hand-sewn anastomosis with an uneventful post-operative recovery. Final histopathology confirmed ypT1 ypN0 moderately differentiated adenocarcinoma with R0 resection margins. The patient has completed 24 months of cancer recurrence free surveillance. Conclusion: We describe the successful management of a patient by LILE on a background of previous hiatal fundoplication surgery, previously refused curative surgery. We highlight the importance of EUS as a staging modality for such cases showing invasive disease to increase the final clinical staging accuracy. We suggest a minimally invasive approach may be utilized for successful re-do hiatal dissection as an alternative to a conventional open surgery.

The delivery of patient centred dietetic care in subacute rehabilitation units: A scoping review

BACKGROUND

Patient centred care (PCC) positively influences individual and organisational outcomes. It is important that dietitians working in rehabilitation units are supported to deliver PCC, as effective rehabilitation is a collaborative and patient centred process. The objective of this scoping review was to explore the literature available regarding the delivery of dietetic PCC, with patients undergoing rehabilitation in subacute inpatient units.

METHODOLOGY

PubMed, MEDLINE, CINAHL, Embase and Scopus were searched for relevant published literature. Searches for grey and unpublished literature were also completed. Studies were eligible for inclusion and data extraction if they demonstrated the delivery of PCC by qualified dietitians, through individual consultations with adult patients undertaking subacute rehabilitation.

RESULTS

Overall, 675 studies were identified and six were included in the review. From the literature available, documentation was lacking regarding conceptualisation and delivery of patient centred nutrition care, with only one study providing quality indicators for patient centred dietetic services. Elements of PCC cited were mostly limited to phrases such as, 'individualised care', 'tailored advice', 'follow-up', and 'team collaboration'.

CONCLUSION

This scoping review identified a considerable gap in the literature regarding the delivery of dietetic PCC in subacute rehabilitation units. Contemporary descriptions of PCC show that delivery of care which is truly patient centred is far more comprehensive than individualising interventions or organising ongoing services. This raises the question, is the delivery of nutrition care in subacute rehabilitation unit's patient centred? This article is protected by copyright. All rights reserved.

Implementation science for dietitians: The 'what, why and how' using multiple case studies

AIM

Implementation science theories, models and frameworks help to address evidence-practice gaps, which have increasing importance for dietetic practice. This paper aims to provide dietitians with insight into how implementation science can be applied to practice, using multiple 'real-life' case studies.

METHODS

Three case studies were purposively selected across areas of dietetics practice to demonstrate application of commonly-used implementation theories, models and frameworks. Reflections from the authors were provided in response to a structured set of questions outlining how the theoretical approach was selected and used, and considerations for future application. Within and cross-case analysis was undertaken.

RESULTS

Dietitians used diverse implementation theories, models and frameworks to identify barriers and enablers, to plan for implementation, and to guide the selection of implementation strategies. Implementation theory was used to evaluate the implementation process in one case study. Cross-case analysis identified that mentoring by those with implementation expertise, multidisciplinary implementation teams, and leadership and investment in research and translation at an organisational and departmental level as key enablers.

CONCLUSIONS

This paper offers dietitians insight into how implementation science can be applied to improve the uptake of evidence-based practices within nutrition and dietetics, and suggests that there needs to be investment in implementation science as a foundation science within nutrition and dietetics, including education, training and mentoring for dietitians.

Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation delivers improved hospital nutrition care processes and patient reported experiences - An implementation study

AIM

Models of hospital malnutrition care reliant on dietitians can be inefficient and of limited effectiveness. This study evaluated whether implementing the Systematised, Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE) improved hospital nutrition care processes and patientreported experiences compared with traditional practice.

METHODS

A multi-site (five hospitals) prospective, pre-post study evaluated the facilitated implementation of SIMPLE, a malnutrition care pathway promoting proactive nutrition support delivered from time of malnutrition screening by the interdisciplinary team, without need for prior dietetic assessment. Implementation was tailored to local site needs and resources. Nutrition care processes delivered to inpatients who were malnourished or at-risk of malnutrition were identified across diagnosis, intervention, and monitoring domains using standardised audits from medical records, foodservice systems and patient-reported nutrition experience measures.

RESULTS

Pre-implementation (n = 365) and post-implementation (n = 397) cohorts were similar for age (74 vs 73 years), gender (47.1% vs 48.6% female), and nutrition risk status (46.6% vs 45.3% at-risk). Post-implementation, at-risk participants were more likely to receive enhanced food and fluids (68.5% vs 83.9%; P < .01), nutrition information (30.9% vs 47.2%; P < .01), mealtime assistance where required (61.4% vs 77.9% P = .04), nutrition monitoring (25.2% vs 46.3%; P < .01) and care planning (17.8% vs 27.7%; P = .01). Patient-reported nutrition experience measures confirmed improved nutrition care. There was no difference in dietetic occasions of service per patient (1.51 vs 1.25; P = .83).

CONCLUSIONS

Tailored SIMPLE implementation improves nutrition care processes and patient reported nutrition experience measures for at-risk inpatients within existing dietetic resources.

Underreporting of Obesity in Hospital Inpatients: A Comparison of Body Mass Index and Administrative Documentation in Australian Hospitals

Despite its high prevalence, there is no systematic approach to documenting and coding obesity in hospitals. This study aimed to determine the prevalence of obesity among inpatients, the proportion of obese patients recognised as obese by hospital administration, and the cost associated with their admission. A cross-sectional study was undertaken in three hospitals in Queensland, Australia. Inpatients present on three audit days were included in this study. Data collected were age, sex, height, and weight. Body mass index (BMI) was calculated in accordance with the World Health Organization's definition. Administrative data were sourced from hospital records departments to determine the number of patients officially documented as obese. Total actual costing data were sourced from hospital finance departments. From a combined cohort of n = 1327 inpatients (57% male, mean (SD) age: 61 (19) years, BMI: 28 (9) kg/m2), the prevalence of obesity was 32% (n = 421). Only half of obese patients were recognised as obese by hospital administration. A large variation in the cost of admission across BMI categories prohibited any statistical determination of difference. Obesity is highly prevalent among hospital inpatients in Queensland, Australia. Current methods of identifying obesity for administrative/funding purposes are not accurate and would benefit from reforms to measure the true impact of healthcare costs from obesity.

Knowledge Translation in Dietetics: A Survey of Dietitians' Awareness and Confidence

This study aimed to determine dietitians' familiarity with knowledge translation (KT), confidence in undertaking KT, and preferences for receiving KT training. An online questionnaire was designed and disseminated to all dietitians working across hospital and health services in Queensland, Australia, for completion over a 6-week period (April-May 2018). Of the 124 respondents, 69% (n = 85) reported being familiar with KT, but only 28% (n = 35) reported being confident in applying KT to their practice. Higher confidence was reported with problem identification, evidence appraisal, and adapting evidence to local context, compared with implementation, evaluation, and dissemination. Almost all respondents reported an interest in learning more about KT (n = 121, 98%), with a preference for easily accessible and short "snippets" of training aimed at beginner-intermediate level. Lack of management support, difficulty attending multi-day courses, cost, travel requirements, and lack of quarantined time were reported barriers to attending KT training. There is a high awareness and interest but low confidence in undertaking KT amongst dietitians. This highlights an opportunity for workforce development to prepare dietitians to be skilled and confident in KT. Training and support needs to be low-cost and multi-modal to meet diverse needs.

Translating Research into Practice: How Confident Are Allied Health Clinicians?

AIM

Knowledge translation (KT) is a multistage process of implementing practice change to align with evidence-based practice. This study aimed to determine the confidence of allied health professionals (AHPs) to undertake KT.

METHODS

A quantitative questionnaire was disseminated to AHPs over a 4-week period. Awareness of and confidence with KT was assessed using a 100-mm visual analogue scale.

RESULTS

374 AHPs responded from 12 metropolitan hospitals in Queensland, Australia. Moderate confidence was reported for identifying an evidence-practice gap (median 70 mm, interquartile range [IQR] 50-80 mm), finding relevant literature/evidence (67 mm, 40-84 mm), and sharing evidence with colleagues (70 mm, 50-85 mm). Clinicians were less confident in choosing a KT framework (20 mm, 3-50 mm), implementing a practice change (40 mm, 15-61 mm), assessing barriers and enablers (50 mm, 25-70 mm) and supporting less experienced clinicians undertaking KT (42 mm, 14-68 mm). There was a weak positive correlation between years of experience and confidence in implementing practice change (rho=0.127, p=0.017). A majority of respondents (89%, n=333) reported an interest in learning more about KT.

CONCLUSIONS

AHPs were interested in KT but had low confidence in implementing research into practice. These findings identify opportunities to support the training and education needs of AHPs in KT.

The effect of NaOCl and heat treatment on static and dynamic mechanical properties and chemical changes of dentine

OBJECTIVES

To determine the effect of heat on flexural strength (FS), maximum strain (MS), storage modulus (SM), tan delta (TD) and chemical changes through micro-Raman spectroscopy of dentine exposed to 2.5% NaOCl or saline.

METHOD

ology: Dentine bars were randomly allocated to 8 test groups. Half (groups 2,4,6,8) were treated with NaOCl for 20 min; the rest (groups 1,3,5,7) remained in saline. FS/MS were measured in groups 1-4 (n = 15) (3/4 were also heated to 200 °C & re-hydrated in saline). Micro-Raman spectroscopy was performed on bars from groups 1-4. SM/TD were measured in 5-8: in 5/6 (n = 10), repeated after heating (200 °C), then following re-hydration; in 7/8 (n = 3) after heating to 25-185 °C.

RESULTS

Increase in MS on heat and FS/MS on heat + NaOCl was not significant (P > 0.05). SM increased (P = 0.06) after heat treatment but reduced to initial state after rehydration (P = 0.03). TD did not change (P = 0.4) after heat (200 °C) treatment but rehydration increased it compared with pre-treatment state (P = 0.001). For dentine bars pre-treated with NaOCl, SM did not change (P = 0.6) after heat (200 °C) treatment or rehydration but TD significantly increased (P = 0.02) upon re-hydration compared with pre- (P=0.007), or post- (P = 0.03) heat-treatment states. SM and TD varied between 25-185 °C with no consistent trend amongst the NaOCl pre-treated bars. Micro-Raman only detected chemical changes following NaOCl treatment in the mineral phase.

CONCLUSIONS

Exposure of dentine bars to heat and NaOCl produced only moderate changes to quasi-static but marked changes to viscoelastic properties, which may be explained by chemical alterations.

Clinicians as novice facilitators: a SIMPLE case study

PURPOSE

The purpose of this paper is to advance understanding about the facilitation process used in complex implementation projects, by describing the function of novice clinician facilitators, and the barriers and enablers they experience, while implementing a new model of care for managing hospital malnutrition.

DESIGN/METHODOLOGY/APPROACH

Semi-structured interviews were undertaken with local facilitators ( n=7) involved in implementing The SIMPLE Approach (Systematised Interdisciplinary Malnutrition Pathway Implementation and Evaluation) in six hospitals in Queensland, Australia. Facilitator networks and training supported the clinicians acting as novice facilitators.

FINDINGS

Key functions of the facilitator role were building relationships and trust; understanding the problem and stimulating change through data; negotiating and implementing the change; and measuring, sharing and reflecting on success. "Dedicated role, time and support" was identified as a theme encompassing the key barriers and enablers to successful facilitation.

PRACTICAL IMPLICATIONS

When implementing complex interventions within short project timelines, it is critical that novice clinician facilitators are given adequate and protected time within their role, and have access to regular support from peers and experienced facilitators. With these structures in place, facilitators can support iterative improvements through building trust and relationships, co-designing strategies with champions and teams and developing internal capacity for change.

ORIGINALITY/VALUE

This case study extends the knowledge about how facilitation works in action, the barriers faced by clinicians new to working in facilitator roles, and highlights the need for an adapt-to-fit approach for the facilitation process, as well as the innovation itself.

Comparison of Patient Food Intake, Satisfaction and Meal Quality Between Two Meal Service Styles in a Geriatric Inpatient Unit

This pilot study evaluated the introduction of a bistro evening meal service in a geriatric inpatient unit by comparing patient intake, satisfaction and meal quality of this new service to the usual central preplated service. Ten meals were observed under each condition (n = 30; mean age 79 years, 47% male). Data were collected on intake of each meal component (none, ¼, ½, ¾, all; converted to energy and protein using known food composition data), patient satisfaction with meals (meal flavor/taste, appearance, quality, staff demeanor; seven-point scale) and meal quality (sensory properties, temperature; five-point scale). Independent t-tests were used to compare energy and protein intakes between bistro and preplated services. There was no difference in mean energy or protein intake (energy: 2524 ± 927 kJ vs. 2692 ± 857 kJ, p = 0.612; protein: 29 ± 12 g vs. 27 ± 11 g, p = 0.699) patient satisfaction or meal quality between the bistro and preplated meal services. Patients were provided with fewer meal items during the bistro service, but ate a higher proportion of what was provided to them. Implementing a bistro service did not increase intake, satisfaction or meal quality in this study, suggesting that meal plating may be only one of many factors influencing intake and satisfaction of older inpatients.

Anatomy of STEM teaching in North American universities

National and local initiatives focused on the transformation of STEM teaching in higher education have multiplied over the last decade. These initiatives often focus on measuring change in instructional practices, but it is difficult to monitor such change without a national picture of STEM educational practices, especially as characterized by common observational instruments. We characterized a snapshot of this landscape by conducting the first large scale observation-based study. We found that lecturing was prominent throughout the undergraduate STEM curriculum, even in classrooms with infrastructure designed to support active learning, indicating that further work is required to reform STEM education. Additionally, we established that STEM faculty’s instructional practices can vary substantially within a course, invalidating the commonly-used teaching evaluations based on a one-time observation.

Although lecture is prominent throughout the undergraduate STEM curriculum, STEM faculty employ varied teaching practices within the same course.

Accuracy and confidence of allied health assistants administering the subjective global assessment on inpatients in a rural setting: a preliminary feasibility study

AIM

Malnutrition has a significant impact on patient outcomes and duration of inpatient stay. However, conducting timely nutrition assessments can be challenging for rural dietitians. A solution could be for allied health assistants (AHAs) to assist with these assessments. The present study aimed to assess the accuracy and confidence of AHAs trained to conduct the subjective global assessment (SGA) compared with dietitians.

METHODS

A non-inferiority study design was adopted. Forty-five adult inpatients admitted to a rural and remote health service were assessed independently by both a trained AHA and dietitian within 24 hours. The order of assessment was randomised, with the second assessor blind to the outcome of the initial SGA. Levels of agreement were examined using kappa and percent exact agreement (PEA; set a priori at ≥80%). Rater confidence after each assessment was assessed using a 10-point scale.

RESULTS

Agreement for overall SGA ratings was high (kappa = 0.84; PEA 84.4%). PEA for individual sub-components of the SGA ranged from 66.4 to 86.7%. Where discrepancies were identified in global SGA ratings, AHAs provided a more severe rating of malnutrition than dietitians. AHAs reported significantly lower confidence than dietitians (t = 4.49, P < 0.001), although mean confidence for both groups was quite high (AHA=7.5, dietitians = 9.0).

CONCLUSIONS

Trained AHAs completed the SGA with similar accuracy to dietitians. Using AHAs may help facilitate timely nutrition assessment in rural health services when a dietitian is not physically present. Further investigation is required to determine the benefits of incorporating this extended role into rural and remote health-care services.

CHERISH (collaboration for hospitalised elders reducing the impact of stays in hospital): protocol for a multi-site improvement program to reduce geriatric syndromes in older inpatients

BACKGROUND

Older inpatients are at risk of hospital-associated geriatric syndromes including delirium, functional decline, incontinence, falls and pressure injuries. These contribute to longer hospital stays, loss of independence, and death. Effective interventions to reduce geriatric syndromes remain poorly implemented due to their complexity, and require an organised approach to change care practices and systems. Eat Walk Engage is a complex multi-component intervention with structured implementation, which has shown reduced geriatric syndromes and length of stay in pilot studies at one hospital. This study will test effectiveness of implementing Eat Walk Engage using a multi-site cluster randomised trial to inform transferability of this intervention.

METHODS

A hybrid study design will evaluate the effectiveness and implementation strategy of Eat Walk Engage in a real-world setting. A multisite cluster randomised study will be conducted in 8 medical and surgical wards in 4 hospitals, with one ward in each site randomised to implement Eat Walk Engage (intervention) and one to continue usual care (control). Intervention wards will be supported to develop and implement locally tailored strategies to enhance early mobility, nutrition, and meaningful activities. Resources will include a trained, mentored facilitator, audit support, a trained healthcare assistant, and support by an expert facilitator team using the i-PARIHS implementation framework. Patient outcomes and process measures before and after intervention will be compared between intervention and control wards. Primary outcomes are any hospital-associated geriatric syndrome (delirium, functional decline, falls, pressure injuries, new incontinence) and length of stay. Secondary outcomes include discharge destination; 30-day mortality, function and quality of life; 6 month readmissions; and cost-effectiveness. Process measures including patient interviews, activity mapping and mealtime audits will inform interventions in each site and measure improvement progress. Factors influencing the trajectory of implementation success will be monitored on implementation wards.

DISCUSSION

Using a hybrid design and guided by an explicit implementation framework, the CHERISH study will establish the effectiveness, cost-effectiveness and transferability of a successful pilot program for improving care of older inpatients, and identify features that support successful implementation.

TRIAL REGISTRATION

ACTRN12615000879561 registered prospectively 21/8/2015.

From Hospital to Home: Limited Nutritional and Functional Recovery for Older Adults

BACKGROUND

The post-hospital period may be a vulnerable time for elders recovering from acute illness. Few studies have examined nutrition outcomes of older people at nutrition risk after acute hospitalisation.

OBJECTIVES

This study aims to describe a) standard nutrition care received by recently discharged older medical patients, b) change in nutritional and functional status at six weeks post-discharge and c) clinical outcomes at twelve weeks post discharge.

DESIGN

Prospective cohort study.

SETTING

Two metropolitan teaching hospitals in Brisbane, Australia.

PARTICIPANTS

Medical patients aged ≥65 years at risk of malnutrition (Malnutrition Screening Score ≥2) and discharged to independent living in the community.

MEASUREMENT

Nutritional status (Mini Nutritional Assessment (MNA), weight, lean body mass), functional status (grip strength, walk speed, activities of daily living) and health-related quality of life assessed on discharge and six weeks post-discharge. Inpatient and post-discharge nutrition intervention was recorded. Death and unplanned admissions were measured at 12 weeks.

RESULTS

Of the 42 consented participants, only 14% (n=6) received post-discharge dietitian review and 19% (n=8) received practical nutrition supports at home (meal delivery, shopping assistance) as part of standard care. While there was a small improvement in MNA (18.4±4.0 to 20.1±4.2, p=0.004) and walk speed (0.7±0.3 m/s to 0.9±0.3, p=0.004) at six weeks, there was no difference in mean weight, lean body mass, grip strength or activities of daily living. Five (15%) participants lost ≥5% body weight. By twelve weeks, 17 participants (46%) had at least one unplanned hospital admission and four (10%) had died.

CONCLUSIONS

Few patients at nutrition risk received nutrition-focussed care in the post-hospital period, and most did not improve nutritional or functional status at 6 weeks.

Conversion, shrinkage, water sorption, flexural strength and modulus of re-mineralizing dental composites

OBJECTIVES

Cure, volumetric changes and mechanical properties were assessed for new dental composites containing chlorhexidine (CHX) and reactive calcium phosphate-containing (CaP) to reduce recurrent caries.

METHODS

20wt.% of light curable urethane dimethacrylate based liquid was mixed with 80wt.% glass filler containing 10wt.% CHX and 0-40wt.% CaP. Conversion versus depth with 20 or 40s light exposure was assessed by FTIR. Solidification depth and polymerization shrinkage were determined using ISO 4049 and 17304, respectively. Subsequent volume expansion and biaxial flexural strength and modulus change upon water immersion were determined over 4 weeks. Hydroxyapatite precipitation in simulated body fluid was assessed at 1 week.

RESULTS

Conversion decreased linearly with both depth and CaP content. Average solidification depths were 4.5, 3.9, 3.3, 2.9 and 5.0 with 0, 10, 20, and 40% CaP and a commercial composite, Z250, respectively. Conversions at these depths were 53±2% for experimental materials but with Z250 only 32%. With Z250 more than 50% conversion was achieved only below 1.1mm. Shrinkage was 3% and 2.5% for experimental materials and Z250, respectively. Early water sorption increased linearly, whilst strength and modulus decreased exponentially to final values when plotted versus square root of time. Maximum volumetric expansion increased linearly with CaP rise and balanced shrinkage at 10-20wt.% CaP. Strength and modulus for Z250 decreased from 191 to 158MPa and 3.2 to 2.5GPa. Experimental composites initial strength and modulus decreased linearly from 169 to 139MPa and 5.8 to 3.8GPa with increasing CaP. Extrapolated final values decreased from 156 to 84MPa and 4.1 to 1.7GPa. All materials containing CaP promoted hydroxyapatite precipitation.

SIGNIFICANCE

The lower surface of composite restorations should both be solid and have greater than 50% conversion. The results, therefore, suggest the experimental composite may be placed in much thicker layers than Z250 and have reduced unbounded cytotoxic monomer. Experimental materials with 10-20wt.% additionally have volumetric expansion to compensate shrinkage, antibacterial and re-mineralizing components and competitive mechanical properties.

Function of glandular secretions in fragrance collection by male euglossine bees (Apidae: Euglossini)

MaleEulaema cingulata (Fabricius) (Apidae: Euglossini) possess large cephalic labial glands that secrete a mixture of lipids. In the process of fragrance collection, males secrete the labial gland lipids onto the substrate. The mixture of lipids and fragrances is then taken up by the front tarsal brushes and transferred to the hind tibial organs. The labial gland secretions apparently serve as a nonpolar solvent and carrier that increases the efficiency of fragrance collection.

Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients

OBJECTIVE

Although several validated nutritional screening tools have been developed to "triage" inpatients for malnutrition diagnosis and intervention, there continues to be debate in the literature as to which tool/tools clinicians should use in practice. This study compared the accuracy of seven validated screening tools in older medical inpatients against two validated nutritional assessment methods.

METHODS

This was a prospective cohort study of medical inpatients at least 65 y old. Malnutrition screening was conducted using seven tools recommended in evidence-based guidelines. Nutritional status was assessed by an accredited practicing dietitian using the Subjective Global Assessment (SGA) and the Mini-Nutritional Assessment (MNA). Energy intake was observed on a single day during first week of hospitalization.

RESULTS

In this sample of 134 participants (80 ± 8 y old, 50% women), there was fair agreement between the SGA and MNA (κ = 0.53), with MNA identifying more "at-risk" patients and the SGA better identifying existing malnutrition. Most tools were accurate in identifying patients with malnutrition as determined by the SGA, in particular the Malnutrition Screening Tool and the Nutritional Risk Screening 2002. The MNA Short Form was most accurate at identifying nutritional risk according to the MNA. No tool accurately predicted patients with inadequate energy intake in the hospital.

CONCLUSION

Because all tools generally performed well, clinicians should consider choosing a screening tool that best aligns with their chosen nutritional assessment and is easiest to implement in practice. This study confirmed the importance of rescreening and monitoring food intake to allow the early identification and prevention of nutritional decline in patients with a poor intake during hospitalization.

Prevalence and correlates of recent vaginal douching among African American adolescent females

STUDY OBJECTIVE

To describe the prevalence and correlates of vaginal douching among urban African American adolescents and to examine the association between douching and sexually transmitted infection (STI) status.

DESIGN

Demographic, psychosocial, and behavioral data were collected through cross-sectional, self-administered surveys. Self-collected vaginal swabs were assayed using nucleic acid amplification tests for trichomoniasis, chlamydia, and gonorrhea.

SETTING

Sexual health clinic in a large metropolitan area of the southeastern United States.

PARTICIPANTS

African American females (N = 701), ages 14-20, participating in a human immunodeficiency virus prevention intervention.

MAIN OUTCOME MEASURE

The outcome of interest was the association between vaginal douching (lifetime, past 90 days, and past 7 days) with demographic characteristics (eg, age, education, and socioeconomic status), physical and mental health status, STI status, sexual behavior (eg, number of vaginal sexual partners, age of sex partners, consistent condom use in the past 90 days, sex while self/partner was high on drugs or alcohol), and psychosocial characteristics (eg, sexual adventurism, social support, peer norms, sexual satisfaction, self-efficacy for sex refusal, self-esteem, relationship power, risk avoidance).

RESULTS

Forty-three percent reported ever douching, and 29% reported douching in the past 90 days. In bivariate analyses, recent douching was associated with demographic, behavioral, and psychosocial variables, but not current STI status. In multivariate analyses, recent douching was associated with age (odds ratio [AOR] = 1.13, confidence interval [CI] = 1.02-1.25), lower socioeconomic status (AOR = 1.25, CI = 1.05-1.47), and having sex with much older partners (AOR = 1.87, CI = 1.22-2.86).

CONCLUSION

Increased age, lower socioeconomic status, and older partners may be salient risk factors for douching behavior among African American young women.

Electrical performances and structural designs of copper bonding in wafer-level three-dimensional integration

The integrity of bonded Cu interconnects in wafer-level three-dimensional integration has been investigated as the function of pattern size and density, as well as bonding process parameter. The desired pattern density coupled with the application of bonding process profile we developed gives optimal yield and alignment accuracy, and provides excellent electrical connectivity and contact resistance through the entire wafer. This result is a key milestone in establishing the manufacturability of Cu-based interconnections for 3D integration technology.

Oncolytic adenoviral gene therapy in ovarian cancer: why we are not wasting our time

Preclinical gene-therapy studies in the past 15 years have repeatedly raised hopes that we were about to enter a brave new era. However, many clinical trials have disappointed. For tumor types with poor response rates to first-line conventional cytotoxic chemotherapy and/or high rates of chemorefractory disease, there remain very few treatment options. In this article we review gene therapy within the context of ovarian cancer. We examine why clinical data have been discouraging and discuss how the lessons learned from earlier trials are being applied to current research.

Dense collagen matrix accelerates osteogenic differentiation and rescues the apoptotic response to MMP inhibition

Bone is distinguished from other tissues by its mechanical properties, in particular stiffness. However, we know little of how osteoblasts react to the stiffness of their microenvironment; in this study we describe their response to a dense (>10 wt.%) collagenous 3D environment. Primary pre-osteoblasts were seeded within a novel form of native collagen, dense collagen, and cultured for up to 14 days in the presence and absence of osteogenic supplements: analysis was via Q-PCR, histology, fluorescent in situ zymography, MMP loss-of-function and tensile testing. Differentiation as measured through the up-regulation of Bsp (247-fold), Alp (14.2-fold), Col1A1 (4.5-fold), Mmp-13 (8.0-fold) and Runx2 (1.2-fold) transcripts was greatly accelerated compared to 2D plastic at 7 and 14 days in the same medium. The scale of this enhancement was confirmed through the use of growth factor stimulation on 2D via the addition of BMP-6 and the Hedgehog agonist purmorphamine. In concert, these molecules were capable of the same level of osteo-induction (measured by Bsp and Alp expression) as the dense collagen alone. Mineralisation was initially localised to remodelled pericellular regions, but by 14 days embedded cells were discernible within regions of apatite (confirmed by MicroRaman). Tensile testing of the matrices showed that this had resulted in a significant increase in Young's modulus at low strain values, consistent with a stiffening of the matrix. To determine the need for matrix remodelling in the mineralisation event the broad spectrum MMP Inhibitor Ilomastat was used. It was found that in its presence mineralisation could still occur (though serum-specific) and the apoptosis associated with MMP inhibition in hydrated collagen gels was abrogated. Analysis of gene expression indicated that this was due to the up-regulation of Mmp-13 in the presence of Ilomastat in dense collagen (400-fold), demonstrating a powerful feedback loop and a potential mechanism for the rescue from apoptosis. Osteoid-like matrix (dense collagen) is therefore a potent stimulant of osteoblast differentiation in vitro and provides an environment that enables survival and differentiation in the presence of MMP inhibition.

Application of mobile phone technology for managing chemotherapy-associated side-effects

BACKGROUND

Novel mobile phone technology linked to a server that communicates patients' symptoms to healthcare professionals has been adapted to register the side- effects of chemotherapy and provide advice on management of toxicity. We report a feasibility study to examine the utility of home monitoring of patients' symptoms via a mobile phone.

METHODS

Six colon cancer patients receiving adjuvant chemotherapy, entered symptom data onto user friendly screens on a mobile phone twice daily. This 'real time' self assessment of nausea, vomiting, mucositis, diarrhoea and hand-foot syndrome and measurement of temperature was sent via a secured connection to a remote computer. In the event of moderate or severe symptoms (generating amber and red alerts respectively), the nurse was immediately alerted by the computer, via a pager. The nurse then contacted the patient to reinforce the automatic advice sent to the patient on their phone and to assess the patient using clinical algorithms.

RESULTS

The patient used the mobile phones during the first two cycles of chemotherapy. The data were successfully analysed by the server software and alerts were generated alerting the study nurses to patients' symptoms at the appropriate time. There were 91 alerts-54 red and 37 amber; 54% (29/54) of the red alerts were data delay and transmission problems which were swiftly rectified. The remaining red alerts were managed appropriately by the study nurses. Both patients and staff felt confident in this approach to symptom management.

CONCLUSIONS

This study demonstrates that the technology for monitoring patients' symptoms worked well. The patients felt secure in the knowledge that their symptoms were being closely monitored and that they were participating effectively in their own care management.

Immune Reconstitution Inflammatory Syndrome Associated With Kaposi's Sarcoma

Purpose

A proportion of patients with HIV infection who subsequently receive highly active antiretroviral therapy (HAART) exhibit a deterioration in their clinical status, despite control of virologic and immunologic parameters. This clinical response, known as the immune reconstitution inflammatory syndrome (IRIS), occurs secondary to an immune response against previously diagnosed pathogens.

Patients and Methods

From our cohort of 5,832 patients treated in the HAART era, we identified 150 therapy-naive patients with a first presentation of Kaposi's sarcoma (KS). Their clinicopathologic features and progress were recorded prospectively.

Results

After commencing HAART, ten patients (6.6%) developed progressive KS, which we identify as IRIS-associated KS. In a comparison of these individuals with those whose KS did not progress, we found that IRIS-KS occurred in patients with higher CD4 counts (P = .03), KS-associated edema (P = .01), and therapy with both protease inhibitors and non-nucleosides together (P = .03). Time to treatment failure was similar for both groups, although the CD4 count declined more rapidly at first, in those patients with IRIS-associated KS. Despite this initial decline, in our clinical experience HAART could be successfully continued in those with IRIS-associated KS.

Conclusion

We have identified IRIS-KS in a cohort of HIV patients with KS who start HAART.

FTIR investigation of monomer polymerisation and polyacid neutralisation kinetics and mechanisms in various aesthetic dental restorative materials

Diamond ATR FTIR has been used to quantify light catalysed polymerisation and polyacid neutralisation rates in various glass ionomer cements (GIC), resin-modified GICs (RMGIC) and compomers. At 150s after the start of light exposure, levels of methacrylate polymerisation on the lower surfaces of 1mm thick specimens were 97% and 98% for the RMGIC, Vitremer and Fuji II LC and 47% and 37% for the compomers, Compoglass and Dyract. After light exposure, polymerisation rates for the compomers decreased linearly with inverse time. By 50,000s Compoglass and Dyract were 62% and 51% polymerised. Initial rate of polyacid neutralisation in the GIC Shofu HIFI was 0.32 times that of Fuji IX GIC. Those in Vitremer, Fuji II LC, Compoglass and Dyract were 0.16, 0.09, 0.004 and 0.004 times that of Fuji IX. Excluding short initial periods, log of neutralisation rates decreased linearly with log-time. Average gradients were -1.35 for the GIC, -0.80 for the RMGIC and -0.59 for the compomers. By 50,000s, polyacid salt concentrations for the RMGIC and compomers were 0.41 and 0.016 times that of the GIC. Reaction mechanisms have been discussed and used to help interpret material mechanical properties, fluoride release rates and adhesion to tooth structure.

FTIR investigation of polymerisation and polyacid neutralisation kinetics in resin-modified glass-ionomer dental cements

A new diamond ATR FTIR method has been developed to quantify the processes occurring in the resin-modified glass-ionomer cement (RMGIC). Fuji II LC (Improved), at 1 mm depth from the cement/water interface. With Fuji II LC (Improved) various changes in the spectra due to 90% monomer polymerisation were observed within 1 min after 20 s exposure to a dental light. Following polymerisation further different peak shifts with time were detected. Comparison with spectral changes seen during setting of the conventional glass-ionomer cement, Fuji IX, showed these could be assigned to water sorption and/or polyacid neutralisation. Any absorbance change due to the acid/glass reaction alone exhibited 2 linear regions when plotted against square root of time. Such behaviour suggests two separate diffusion mechanisms for acid neutralisation. The first faster one ceases at 30 or 150 min after mixing in Fuji IX and Fuji II LC (Improved), respectively. It was proposed that these were the times at which all the water (a required component of the reaction) in the original formulation is used up. The slower process was the same acid/glass reaction but initiated by water sorption. The initial rates of absorbance change due to acid neutralisation were 17 times faster for Fuji IX than Fuji II LC (Improved). By 4 days however, the total absorbance change due to acid neutralisation for Fuji IX was only 4 times that for Fuji II LC (Improved). Such results can help to explain changes in cement properties with time.

Prospective randomized comparison of dacarbazine (DTIC) versus DTIC plus interferon-alpha (IFN-alpha) in metastatic melanoma

Dacarbazine (DTIC) has been the mainstay of chemotherapy for metastatic melanoma for over two decades, but only 15%-20% of patients respond and benefit is usually transient. Randomized studies combining DTIC with interferon-alpha (IFN-alpha) in advanced disease have so far been inconclusive in terms of response and survival. We report a randomized prospective pilot Phase III trial of DTIC +IFN-alpha in patients with metastatic melanoma. The primary endpoint was death. A total of 61 patients were randomized between April 1995 and April 1998. Differences in survival between groups were assessed using log-rank analysis. Quality of life was measured using the European Organization for Research on Treatment of Cancer QLQ C30 (+3) questionnaire. Fifty-seven patients died during the study. The median survival for patients receiving DTIC was 7.2 months (95% confidence interval (CI) 4.4-9.0); it was 4.8 months for DTIC + IFN-alpha (95% CI 2.0-8.0). There was no significant difference in survival between the two treatment arms (chi2 unadjusted = 0.15, P = 0.70; chi2 adjusted = 0.01, P = 0.91). The 6-month survival of those patients randomized to DTIC alone was 58% compared with 40% for those patients randomized to DTIC + IFN-alpha. There were no differences in quality of life between treatment groups. This study failed to demonstrate a survival benefit for patients receiving IFN-alpha in combination with DTIC. These results are inconclusive primarily owing to the small size of the trial. A meta-analysis is required to determine whether there is a role for the addition of IFN-alpha to DTIC in the treatment of this disease.

Dealing with daily hassles: smoking and African-American adolescent girls

PURPOSE

To examine cigarette use and its relationship to daily life hassles in an urban sample of African-American adolescent girls.

METHODS

A sample of 105 African-American adolescent girls (mean age of 15.45 years) derived from a larger cross-sectional research project titled "Female Adolescent Substance Experience Study" funded by the National Institute of Drug Abuse comprised the sample. The sample was divided into adolescents who had ever smoked in their lifetime and adolescents who had never smoked before. Student's t-tests were conducted to determine whether there were differences between these groups on demographic characteristics and the number of daily life hassles. Pearson product moment correlations were also conducted to examine the association between age of smoking initiation and number of hassles.

RESULTS

Less than 50% of the teenagers had ever smoked cigarettes in their lifetime, and of those who had ever smoked, the average age of initiation was 12.55 years (SD = 2.63). Furthermore, girls who had ever smoked, in contrast to girls who had never smoked, had a significantly greater number of daily life hassles, in general, and within the school/academic and family/economic domains in particular. Age of smoking initiation was negatively related to the number of hassles, indicating that girls who started to smoke at a younger age reported more hassles.

CONCLUSIONS

These findings are discussed in terms of developing an understanding of gender and ethnic-specific correlates of smoking that can be used to better delineate the developmental smoking trajectory of African-American girls.

Social Isolation & Sexual Abuse Among Women Who Smoke Crack

The purpose of this study was to explore the prevalence of social isolation and its relationship to sexual trauma in a sample of Black women who smoke crack cocaine. Using a convenience sample of 115 Black women with a history of smoking crack cocaine, participants were interviewed for 2 to 4 hours and asked a variety of questions about their health, relationships, sexuality, and drug use. Bivariate and multivariate logistical regressions were used to predict whether the women reported being socially isolated. While social isolation was not necessarily a common experience among the sample, it was found that women who had been sexually abused were three times more likely to report being socially isolated than women who had not been sexually abused. In addition, social isolation was more common among women who had been abused by a family member, who had been abused when they were young, and who had been abused for a long period of time. However, multivariate analyses revealed that the age at which the sexual trauma occurred was the most salient predictor of social isolation in adulthood. Implications for drug treatment are discussed.

Presynaptic alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate receptor-mediated stimulation of glutamate and GABA release in the rat striatum in vivo: a dual-label microdialysis study

The existence of presynaptic alpha-amino-3-hydroxy-5-methyl-4-isoxazole propionate (AMPA)-type glutamate autoreceptors on glutamate nerve terminals in vitro has recently been demonstrated using synaptosomal and brain slice preparations. In the present study we have used a modification of a rapid dual-label intracerebral microdialysis method, previously developed by Young and co-workers(80,81) for the study of presynaptic mechanisms of neurotransmitter release, to investigate whether presynaptic AMPA receptors also play a role in the control of striatal glutamate release in vivo. For comparative purposes, the action of locally applied AMPA on striatal GABA release in vivo was also monitored. Local application of AMPA (0.01-100 microM), by reverse dialysis, into the striatum resulted in concentration-dependent increases in the Ca(2+)-dependent efflux of both [3H]L-glutamate and [14C]GABA. Maximum responses reached 142.0+/-6.5% and 166.8+/-7.7% of basal efflux for [3H]L-glutamate and [14C]GABA, respectively. No marked behavioural changes were observed at any dose of the agonist. Unexpectedly, the AMPA-evoked responses were not potentiated by the AMPA receptor desensitization inhibitors cyclothiazide (10-100microM) or aniracetam (1mM). Consistent with this finding, AMPA-stimulated [3H]L-glutamate and [14C]GABA efflux were significantly attenuated by co-perfusion with the selective, competitive AMPA receptor antagonist 6-nitro-7-sulphamoylbenzo(F)quinoxaline-2,3-dione (100microM) but not 1-(aminophenyl)-4-methyl-7,8-methylendioxy-5H-2,3-benzodiazepine (100microM), a non-competitive AMPA receptor antagonist known to interact with the cyclothiazide site to control AMPA receptor function. The broad spectrum ionotropic glutamate receptor antagonist, kynurenic acid (100-1000microM) also markedly inhibited the AMPA-evoked responses in the striatum in vivo. None of the antagonists, when given alone, influenced basal efflux of [3H]L-glutamate suggesting a lack of tonic regulatory control of glutamate release via presynaptic AMPA-type autoreceptors in the rat striatum. These results demonstrate the presence of presynaptic AMPA receptors, of a novel cyclothiazide- and aniracetam-insensitive subtype, on presynaptic nerve terminals in the rat striatum in vivo, acting to enhance glutamate and GABA release. Our data support the concept of AMPA receptor heterogeneity in vivo, a finding which may facilitate the development of novel, more selective drugs for the treatment of a range of neurological disorders associated with abnormal cerebral glutamate release. The pharmacological profile of these novel presynaptic receptors is currently under investigation.

Access conditions are crucial: comment on Lynch and Carroll (2001)

W. J. Lynch and M. E. Carroll (2001) sought to identify factors that control drug intake, that is, factors that decrease the avidity of drug seeking and drug taking while drug is obviously available. The review provides updated information about factors that regulate drug intake and a heuristic framework for future studies of regulatory processes throughout the natural history of a substance abuse disorder. In particular, the review suggests a productive framework for studies of transitions from early drug use to later abusive use. Forceful identification of factors that control the avidity of drug seeking and drug taking under the controlled conditions of the laboratory may encourage development of therapeutic interventions that capitalize on these factors for successful treatment of human drug abuse. Extending the analysis of regulation of intake to include factors that can be manipulated to reorganize behavior may improve the design of interventions to treat drug abuse.

Effect of radiographic quality on computer-assisted head penetration measurements

Even the most sophisticated computer-assisted radiographic techniques of measuring femoral head penetration into the polyethylene liner depend on the quality of the radiograph being evaluated, which varies greatly in clinical settings. The authors of this study sought to determine how the accuracy and reproducibility of three commercially available computer-assisted measurement systems differed when measuring optimal radiographs (with sharply defined component edges) and suboptimal radiographs (with less well defined edges). Using three computer-assisted measurement systems, the authors measured head penetration on simulated and clinical hip radiographs. All systems calculated head penetration as the movement of the head center relative to the cup center. To define the periphery of the prosthetic head and cup, one method (System One) used the human eye and a digitizing tablet, whereas the other two methods (System Two and System Three) used digital edge detection algorithms. For simulated hip radiographs, error was calculated as the absolute value of the difference between the known amount of head penetration, determined by a coordinate measuring machine, and the amount of penetration determined by the software. Three way analysis of variance showed a significant difference in absolute error among the three measurement techniques. System One had a significantly smaller absolute error (0.11 +/- 0.06 mm) than did System Two (0.25 +/- 0.25 mm) and System Three (0.19 +/- 0.13 mm). In addition, three-way analysis of variance showed that optimal radiographs were associated with a significantly lower absolute error (0.14 +/- 0.09 mm) than were suboptimal radiographs (0.23 +/- 0.22 mm). For optimal radiographs, there was no significant difference in error among the three measurement methods; all systems were accurate and reproducible. However, for suboptimal radiographs absolute error increased and varied widely, and a significant difference among the methods existed. These data show the susceptibility of head penetration measurements to radiographic technique and underscore the importance of good quality radiographs for all analyses of head penetration.