Bridging the Gap: Impact of dedicated post-discharge services on readmission rates and emergency department visits for psychiatrically hospitalized youth

BACKGROUND

For psychiatrically hospitalized youth, discharge care coordination can reduce suicide risk and rehospitalization, but studies on effective interventions or programs are sparse. This study aimed to examine the impact of a dedicated post-discharge bridging service including case management and therapeutic supports on readmissions and emergency department presentations.

METHODS

This retrospective cohort study compared emergency department mental health visits (EDMH) and psychiatric hospitalizations in the 60 days before the hospitalization which included referral to the bridging service, and in the 60 days post-hospitalization.

RESULTS

This diagnostically heterogeneous group of 238 youth had a mean age of 14 years and were of similar racial and ethnic background as the broader inpatient population. There was a nominal decrease in hospitalizations (p = 0.251), and a significant decrease in EDMH (p < 0.001) in the 60 days following referral to this program compared to the 60 days prior. Further, the proportion of patients with at least one EDMH or hospitalization decreased significantly before and after linkage with this service from 42.4% to 27.3% (p < 0.001).

CONCLUSION

Dedicated post-discharge bridging services including family-centered, flexible case management and therapeutic supports can reduce EDMH visits and potentially lower readmission for children and adolescents.

Double faecal immunochemical testing in patients with symptoms suspicious of colorectal cancer

BACKGROUND

Faecal immunochemical test (FIT)-directed pathways based on a single test have been implemented for symptomatic patients. However, with a single test, the sensitivity is 87 per cent at 10 µg haemoglobin (Hb) per g faeces. This aims of this study were to define the diagnostic performance of a single FIT, compared with double FIT in symptomatic populations.

METHODS

Two sequential prospective patient cohorts referred with symptoms from primary care were studied. Patients in cohort 1 were sent a single FIT, and those in cohort 2 received two tests in succession before investigation. All patients were investigated, regardless of having a positive or negative test (threshold 10 µg Hb per g).

RESULTS

In cohort 1, 2260 patients completed one FIT and investigation. The sensitivity of single FIT was 84.1 (95 per cent c.i. 73.3 to 91.8) per cent for colorectal cancer and 67.4 (61.0 to 73.4) per cent for significant bowel pathology. In cohort 2, 3426 patients completed at least one FIT, and 2637 completed both FITs and investigation. The sensitivity of double FIT was 96.6 (90.4 to 99.3) per cent for colorectal cancer and 83.0 (77.4 to 87.8) per cent for significant bowel pathology. The second FIT resulted in a 50.0 per cent reduction in cancers missed by the first FIT, and 30.0 per cent for significant bowel pathology. Correlation between faecal Hb level was only modest (rs = 0.58), and 16.8 per cent of double tests were discordant, 11.4 per cent in patients with colorectal cancer and 18.3 per cent in those with significant bowel pathology.

CONCLUSION

FIT in patients with high-risk symptoms twice in succession reduces missed significant colorectal pathology and has an acceptable workload impact.

Prefrontal feature representations drive memory recall

Memory formation involves binding of contextual features into a unitary representation1-4, whereas memory recall can occur using partial combinations of these contextual features. The neural basis underlying the relationship between a contextual memory and its constituent features is not well understood; in particular, where features are represented in the brain and how they drive recall. Here, to gain insight into this question, we developed a behavioural task in which mice use features to recall an associated contextual memory. We performed longitudinal imaging in hippocampus as mice performed this task and identified robust representations of global context but not of individual features. To identify putative brain regions that provide feature inputs to hippocampus, we inhibited cortical afferents while imaging hippocampus during behaviour. We found that whereas inhibition of entorhinal cortex led to broad silencing of hippocampus, inhibition of prefrontal anterior cingulate led to a highly specific silencing of context neurons and deficits in feature-based recall. We next developed a preparation for simultaneous imaging of anterior cingulate and hippocampus during behaviour, which revealed robust population-level representation of features in anterior cingulate, that lag hippocampus context representations during training but dynamically reorganize to lead and target recruitment of context ensembles in hippocampus during recall. Together, we provide the first mechanistic insights into where contextual features are represented in the brain, how they emerge, and how they access long-range episodic representations to drive memory recall.

Maternal and Child Health Pipeline Training Programs: A Description of Training Across 6 Funded Programs

Purpose

The HRSA-funded maternal and child health pipeline training programs (MCHPTPs) are a response to the critical need to diversify the MCH workforce, as a strategy to reduce health disparities in MCH populations. These MCHPTPs support students from undergraduate to graduate education and ultimately into the MCH workforce.

Description

The models and components of training across the six MCHPTPs funded in 2016–2021 are summarized, to examine the design and delivery of undergraduate pipeline training and the insights gained across programs.

Assessment

Strategies that emerged across training programs were organized into three themes: recruitment, support for student persistence (in education), and pipeline-to-workforce intentionality. Support for student persistence included financial support, mentoring, creating opportunity for students to develop a sense of belonging, and the use of research as a tool to promote learning and competitiveness for graduate education. Finally, the link to Maternal and Child Health Bureau (MCHB) long-term training and other MCHB opportunities for professional development contributed significant nuance to the pipeline-to-workforce objectives of these programs.

Conclusions

The MCHPTPs not only increase the diversity of the MCH workforce, they also actively prepare the next generation of MCH leaders. The intentional connection of undergraduates to the infrastructure and continuum of MCH training, underscores the comprehensive impact of this funding.

A Thalamic Orphan Receptor Drives Variability in Short-Term Memory

Working memory is a form of short-term memory that involves maintaining and updating task-relevant information toward goal-directed pursuits. Classical models posit persistent activity in prefrontal cortex (PFC) as a primary neural correlate, but emerging views suggest additional mechanisms may exist. We screened ∼200 genetically diverse mice on a working memory task and identified a genetic locus on chromosome 5 that contributes to a substantial proportion (17%) of the phenotypic variance. Within the locus, we identified a gene encoding an orphan G-protein-coupled receptor, Gpr12, which is sufficient to drive substantial and bidirectional changes in working memory. Molecular, cellular, and imaging studies revealed that Gpr12 enables high thalamus-PFC synchrony to support memory maintenance and choice accuracy. These findings identify an orphan receptor as a potent modifier of short-term memory and supplement classical PFC-based models with an emerging thalamus-centric framework for the mechanistic understanding of working memory.

A Metabolic Intravascular Platform to Study FDG Uptake in Vascular Injury

PURPOSE

Metabolic alterations underlie many pathophysiological conditions, and their understanding is critical for the development of novel therapies. Although the assessment of metabolic changes in vivo has been historically challenging, recent developments in molecular imaging have allowed us to study novel metabolic research concepts directly in the living subject, bringing us closer to patients. However, in many instances, there is need for sensors that are in close proximity to the organ under investigation, for example to study vascular metabolism.

METHODS

In this study, we developed and validated a metabolic detection platform directly in the living subject under an inflammatory condition. The signal collected by a scintillating fiber is amplified using a photomultiplier tube and decodified by an in-house tunable analysis platform. For in vivo testing, we based our experiments on the metabolic characteristics of macrophages, cells closely linked to inflammation and avid for glucose and its analog ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG). The sensor was validated in New Zealand rabbits, in which inflammation was induced by either a) high cholesterol (HC) diet for 16 weeks or b) vascular balloon endothelial denudation followed by HC diet.

RESULTS

There was no difference in weight, hemodynamics, blood pressure, or heart rate between the groups. Vascular inflammation was detected by the metabolic sensor (Inflammation: 0.60 ± 0.03 AU vs. control: 0.48 ± 0.03 AU, p = 0.01), even though no significant inflammation/atherosclerosis was detected by intravascular ultrasound, underscoring the high sensitivity of the system. These findings were confirmed by the presence of macrophages on ex vivo aortic tissue staining.

CONCLUSION

In this study, we validated a tunable very sensitive metabolic sensor platform that can be used for the detection of vascular metabolism, such as inflammation. This sensor can be used not only for the detection of macrophage activity but, with alternative probes, it could allow the detection of other pathophysiological processes.

Evaluation of a multispecies probiotic as a supportive treatment for diarrhea in dairy calves: A randomized clinical trial

The objectives of this randomized clinical trial were to determine whether the utilization of a multispecies probiotic bolus (MSP) in dairy calves with diarrhea led to a rapid resolution of diarrhea and improved average daily gain (ADG). Calves, from a convenience sample of dairy farms with diarrhea challenges, having fecal scores of ≥2 were randomly assigned to receive MSP or a placebo (PLB). The MSP bolus contained Pediococcus acidilactici, Enterococcus faecium, Lactobacillus acidophilus, Lactobacillus casei, Bifidobacterium bifidum, peptide extract, an enzyme blend, killed yeast extract, dried whey, and natural flavors (Revive, Partnar Animal Health, Ilderton, ON, Canada). The enrolled calves were fecal scored daily for 7 consecutive days and resolution of diarrhea was defined as having 2 consecutive days with a fecal score ≤1. Calves were also weighed at enrollment, 7, and 14 d following enrollment and ADG was calculated. A Cox proportional hazards model was built to investigate time to resolution of an abnormal fecal score. Two mixed linear regression models were created to evaluate the effect of treatment group on ADG in the first and second weeks following enrollment. A total of 148 calves were enrolled in the experiment and no differences were observed between the groups with respect to the age or weight at enrollment. The mean time to resolution of abnormal fecal score was 5.1 and 5.9 d in the MSP and PLB groups, respectively. In the Cox proportional hazards model, the calves in the MSP group had faster resolution of diarrhea when compared with the PLB group; however, an interaction between time from enrollment of the first calf and treatment group was present. No differences were found between the 2 groups with respect to ADG. This study demonstrates a multispecies probiotic and yeast bolus administered to calves at the onset of diarrhea reduced the duration of diarrhea; however, the clinical and economic relevance of this reduction requires further exploration.

Cancer-Related Stigma in South Africa: Exploring Beliefs and Experiences Among Cancer Patients and the General Public

Background: Stigma refers to a distinctive, discrediting characteristic, rendering its bearer tainted or inferior by others. Definitions of stigma acknowledge the recognition of difference; and devaluation. Evidence, largely from high-income countries suggests that cancer is a stigmatized disease. Cancer-related stigma is not well-documented in South Africa, and little is known about how it impacts health-seeking behavior, treatment adherence, quality of life and psychosocial well-being in cancer patients. Limited research has explored perceptions and cultural representations of cancer but an in-depth focus on this is lacking. This context-specific information is essential for relevant, effective intervention. Aim: This study aims to increase understanding of cancer-related stigma in South Africa and the role of cultural beliefs in contributing to this. Findings will be used to inform a larger study and ultimately, interventions to address cancer-related stigma in communities in which the Cancer Association of South Africa (CANSA) is working. Methods: This qualitative study was conducted in two provinces of South Africa, KwaZulu Natal and the Western Cape and included participants from a range of cultural and racial groups. Cancer patients over 18 years were recruited through CANSA's Service Delivery teams to participate in focus groups or one to one in depth interviews. Six focus groups and 40 in depth interviews were conducted with cancer patients. Data collection focused on understanding patient experiences of cancer stigma; cognitive, emotional and behavioral responses to this; and inputs on interventions to address this. Six focus groups were also conducted with noncancer patients recruited from local communities to explore cultural perceptions of cancer and reasons for stigmatization. Audio recordings were transcribed and translated; coded using NVivo 11; and analyzed by the authors using thematic analysis. Results: Results indicated very poor knowledge of cancer both in patients and nonpatients. Overwhelmingly, findings highlight the perception of cancer as a “death sentence”, influencing patients' experiences and responses of others in numerous ways. The influence of cultural beliefs was relevant, exacerbating stigma in some cases. The location of the cancer also played a role in determining level of stigmatization. Certain body parts (associated with masculine and feminine roles) as well as more visible cancers/side-effects were more stigmatised. Conclusion: Results indicate that stigmatization is a significant factor for cancer patients in South Africa, increasing social isolation and negatively impacting quality of life. The implications of the findings for intervention development will be discussed. Education is needed but requires a different focus for different cultural groups.

Fast size-determination of intact bacterial plasmids using nanofluidic channels

We demonstrate how nanofluidic channels can be used as a tool to rapidly determine the number and sizes of plasmids in bacterial isolates. Each step can be automated at low cost, opening up opportunities for general use in microbiology labs.

Visualizing the entire DNA from a chromosome in a single frame

The contiguity and phase of sequence information are intrinsic to obtain complete understanding of the genome and its relationship to phenotype. We report the fabrication and application of a novel nanochannel design that folds megabase lengths of genomic DNA into a systematic back-and-forth meandering path. Such meandering nanochannels enabled us to visualize the complete 5.7 Mbp (1 mm) stained DNA length of a Schizosaccharomyces pombe chromosome in a single frame of a CCD. We were able to hold the DNA in situ while implementing partial denaturation to obtain a barcode pattern that we could match to a reference map using the Poland-Scheraga model for DNA melting. The facility to compose such long linear lengths of genomic DNA in one field of view enabled us to directly visualize a repeat motif, count the repeat unit number, and chart its location in the genome by reference to unique barcode motifs found at measurable distances from the repeat. Meandering nanochannel dimensions can easily be tailored to human chromosome scales, which would enable the whole genome to be visualized in seconds.

Does feeding time affect fish welfare?

Increased aquaculture production has raised concerns about managing protocols to safeguard the welfare of farmed fish, as consumers demand responsible aquaculture practices to provide 'welfare friendly' products. Feeding is one of the largest production cost in a fish farm and can be one of the biggest stressors for fish. Under farming conditions, fish are challenged with artificial diets and feeding regimes, and inadequate feeding conditions cause stress, alteration of normal behavioural patterns, poor performance and eventually diseases and death, which are by no means acceptable neither economically nor ethically. This review aims to highlight the impact of feeding rhythms and feeding time upon physiological and behavioural welfare indicators, which show circadian rhythms as well. Therefore, all these variables should be considered when designing feeding strategies in farming conditions and assessing the welfare state of cultured fish.

Increase in de novo allergies after paediatric liver transplantation: the Brisbane experience

  Pediatric liver transplantation is a successful procedure with 10-yr survival rate of 70%; following transplantation, the emphasis on promoting good quality of life is important. The increasing prevalence of allergic disorders in the general population and an increase in food allergy following solid organ transplantation are described in patients, especially in children, but the contribution to morbidity post-OLT has not been addressed.

OBJECTIVES

Identifying the incidence de novo allergies post-OLT performed by QLTS over 11 yr.

METHODS

Comprehensive medical record review of OLT recipients during study period.

RESULTS

From 1st July 1998 to 1st August 2009, 78 children received 85 cadaveric OLT; 60 children survived. Allergic disease was documented in 24/60 (40%) survivors. De novo food allergies were diagnosed in 12/60 (20%) (Table 2), 9/12 occurred in children who were infants at time of transplant. Ten of 12 had severe allergies, six anaphylactic; 6/60 (10%) carry an EpiPen. Only 31/60 (51%) diagnosed are followed in Queensland, suggesting severe allergic disease in our cohort is an underestimate.

CONCLUSION

Serious allergic disease post-OLT is clinically important, especially in infants at time of transplant, and should be targeted for specialist allergist referral and risk management. [Table: see text].

Audit of eosinophilic oesophagitis in children post-liver transplant

Pediatric liver transplantation has proven so successful that 10-yr survival post-transplantation is in excess of 70% and following transplantation, emphasis of medical care switches from life saving to promotion of good quality of life. EE is an increasingly recognised phenomenon in the general population. Eosinophilic disorders of the GI tract are increasingly recognised in patient's post-solid organ transplantation but the contribution of EE to morbidity in this population has not been addressed to date. The objective of this study was to identify the incidence of EE in children receiving liver transplantation by the QLTS over the last 15.5 yr. Comprehensive review of medical records of all liver transplant recipients during study period via cross-checking procedural and electronic laboratory results was performed. All oesophageal biopsies reporting mucosal inflammation were reviewed. EE can be diagnosed when oesophageal biopsy reveals > or =5 eosinophils per HPF; however, we used a cut-off of 20 eosinophils per HPF, which is in accordance with current opinion. In the 159 children who received DD OLT, 130 survived and four have been diagnosed with EE (3%). Only 34 are currently followed in Queensland and all four patients diagnosed are in this cohort representing 12% of our follow-up clinic. Many patients are followed elsewhere so occurrence of EE in our total surviving population is an underestimate. EE is clinically important in the post-liver transplant community. Children post-OLT who have upper GI symptoms should be considered for endoscopic evaluation and biopsy to exclude EE.

Understanding Parkinson's disease

This article describes the signs and symptoms of Parkinson's disease and the complications that arise as the condition progresses. Motor and non-motor symptoms are discussed as well as the problems that patients experience on admission to hospital. The complexities of medication management--including issues of concordance--are outlined and advice is given on how nurses can help patients and their carers to manage this condition.

The effect of social demographic factors, snack consumption and vending machine use on oral health of children living in London

OBJECTIVE

To investigate the effect of socio-economic status, sugar, snack consumption and vending machine use on the prevalence and severity of caries (DMF) in children.

DESIGN

An observational study was carried out in a dental practice in inner city London. Sixty children were asked to complete a questionnaire and a three day food and drink diary. After a dental examination the number of decayed (D), missing (M) or filled (F) teeth provided a DMF score. Anova and Pearsons correlations were used to analyse the data statistically.

RESULTS

Children from social groups I and II consumed significantly less (P < 0.05) sugar, confectionery, crisps and used a vending machine less often than children from other social groups. Children from Social groups I, II and III had significantly lower DMF scores. The average DMF from social group I children was 0.5 +/- 0.6, whilst group IV children had the greatest incidence and a DMF of 4.6 +/- 0.8. Significant correlations were identified between DMF and sugar, confectionery and crisp consumption and vending machine use, and a negative correlation between DMF and vegetable consumption.

CONCLUSIONS

Socio-economic status and access to vending machines were found to have a significant effect on sugar intakes, foods choices, and dental health. The removal of vending machines from schools or at least installing 'healthy' vending machines is recommended. Health promotion programmes that account for social groups and snacking habits that are cost effective are required.

The role of acidic organelles in the development of schistosomula of Schistosoma mansoni and their response to signalling molecules

The cercariae of Schistosoma mansoni become transformed into schistosomula during host skin penetration. We have found that large acidophilic compartments are detected in schistosomula but not in cercariae or in any other stages of the parasite by use of the fluorescent dye LysoTracker, a dye specific for mammalian lysosomes. Some of these large acidic compartments incorporated monodansylcadaverine, a specific dye for autophagosomes. We have used potent inhibitors (wortmannin and 3-methyladenine) and a potent inducer (starvation) of autophagy to show that the pathway to the formation of the acidic compartments requires specific molecular signals from the environment and from the genome. Certain doses of ultraviolet light inhibited significantly the formation of the acidic compartments, which may indicate disruption of the lysosome/autophagosome pathway. We have also defined two proteins that are commonly associated with lysosomes and autophagosomes in mammalian cells, the microtubule-associated membrane protein (MAP-LC3) and lysosome-associated membrane protein (LAMP-1), in extracts of schistosomula. We suggest that the autophagy pathway could be developed in transformed schistosomula.

Percutaneous resection of renal cysts

Symptomatic renal cysts can be managed endoscopically via retrograde ureterorenoscopy, antegrade percutaneous nephroscopy, or laparoscopy. Although all three methods are minimally invasive and effective, the retrograde approach is limited by the size and location of the cyst. Laparoscopy is also effective but is associated with multiple port sites, extensive dissection, and technical difficulty. We utilize percutaneous trans-parenchymal endocystolysis as a first-line therapy. The technique is described in detail.

Bilingual health communicators: role delineation issues

Managers of health care services are seeking new opportunities to improve communication with clients who have limited English proficiency. An increase in bilingual health staff and the frequent use of their language skills in patient encounters provides opportunities but also brings with it confusion surrounding the role of interpreters and bilingual health staff. Secondary analysis of transcripts from 18 focus groups with monolingual and bilingual health staff has provided a method of distinguishing the roles of these complementary communicators. This paper clarifies the roles of interpreters and bilingual communication facilitators using seven key features: scope of language, language proficiency, nature of communication/interaction, nature of the contact and relationship, client responsibilities, and relationship with other health care providers. We discuss differences in how bilingual health staff use language when providing care, and alternative types of interactions interpreters could adopt to extend their current role. A collaborative group of communicators located within a health team is proposed, that is able to identify need and select the best communicator for the task.

Evaluation of pulsed-field gel electrophoresis in epidemiological investigations of meningococcal disease outbreaks caused by Neisseria meningitidis serogroup C

Since 1990, the frequency of Neisseria meningitidis serogroup C (NMSC) outbreaks in the United States has increased. Based on multilocus enzyme electrophoresis (MEE), the current molecular subtyping standard, most of the NMSC outbreaks have been caused by isolates of several closely related electrophoretic types (ETs) within the ET-37 complex. We chose 66 isolates from four well-described NMSC outbreaks that occurred in the United States from 1993 to 1995 to evaluate the potential of pulsed-field gel electrophoresis (PFGE) to identify outbreak-related isolates specific for each of the four outbreaks and to differentiate between them and 50 sporadic isolates collected during the outbreak investigations or through active laboratory-based surveillance from 1989 to 1996. We tested all isolates collected during the outbreak investigations by four other molecular subtyping methods: MEE, ribotyping (ClaI), random amplified polymorphic DNA assay (two primers), and serotyping and serosubtyping. Among the 116 isolates, we observed 11 clusters of 39 NheI PFGE patterns. Excellent correlation between the PFGE and the epidemiological data was observed, with an overall sensitivity of 85% and specificity of 71% at the 95% pattern relatedness breakpoint using either 1.5 or 1.0% tolerance. For all four analyzed outbreaks, PFGE would have given public health officials additional support in declaring an outbreak and making appropriate public health decisions.

Parkinson's disease: the challenge

Parkinson's disease is a chronic and degenerative condition. Rather than effecting a cure, the nurse's role in caring for those with this condition is to enable them to live as independent a life as possible.

Towards culturally competent health care: language use of bilingual staff

The presence of diverse language skills within health staff provides opportunities to better meet the needs of a multicultural population. A cross-sectional survey of all staff within the South Western Sydney Area Health Service was undertaken to compare language skills with population needs and examine the context of language use. Thirty-one per cent of staff (n = 964) were bilingual or multilingual, with the predominant languages spoken being Tagalog (Filipino), Cantonese, Hindi, Spanish, Vietnamese and Italian. Thirty-seven per cent of bilingual staff used their language skills at least weekly, predominantly in situations of simple conversation and giving directions. Bilingual staff are a valuable resource for the organisation and the presence of a similar overall proportion of bilingual and bicultural staff may engender tolerance and adaptability in providing care to a diverse population. However, supply does not directly match community demand. This mismatch will continue unless recruitment is focused towards identified language groups. The high proportion of staff who rarely used their language skills (37%) may be due to lack of opportunity or limited need, and suggests that further research needs to examine service models that locate bilingual workers close to client need. This study takes a crucial first step towards realising equitable and culturally appropriate care utilising the principles of productive diversity.

Longitudinal changes in body composition measured with a variety of methods in patients with AIDS

We test the hypothesis that human immunodeficiency virus (HIV)-related weight loss is accompanied by inappropriately large losses of fat-free mass (FFM). Our secondary aims were to examine whether FFM increases during weight gain and to compare several techniques for measuring FFM change. FFM was measured at intervals averaging 5 months in 21 AIDS patients by means of skinfold thickness (SF), dual-energy x-ray absorptiometry (DEXA), total body water (TBW), and bioelectrical impedance using the equation of the manufacturer of the equipment (BIA(EZComp)) and a published prediction equation (BIA(Segal)). The FFM content of weight loss was similar for SF (57%), DEXA (60%), TBW (55%) and BIA(EZComp) (65%), but the result from BIA(Segal) (78%) was higher. The results were close to predicted starvation values apart from the results with BIA(Segal), which were significantly higher than predicted values. Weight gain was also composed of a large proportion of FFM. There were large intermethod differences in measurements of absolute FFM, but for measuring changes in FFM, the bias between SF, DEXA, and TBW was minimal. The results of BIA vary with the prediction equation used. In this group of patients with the acquired immune deficiency syndrome (AIDS), weight loss was composed of a large proportion of FFM, but in general this is compatible with undernutrition as the underlying cause and does not support the hypothesis of excessive FFM catabolism in HIV disease. SF, DEXA, TBW, and BIA(Segal) show reasonable agreement for measuring body composition changes. This information should be considered in the design of future intervention studies for HIV-related wasting.

Energy expenditure and wasting in human immunodeficiency virus infection

BACKGROUND

Increased expenditure of energy at rest has been considered a contributing factor to the negative energy balance and weight loss that occur in patients with human immunodeficiency virus (HIV) infection. However, the true determinant of energy balance is not resting but total energy expenditure. We sought to determine the contribution of total energy expenditure to weight changes in patients with HIV-associated wasting.

METHODS

We performed 51 assessments of energy metabolism in 27 men with HIV infection at different stages of disease, including periods of both rapid and slow weight loss. Resting energy expenditure was measured by indirect calorimetry, total energy expenditure by the doubly-labeled-water technique, and energy intake by recording the weight of food consumed. The results were compared with the rate of weight loss or gain.

RESULTS

The mean (+/- SD) total energy expended by the HIV-infected men was 2750 +/- 670 kcal per day, no more than that expended by normal men. There was a significant positive relation between total energy expenditure and the rate of weight change (r = 0.61, P < 0.001); thus, during rapid weight loss, total energy expenditure was reduced to 2180 +/- 580 kcal per day (P = 0.009), primarily because of reduced physical activity. During rapid weight loss, the negative energy balance (-850 +/- 580 kcal per day) was primarily the result of the reduction in energy intake, to 1330 +/- 610 kcal per day; intake correlated strongly with the rate of weight change (r = 0.84, P < 0.001).

CONCLUSIONS

In patients with HIV infection, total energy expenditure is reduced during episodes of weight loss. Reduced energy intake, not elevated energy expenditure, is the prime determinant of weight loss in HIV-associated wasting.

Long term effects of early nutritional support with new enterotropic peptide-based formula vs. standard enteral formula in HIV-infected patients: randomised prospective trial

This paper describes a prospective trial of a new peptide based formula (NEF) compared with a standard enteral formula (SEF) in the management of weight loss in people with HIV infection. 80 largely asymptomatic patients were randomised to receive 2-3 8 oz cans of either the NEF or SEF supplement. Outcome measures included adherence, weight change, anthropometric measurements, serum biochemistry, gastrointestinal symptoms, physical performance and intercurrent health events and were assessed at baseline, 3 and 6 month intervals. For the 56 evaluable patients those receiving the NEF supplement maintained body weight better (p = 0.04), had more stable triceps skinfold measurements (p = 0.03), lower blood urea nitrogen (p = 0.04), and reduced hospitalisation during the 3-6 month evaluation period (p = 0.02) than those consuming the SEF supplement. The NEF supplement was well tolerated and did not result in untoward clinical effects. These data suggest that the supplemental use of a NEF provides superior nutritional management compared to an SEF for patients with early stage HIV infection.

Prospective analysis of patterns of weight change in stage IV human immunodeficiency virus infection

Weight loss is a major manifestation of infection with the human immunodeficiency virus (HIV). Prospective analysis of weight change was performed in 30 male subjects with stage IV HIV infection over a period of 9-49 mo and weight change events (> 4 kg) related to contemporaneous clinical events. Two distinct patterns of weight loss were observed: episodes of acute severe weight loss and episodes of chronic unremitting progressive weight loss. Thirty-three acute episodes (median 9.1 kg in 1.7 mo) and 23 chronic episodes (13.2 kg in 9.5 mo) were identified. Twenty-seven of 33 (82%) acute weight-loss episodes were associated with nongastrointestinal opportunistic infections and 15 of 23 (65%) chronic episodes with gastrointestinal disease (P < 0.01). Weight loss was neither inevitable nor unremitting. Periods of weight stability (> 4 mo) occurred in 13 individuals (43%); 35 episodes of weight gain were identified, mostly related to recovery from opportunistic infection. These findings have important implications for our understanding of the natural history of weight loss in HIV infection.

Iron status, energy intake, and nutritional status of healthy young Asian children

The iron status, dietary intake, and protein energy nutritional status of healthy Asian children ranging in age from 4 to 40 months was investigated. The serum ferritin, erythrocyte zinc protoporphyrin, haemoglobin and mean corpuscular haemoglobin concentrations, and mean corpuscular volume were determined in a community study of 138 children. Protein energy nutritional status was estimated by anthropometry and a four or five day weighed dietary inventory was completed by 97 children. Concentrations of the serum ferritin, haemoglobin, and mean corpuscular haemoglobin, and the mean corpuscular volume decreased progressively with increasing age. The mean values for these four indices were significantly lower in toddlers between 21 and 23 months age than in infants less than 6 months old. The mean erythrocyte zinc protoporphyrin was high in the first six months, later falling and rising again to peak in the 21 to 23 month age group. Thirty five per cent of children were iron deficient (serum ferritin concentration less than 10 micrograms/l) and low values for the mean corpuscular volume and mean corpuscular haemoglobin were observed in 33% and 35% respectively and 17% were anaemic (haemoglobin concentration less than 110 g/l). No association was observed between biochemical iron status and the dietary intake of energy or iron. Nor was there an association between protein energy nutritional status and iron status. Screening for iron deficiency in communities at risk is recommended and nutrition education using trained link workers is preferred to prophylactic iron treatment.

Are nurses good patient educators?

Health care demands are rising rapidly as we move towards the year 2000 and effective health education is essential if increasing numbers of patients are to be nursed in the community and the effects of preventable illnesses are to be minimized. It is therefore extremely pertinent to discuss how well nurses are educating their patients at present and what strategies the profession may need to consider in order to meet educational needs of the future. It seems clear that nurses have a responsibility to provide the information that their patients require, although there remains some debate regarding whether they are the most appropriate member of the health care team to do so. Recent studies show that nurses can be effective educators. However, although many recognize the importance of this role, they still often lack the skills, knowledge, motivation and support required to organize and implement an adequate programme of patient education.