Multidisciplinary Provision of Food and Nutritional Care to Hospitalized Adult In-Patients: A Scoping Review

PURPOSE

Multidisciplinary approaches to nutritional care are increasingly emphasized and recommended. However, there is little evidence of how different disciplines work together collaboratively to deliver optimum quality care to adult in-patients. This scoping review aimed to describe the existing literature on multidisciplinary collaboration to identify the various disciplines involved and the features that influence collaborative working in implementing multidisciplinary food and nutritional care with adult in-patients.

METHODS

Multiple databases were searched, including MEDLINE Complete, Embase, CINAHL Complete, HMIC, and Scopus, from their inception to December 2019. Data were retrieved from eligible studies. A narrative description of findings is reported with respect to the disciplines involved, the aspects of nutritional care explored, and the collaborative processes categorized using the input, process, and outcome framework.

RESULTS

Thirty-one studies with heterogeneous study designs met the eligibility criteria. Studies were undertaken in six countries. Findings show a wide diversity of multidisciplinary collaborations in various aspects of nutritional care in all studies. Multidisciplinary nutritional care provision was facilitated by several processes, including training and development, communication and information sharing, and clinical leadership and management support. Outcomes were reported at the patient, team, and organizational levels.

CONCLUSION

This review reveals the significance of the interrelationship between different disciplines and their complementary contributions towards the delivery of optimal food and nutritional care. Key aspects include the involvement of different disciplines, the clarification of roles and multidisciplinary interrelationships, communication, information sharing, clinical leadership, and management support, all of which facilitated collaborative working. Our review uncovered that these features can significantly influence multidisciplinary working. This review is the first to present literature concerning the attributes that affect collaborative working. Further research is recommended specifically around multidisciplinary nutritional care processes and conditions that allow for better collaborative working.

Effective detection and identification of sheath-tailed bats of Australian forests and woodlands

Assessing the risk to threatened species of population decline from anthropogenic disturbances is challenging when there are issues with species identification, and little is known of their biology, distribution, population size, and habitat preference. The bare-rumped sheath-tailed bat (Saccolaimus saccolaimus) is one such species that has a poorly defined distribution over two broad areas of northern Australia. Environmental impact assessments are expected to consider the possibility of its presence in intervening areas outside the known distributions. Our study presents new empirical data that can assist with detection of S. saccolaimus across the entire expanse of northern Australia, provides a critical analysis of acoustics-based identification of the species, and assessed presence within the potentially high value habitat of tall Eucalyptus tetrodonta-dominated forest on the western side of Cape York Peninsula using a combination of trapping and acoustic recordings. Capture of other Saccolaimus species was the greatest of any survey conducted to date in Australia, demonstrating that the capture of these high-flying bat species in tall forest habitats can be relatively effective with mist net arrays hoisted into the tree canopy. In addition, reference echolocation call collections from the focal trapping area plus other locations across northern Australia allowed characterisation and comparison of the calls of most low-frequency-emitting (LFE) echolocating bat species of northern Australia. In addition to separation of species-specific search phase call types using multivariate statistics, a compilation of features from search phase, approach phase and feeding buzz echolocation calls will help distinguish S. saccolaimus from most other LFE species. However, the similarity of the echolocation calls of S. mixtus and S. saccolaimus prevented them from being distinguished from one another. A multi-method approach that emulates the present study and incorporates our recommendations and cautions will lead to robustness in ecological studies and greater clarity in environmental impact assessments.

P2649Do these data apply to me? Examining the applicability of trials assessing strategies for optimal management of blood pressure to older patients in UK primary care

Background

There is debate as to what extent older patients (≥80 years) should be treated for high blood pressure. Existing trials show that blood pressure lowering in this population is effective at preventing stroke and heart failure but also results in an increased risk of adverse events. However, it has been suggested that these studies enrolled healthier patients, who are less representative of the general population and more likely to benefit from treatment.

Purpose

This study aimed to compare the characteristics of patients eligible for three blood pressure management trials and assess the likelihood of eligibility for each trial based on common characteristics of older patients.

Methods

Cross-sectional study of data extracted from the medical records of 15,376 patients aged ≥80 years, registered to 24 general practices in the south of England. Anonymised patient data relating to the eligibility criteria for two previous medication intensification trials (HYVET, SPRINT) and one medication reduction trial (OPTiMISE) were extracted. Patients eligible for each trial were defined according to criteria specified in each trial protocol. Descriptive statistics were used to define the characteristics of each trial population. A logistic regression model was constructed to estimate predictors of eligibility for each trial, with practice included as a random effect.

Results

Approximately 268 (1.7%), 5,290 (34.4%) and 3,940 (25.6%) patients were eligible for HYVET, SPRINT and OPTiMISE trials respectively. There was little overlap in eligibility for each trial (1.0% were eligible for HYVET and SPRINT; 0% were eligible for HYVET and OPTiMISE; 10.2% were eligible for SPRINT and OPTiMISE). Patients eligible for OPTiMISE were comparable to the general population in terms of frailty (eFI 0.12 [OPTiMISE] vs 0.11 [general population]), but had more morbidities (4 vs 3) and cardiovascular medications prescribed (4 vs 2). Patients in HYVET and SPRINT were less frail, multi-morbid and prescribed less cardiovascular medications. Overall, increasing frailty and a history of cardiovascular disease reduced the likelihood of being eligible for any trial.

Conclusions

Patients eligible for OPTiMISE appear to best represent the population aged ≥80 years attending UK primary care. Increasing frailty and/or multi-morbidity reduce the likelihood of eligibility for all three blood pressure trials. Caution should be exercised when applying the results from randomised controlled trials to management of blood pressure in frail and multi-morbid patients.

Acknowledgement/Funding

This study was funded by the National Institute for Health Research (NIHR) SPCR and Oxford CLAHRC

Biological Effects of Mount Saint Helens Volcanic Ash on Cultured Human Alveolar Macrophages

Free alveolar macrophages (FAMs) obtained by bronchoalveolar lavage from healthy nonsmoking volunteers were incubated with varying concentrations (0–300 μg/ml) of Mt. Saint Helens volcanic ash obtained from either Portland, Oregon, or Pullman, Washington, to assess the cytotoxic effects of the ash on human lung cells. Trypan dye exclusion techniques were employed for assessment of cell viability. Following the initial 24 hour culture with the Portland ash samples, decreased viability was observed at all ash concentrations (P < 0.001 in all instances), and further decreases in viability were noted at 48 and 72 hours for all concentrations of ash tested (P < 0.001 in all instances). When the Pullman, Washington, ash sample was evaluated, a decrease in cell viability was noted for the 300 μg/ml concentration (P < 0.017) after the initial 24 hours in culture. Further decreases in cell viability were noted only when cells were cultured for longer time intervals (48 and 72 hours) (P < 0.05 in all instances). Differences in cellular response to the 2 ash samples were further investigated by exposing FAMs from a single individual to the 2 different types of ash. These studies demonstrated similar cytotoxic effects of the 2 ash samples at all concentrations and times tested (P < 0.30 in all instances) with the exception of the 100 μg/ml concentrations at 72 hours (P < 0.020). These data suggest that the differences observed between the 2 types of ash in the independent studies are probably related to interindividual variation in FAM response to the ash rather than to differences in the cytotoxicities of the 2 ash samples. Cytotoxicity of the volcanic ash was also compared with other environmentally relevant airborne particulates, such as amosite and chrysotile asbestos, as well as amorphous and crystalline silica. These results demonstrated an intermediate cytotoxic effect of the ash between innocuous amorphous silica and the very cytotoxic chrysotile asbestos. The affinity for volcanic ash to adsorb tritiated benzo(a)pyrene (3H-BaP) was also compared with that of amorphous silica and amosite asbestos. These studies demonstrate that volcanic ash has intermediate adsorption qualities (4.3 ± 0.1; pmoles 3H-BaP adsorbed/μg particulate ± SD) between those of amorphous silica (1.9 ± 1.0) and amosite asbestos (7.8 ± 1.2) (P < 0.05 in all instances). These data suggest volcanic ash exhibits moderate biological properties compared with those of other environmentally important airborne particulates. Whether in vitro studies reflect in vivo response of human lung cells to the ash cannot be determined at this time, and follow-up of assessment of individuals exposed to the ash will be required to assess its long-term effects on pulmonary tissue.

Extending the clinical research network approach to all of healthcare

The development of Clinical Research Networks (CRN) has been central to the work conducted by Health Departments and research funders to promote and support clinical research within the NHS in the UK. In England, the National Institute for Health Research has supported the delivery of clinical research within the NHS primarily through CRN. CRN provide the essential infrastructure within the NHS for the set up and delivery of clinical research within a high-quality peer-reviewed portfolio of studies. The success of the National Cancer Research Network is summarized in Chapter 5. In this chapter progress in five other topics, and more recently in primary care and comprehensively across the NHS, is summarized. In each of the 'topic-specific' networks (Dementias and Neurodegenerative Diseases, Diabetes, Medicines for Children, Mental Health, Stroke) there has been a rapid and substantial increase in portfolios and in the recruitment of patients into studies in these portfolios. The processes and the key success factors are described. The CRN have worked to support research supported by pharmaceutical, biotechnology and medical device companies and there has been substantial progress in improving the speed, cost and delivery of these 'industry' studies. In particular, work to support the increased speed of set up and delivery of industry studies, and to embed this firmly in the NHS, was explored in the North West of England in an Exemplar Programme which showed substantial reductions in study set-up times and improved recruitment into studies and showed how healthcare (NHS) organizations can overcome delays in set up times when they actively manage the process. Seven out of 20 international studies reported that the first patient to be entered anywhere in the world was from the UK. In addition, the CRN have supported research management and governance, workforce development and clinical trials unit collaboration and coordination. International peer reviews of all of the CRN have been positive and resulted in the continuation of the system for a further 5 years in all cases.

Impact of model perfumes on surfactant and mixed surfactant self-assembly

The impact of some model perfumes on surfactant self-assembly has been investigated, using small-angle neutron scattering. A range of different model perfumes, with differing degrees of hydrophilicity/hydrophobicity, have been explored, and in order of increasing hydrophobicity include phenyl ethanol (PE), rose oxide (RO), limonene (LM), linalool (LL), and dihydrogen mercenol (DHM). The effect of their solubilization on the nonionic surfactant micelles of dodecaethylene monododecyl ether (C12EO12) and on the mixed surfactant aggregates of C12EO12 and the cationic dialkyl chain surfactant dihexadecyl dimethyl ammonium bromide (DHDAB) has been quantified. For PE and LL the effect of their solubilization on the micelle, mixed micelle/lamellar and lamellar regimes of the C12EO12/DHDAB mixtures, has also been determined. For the C12EO12 and mixed DHDAB/C12EO12 micelles PE is solubilized predominantly at the hydrophilic/hydrophobic interface, whereas the more hydrophobic perfumes, from RO to DHM, are solubilized predominantly in the hydrophobic core of the micelles. For the C12EO12 micelles, with increasing perfume concentration, the more hydrophobic perfumes (RO to DHM) promote micellar growth. Relatively modest growth is observed for RO and LM, whereas substantial growth is observed for LL and DHM. In contrast, for the addition of PE the C12EO12 micelles remain as relatively small globular micelles, with no significant growth. For the C12EO12/DHDAB mixed micelles, the pattern of behavior with the addition of perfume is broadly similar, except that the micellar growth with increasing perfume concentration for the more hydrophobic perfumes is less pronounced. In the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram, the addition of PE results in a less structured (less rigid) lamellar phase, and ultimately a shift toward a structure more consistent with a sponge or bicontinuous phase. In the mixed L1/Lbeta region of the phase diagram PE induces a slight shift in the coexistence from Lbeta toward L1. The addition of LL to the Lbeta (Lv) region of the DHDAB-rich C12EO12/DHDAB phase diagram also results in a reduction in the lamellar structure (less rigid lamellae), and a shift toward a structure more consistent with a sponge or bicontinuous phase, or a coexisting phase of small vesicles. For the mixed L1/Lbeta region of the phase diagram LL induces a shift toward a greater L beta component.

Impact on patients' health status following early identification of a COPD exacerbation

The current study aimed to assess the impact on patient health status during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A total of 421 COPD patients were enrolled in a multicentre, single-arm study with a 6-month observational follow-up period. Patients received two inhalations of Symbicort 200 Turbuhaler(R) twice a day. Patients were assessed before the run-in period, at baseline and at 1, 3 and 6 months. Patients were instructed to report a change in respiratory symptoms lasting >24 h. This defined an AECOPD. In addition to the initial call, the St George's Respiratory Questionnaire (SGRQ), COPD Control Questionnaire (CCQ), Medical Research Council (MRC) dyspnoea scale and activities of daily living (ADL) were completed at 5-7 and 12-14 days. A group of 176 patients reported at least one AECOPD. Exacerbations were associated with statistically significant mean changes (worsening) in the SGRQ activity and impact domains at onset (mean +/- sd 12.1 +/- 18.1 and 14.0 +/- 15.2), during the first (9.8 +/- 19.0 and 9.4 +/- 16.6) and second weeks (3.1 +/- 15.5 and 3.3 +/- 14.7). Clinically significant deterioration in SGRQ impact scores was shown in 71% of patients following early identification, with 55 and 37% during the first and second weeks of an AECOPD, respectively. Acute exacerbation severely impacts on health status. The current study provides valuable information on the change in health status during an acute exacerbation of chronic obstructive pulmonary disease that can be utilised for future trials that evaluate therapeutic intervention.

The Microstructure of Di-alkyl Chain Cationic/Nonionic Surfactant Mixtures: Observation of Coexisting Lamellar and Micellar Phases and Depletion Induced Phase Separation

The evolution of the microstructure and composition occurring in the aqueous solutions of di-alkyl chain cationic/nonionic surfactant mixtures has been studied in detail using small angle neutron scattering, SANS. For all the systems studied we observe an evolution from a predominantly lamellar phase, for solutions rich in di-alkyl chain cationic surfactant, to mixed cationic/nonionic micelles, for solutions rich in the nonionic surfactant. At intermediate solution compositions there is a region of coexistence of lamellar and micellar phases, where the relative amounts change with solution composition. A number of different di-alkyl chain cationic surfactants, DHDAB, 2HT, DHTAC, DHTA methyl sulfate, and DISDA methyl sulfate, and nonionic surfactants, C12E12 and C12E23, are investigated. For these systems the differences in phase behavior is discussed, and for the mixture DHDAB/C12E12 a direct comparison with theoretical predictions of phase behavior is made. It is shown that the phase separation that can occur in these mixed systems is induced by a depletion force arising from the micellar component, and that the size and volume fraction of the micelles are critical factors.

CHHIPS (Controlling Hypertension and Hypotension Immediately Post-Stroke) Pilot Trial: rationale and design

RATIONALE

High and low blood pressure (BP) levels are common following acute stroke, with up to 60% of patients being hypertensive (SBP > 160 mmHg) and nearly 20% having relative hypotension (SBP < or = 140 mmHg), within the first few hours of ictus, both conditions being associated with an adverse prognosis. At present, the optimum management of blood pressure in the immediate post-stroke period is unclear.

OBJECTIVE

The primary aim of the Controlling Hypertension and Hypotension Immediately Post-Stroke (CHHIPS) Pilot Trial is to assess whether hypertension and relative hypotension, manipulated therapeutically in the first 24 h following acute stroke, affects short-term outcome measures.

DESIGN

The CHHIPS Pilot Trial is a UK based multi-centre, randomized, double-blind, placebo-controlled, titrated dose trial.

SETTING

Acute stroke and medical units in teaching and district general hospitals, in the UK.

PATIENTS

The CHHIPS Pilot Study aims to recruit 2050 patients, with clinically suspected stroke, confirmed by brain imaging, who have no compelling indication or contraindication for BP manipulation.

STUDY OUTCOMES

The primary outcome measure will be the effects of acute pressor therapy (initiated < or = 12 h from stroke onset) or depressor therapy (started < or = 24 h post-ictus) on death and dependency at 14 days post-stroke. Secondary outcome measures will include the influence of therapy on early neurological deterioration, the effectiveness of treatment in manipulating BP levels, the influence of time to treatment and stroke type on response and a cost-effectiveness analysis.

Morbidity and Irish Catholic descent in Britain. Relating health disadvantage to socio-economic position

In common with some other ethnic and religious minorities whose forebears migrated from their country of origin, Irish Catholics in Britain are less well off than the host population in terms of socio-economic position and health. Results are presented from a Scottish study, where Catholic religion of origin mainly indicates Irish ancestry, and it is estimated that about one-third of the population is of significant Irish descent. In this study, excess of physical and mental health problems and disability have previously been reported for those of Catholic background, particularly in the eldest cohort (aged 56 in 1988), and have not been fully explained by health-related behaviour. In this paper, we examine a number of key health measures, namely self-assessed health, number of symptoms in the month prior to interview, sadness or depression, disability and lung function, and various indicators of socio-economic position (head of household social class, main source of income, car ownership, housing tenure and school-leaving age), which all show Catholic disadvantage. Using longitudinal results from the 723 respondents who completed interviews both at sweeps one (1988) and three (1995), it is estimated that about half of the morbidity excess amongst middle-aged Catholics in Glasgow can be explained by socio-economic disadvantage. The health and socio-economic position of white minorities and disadvantaged religious minorities like Catholics in Scotland should be monitored by a co-ordinated information strategy.

Children followed with difficulty: how do they differ?

OBJECTIVE

To determine if very low birthweight children followed with ease differ in any perinatal or sociodemographic characteristics, or outcomes, compared with children followed with more difficulty.

METHODOLOGY

Consecutive children of birthweight < 1000 g or with gestational ages < 28 weeks born in 1991 (n = 51) or of birthweight < 1500 g born in 1992 (n = 166) at the Royal Women's Hospital, Melbourne, surviving to 5 years of age, were assessed at 5 years of age, corrected for prematurity. Those who attended on the first mutually agreed appointment without substantial reluctance were considered to have been followed with ease. The remainder were considered to have been followed with difficulty. Outcomes included impairments such as cerebral palsy, blindness, deafness, and low IQ. Children had a disability if they had any of cerebral palsy, blindness, deafness requiring amplification, or an IQ more than 1 SD below the mean.

RESULTS

Of the 217 survivors, 204 (94%) were assessed fully at 5 years of age. Of the 204 children assessed, 153 (75%) were followed with ease, and 51 (25%) with difficulty. Of data available in the perinatal period, significantly fewer children followed with more difficulty came from intact families, and more of their mothers had fewer than 12 years of schooling. More children followed with difficulty had a disability (41% compared with 19%), as they predominantly had lower IQ scores (mean difference in IQ - 12.7, 95% confidence interval - 18.0, - 7.4). The association between difficulty of assessment and both higher rates of disability and lower IQ scores remained after adjustment for significant perinatal and sociodemographic variables.

CONCLUSIONS

Children followed with difficulty can partly be recognized on several sociodemographic characteristics in the perinatal period, and have substantially worse sensorineural outcomes than those followed with ease. In any longitudinal study, the more incomplete the follow up, the lower will be the rate of adverse sensorineural outcome.

Antibodies to Toxoplasma gondii in individuals with first-episode schizophrenia

We employed enzyme immunoassay (EIA) and Western blotting techniques to measure the level of antibodies to Toxoplasma gondii proteins in serum samples from 38 individuals undergoing their first episode of schizophrenia and from a group of matched control subjects. We found that the individuals with first-episode schizophrenia had significantly increased levels of IgG, IgM, and IgA class antibodies to Toxoplasma proteins, as compared with the control subjects.

Three aldo-keto reductases of the yeast Saccharomyces cerevisiae

Saccharomyces cerevisiae is an industrially important yeast, which is also used extensively as a model eukaryote. The S. cerevisiae genome has been sequenced in its entirety and therefore represents an ideal organism in which to carry out functional analysis of genes. We have identified several open reading frames in the S. cerevisiae genome which show significant similarity to members of the aldo-keto reductase superfamily. The physiological roles of these gene products have not been previously determined, but their similarity to other enzymes suggests they may perform roles in carbohydrate metabolism and detoxification pathways. Cloning and expression of three of these enzymes has allowed their substrate specificities to be determined. Expression profiling and gene disruption analysis will allow potential roles for these enzymes within the cell to be examined.

Lubeluzole in acute ischemic stroke treatment: A double-blind study with an 8-hour inclusion window comparing a 10-mg daily dose of lubeluzole with placebo

BACKGROUND AND PURPOSE

This trial was a double-blind, placebo-controlled, phase III trial with an 8-hour inclusion window to assess the efficacy and safety of an intravenous loading dose of 7.5 mg followed by a daily intravenous dose of 10 mg lubeluzole for 5 days in acute ischemic stroke patients.

METHODS

A total of 1786 patients were randomized: 901 to lubeluzole and 885 to placebo. Overall, 212 patients (23.5%) from the lubeluzole group and 213 (24.1%) from the placebo group discontinued the trial prematurely. In the lubeluzole group 201 patients (22.3%) discontinued because of adverse events compared with 193 patients (21.8%) in the placebo group.

RESULTS

The primary population for the efficacy analysis comprised the core stroke patients (exclusion of older patients aged >75 years with severe stroke) in the 0- to 6-hour inclusion time window. The primary efficacy parameter was a 3-category functional status (Barthel Index 70 to 100/0 to 70/vegetative, dead) at week 12. In the lubeluzole group 207 patients (47.8%) were classified as mildly dependent/independent at week 12, 131 (30.3%) were moderately/severely dependent, and 95 (21.9%) were vegetative/dead. In the placebo group these numbers were 221 (54.4%), 112 (27.6%), and 73 (18.0%), respectively. Logistic regression analysis showed no statistically significant difference between the treatment groups (P:=0.162). Additionally, for none of the secondary efficacy parameters (mortality at week 12, modified Rankin score, total Barthel score) was a statistically significant difference between the lubeluzole and placebo groups obtained. There were no statistically significant differences between the 2 treatments for all treated patients, patients included within the 6- to 8-hour window, and patients with severe strokes aged >75 years. Overall, of all treated patients, 401 (22.5%) died: 203 (22.5%) in the lubeluzole group and 198 (22.4%) with placebo. Of all subjects treated, 853 (95%) on lubeluzole and 826 (93%) on placebo reported an adverse event during their treatment period or within the next 2 days after discontinuation of treatment. The most frequently observed adverse events were fever (25.9% lubeluzole; 23.4% placebo), constipation (20.2%; 19.7%), and headache (17.6%; 21.2%). Imbalances were found for atrial fibrillation (1.8% lubeluzole; 1.1% placebo) and QT prolongation (0.9%; 0.2%).

CONCLUSIONS

This study failed to show an efficacy of lubeluzole in the treatment of acute stroke. On the other hand, lubeluzole treatment by the current dosage schedule was not associated with a significant safety problem.

Evaluation of measures used to assess quality of life after stroke

BACKGROUND AND PURPOSE

Assessment of quality of life (QOL) after stroke is becoming common with the recognition that evaluation of treatment should include quality as well as quantity of survival. This article will outline the main conceptual and methodological issues in QOL assessment, highlight advantages and disadvantages of measures used in stroke QOL research, and discuss some unresolved issues.

SUMMARY OF REVIEW

We undertook a MEDLINE search using the keywords "stroke" and "quality of life" and reviewed 3 key texts on QOL measurement in stroke. Fifteen generic and 10 condition-specific measures used to assess QOL in stroke were identified and evaluated with the following criteria: reliability, validity, responsiveness, precision, acceptability, suitability for proxy respondents, mode of administration, and use of patient-centered approaches in development. Domains covered and level of comprehensiveness varied widely between generic and stroke-specific measures. No stroke-specific instruments used patient-centered approaches in their development. Four stroke-specific measures (Frenchay Activities Index, Niemi QOL scale, Ferrans and Powers QOL Index-Stroke Version, and Stroke-Adapted Sickness Impact Profile [SA-SIP30]) provided evidence of reliability and validity.

CONCLUSIONS

The need remains for a patient-centered, psychometrically robust, stroke-specific QOL measure. Patients should be involved in each stage of instrument development. Caution is needed in the selection of an instrument to measure QOL after stroke. Although the Ferrans and Powers QOL Index-Stroke Version, Niemi QOL scale, SA-SIP30, and Sickness Impact Profile come closest to satisfying many of the criteria outlined in this article, the selection of any individual instrument depends on the specific goals and constraints of a particular study.

Are perceptions of a family history of heart disease related to health-related attitudes and behaviour?

It has been argued that perceptions of familial tendencies to disease are common and important in decisions about health-related behaviours. Indeed, it has been suggested that the increased 'geneticization' of society may lead to an increased fatalism about health, which could undermine initiatives aimed at reducing coronary-prone behaviour. To date, much of the research on lay perceptions of inheritance has been based on people at high risk of particular genetic disorders or on qualitative research with small general population samples. Here we investigate perceptions of a family history of heart disease, using quantitative techniques, to test hypotheses about the relationship between a perceived family history (pFH), coronary 'candidacy' and adherence to health promotion advice which were raised by earlier anthropological work. We find that reported perceptions of a family history of heart disease are common, particularly amongst women in middle-age. In isolation a pFH is not related to current smoking; however, the odds of smoking are lower for those with a pFH of heart disease when account is also taken of other attitudinal factors (the 'salience' of heart disease and the strength of adherence to conventional coronary health promotion.

Social class, sex, and age differences in mucosal immunity in a large community sample

There have been very few reports addressing levels and distribution of commonly used PNI measures in large community samples. In this study, we report such data for secretion rates of secretory immunoglobulin A (sIgA), as determined from saliva samples taken from 1971 subjects interviewed as part of the West of Scotland Twenty-07 survey of health in West Central Scotland. Univariate analyses of demographic variables found lower sIgA and salivary flow to be significantly related to poorer social class, increased age, and being female. Smokers also had lower sIgA but not lower salivary flow. Multivariate analysis showed that demographic variables were significant predictors of sIgA independently of each other and assay variation. Adding smoking status to the equation confirmed it as an independent predictor and also indicated that social class differences in sIgA are partly explicable in terms of smoking status. In view of reported associations between sIgA levels and stress, its role as a first line of mucosal defense, and its relevance to health, these first results from a large survey are of interest. Further work is now needed to explore which factors, including psychosocial ones, may be contributing to subgroup differences.

A confirmatory factor analysis of the Hospital Anxiety and Depression scale: comparing empirically and theoretically derived structures

OBJECTIVES

To compare the fit of various factor solutions for the Hospital Anxiety and Depression scale (HAD; Zigmond & Snaith, 1983).

DESIGN

A cross-sectional postal survey was used to collect the data from community-based participants in the West of Scotland Twenty-07 study.

METHODS

The HAD scale, a 14-item self-administered measure of anxiety and depression, was completed by 2547 participants from three age cohorts (aged approximately 18, 39 and 58 years). Using confirmatory factor analyses four models suggested by prior exploratory factor analyses were compared to a model derived from Clark and Watson's (1991) tripartite theory of anxiety and depression.

RESULTS

The model derived from the tripartite theory of anxiety and depression (with factors labelled negative affectivity, anhedonic depression and autonomic anxiety) produced the closest fit to the data. This model produced a good fit in all three cohorts although group comparisons suggested that there were variations in the strength of some factor loadings across the three age groups. A model that had a hierarchical arrangement of the three factors in the tripartite model was also produced. This model fit the data equally as well as did the 'flat' tripartite model.

CONCLUSIONS

Three factors appear to underlie the HAD scale. Research is needed that examines whether or not using sub-scales based on these factors increases the ability of the HAD scale to detect cases of anxiety and depression.

Morbidity and Irish Catholic descent in Britain: relating health disadvantage to behaviour

OBJECTIVES

This paper critically evaluates the evidence for two health-related stereotypes of the Irish, namely that behaviours such as smoking and heavy drinking explain their excess morbidity in Britain, and secondly that, in illness, this ethnic group behaves more stoically.

DESIGN

Data are reported on over 850 respondents from each of three cohorts (aged 18, 39 and 58 in 1990/91) of the West of Scotland 20-07 Study, in which a small but pervasive excess of morbidity has been observed in those of Catholic background (in this area associated with Irish descent). Logistic regression was used to investigate any differences in drinking, smoking and participation in sport between those of Catholic and non-Catholic heritage, whilst controlling for sex and social class. Where a difference was observed, we looked for an association between health-related behaviour and the Catholic morbidity excess for six measures of physical and mental health. Finally, illness behaviour at age 39 and 58 was investigated for those experiencing one of a number of common symptoms in the month prior to interview, by noting whether a general medical practitioner (GP) was consulted.

RESULTS

The only difference in health-related behaviour was in the eldest cohort, where an excess of smoking was observed for the Catholics. However, except for lung power, smoking was not able to explain very much, if any, of the Catholic morbidity disadvantage. For most of the symptoms studied, GP consultation rates were similar, although there was a tendency towards Catholic over-consulting.

CONCLUSION

This paper finds minimal evidence in favour of either stereotype: behaviours such as smoking and excess drinking were not strongly associated with the poor morbidity status of the Irish in the population we have studied; neither have the Irish been found to be more stoic in illness. Therefore the stereotypes are not an adequate explanation, nor a necessary correlate, of the frequent finding of raised morbidity in communities of Irish Catholic origin.

Are women more ready to consult than men? Gender differences in family practitioner consultation for common chronic conditions

BACKGROUND

When consultations for all reasons are combined, women are seen to consult their general practitioners more than men through most of adult life. It is, therefore, often assumed that women are more likely to consult for every condition.

OBJECTIVES

To examine whether women report being more likely to consult a general practitioner than men when taking account of the underlying condition and various aspects of the experience of the condition consulted for.

METHODS

Home-based nurse-interviews with 852 people in early middle age (39 years) and 858 in late middle age (58 years) sampled from the general population in the West of Scotland. Detailed information about current chronic conditions included general practitioner consultation and reported experience of pain frequency, pain severity, limitation to normal activities and restricted activity in the previous four weeks.

RESULTS

Women were no more likely than men to consult a general practitioner in the previous year when experiencing the five most common groups of conditions; in addition, women were no more likely than men to consult at a given level of severity for a given condition type, except in the case of one aspect of reported experience of mental health problems.

CONCLUSIONS

The results argue against the most widely accepted explanation for gender differences in consulting, namely, that women are simply more likely to consult a general practitioner than men irrespective of underlying morbidity. Reasons for the higher rates of women consulting observed in general practice-based studies are discussed in relation to these data.

Do women 'over-report' morbidity? Men's and women's responses to structured prompting on a standard question on long standing illness

It is frequently observed in contemporary industrialised societies that although women live longer than men, they are sicker than men in that they report higher rates of morbidity, disability and health care use. One common element of the explanation for women's higher rates of morbidity is that there are gender differences in the way that symptoms are perceived, evaluated and acted upon. It is widely assumed that women will be more ready to report illness and to seek help and that they have greater flexibility in their lives to accommodate illness. The few studies that have examined men and women with the same conditions or symptoms are contradictory, but lend little support to this hypothesised greater propensity, yet it is still widely believed. Here we compare men's and women's answers to a global, commonly used question about chronic illness and to a series of more specific prompts and classify the conditions reported by an externally defined categorisation of severity and International Classification of Disease chapter. Contrary to the common expectation that women report higher rates of morbidity and are more ready to report mental health problems, we found: no gender differences in the initial reporting of conditions; men reported a higher proportion of their conditions in response to the initial global question; and no evidence that women were more likely to report 'trivial' or mental health conditions in response to the initial question.

Do housing tenure and car access predict health because they are simply markers of income or self esteem? A Scottish study

OBJECTIVE

To investigate relations between health (using a range of measures) and housing tenure or car access; and to test the hypothesis that observed relations between these asset based measures and health are simply because they are markers for income or self esteem.

DESIGN

Analysis of data from second wave of data collection of West of Scotland Twenty-07 study, collected in 1991 by face to face interviews conducted by nurse interviewers.

SETTING

The Central Clydeside Conurbation, in the West of Scotland.

SUBJECTS

785 people (354 men, 431 women) in their late 30s, and 718 people (358 men, 359 women) in their late 50s, participants in a longitudinal study.

MEASURES

General Health Questionnaire scores, respiratory function, waist/hip ratio, number of longstanding illnesses, number of symptoms in the last month, and systolic blood pressure; household income adjusted for household size and composition; Rosenberg self esteem score; housing tenure and care access.

RESULTS

On bivariate analysis, all the health measures were significantly associated with housing tenure, and all except waist/hip ratio with car access; all except waist/hip ratio were related to income, and all except systolic blood pressure were related to self esteem. In models controlling for age, sex, and their interaction, neither waist/hip ratio nor systolic blood pressure remained significantly associated with tenure or care access. Significant relations with all the remaining health measures persisted after further controlling for income or self esteem.

CONCLUSIONS

Housing tenure and car access may not only be related to health because they are markers for income or psychological traits; they may also have some directly health promoting or damaging effects. More research is needed to establish mechanisms by which they may influence health, and to determine the policy implications of their association with health.

Intraabdominal desmoplastic small round cell tumor: cytopathologic findings in two cases

Intraabdominal desmoplastic small round cell tumor (DSRCT) is an extremely rare entity. This study describes fine-needle aspiration, ascitic fluid, and touch imprint cytomorphology of DSRCT in 2 patients with extensive abdomino-pelvic disease. Cytopathologic features were unique and showed good morphologic correlation with subsequent histology of the resected tumor. Immunocytochemical profile and differential diagnosis with other small round cell tumors in this age group are also discussed.

Gender differences in consulting a general practitioner for common symptoms of minor illness

The aim of this paper is to examine whether, in response to the same symptoms of minor illness, women reported a greater propensity to consult a general practitioner than men. Respondents taking part in the West of Scotland Twenty-07 Study (853 aged 39 and 858 aged 58) were presented with a check-list of 33 symptoms during the course of a home interview conducted by nurses. They were asked whether they had experienced any of these symptoms in the last month, and if they had, whether they consulted a general practitioner about it. A summary indicator for reporting, or consulting for, at least one symptom was constructed, and statistical associations between gender, reporting and consulting for symptoms were examined using chi-square tests with Yates' correction. Women were more likely to have consulted a general practitioner for at least one of the 33 symptoms of minor illness reported in the previous month (34% of women, 27% of men aged 39, chi2 = 3.97, p < 0.05; 49% of women, 43% of men aged 58, chi2 = 3.21, (NS)). Women were significantly more likely to have consulted for five individual symptoms in the younger cohort, and for three symptoms in the older cohort, whilst men were significantly more likely to have consulted for only one symptom, in the younger cohort. However, when only those who had reported a symptom in the last month were included in analysis there were no gender differences in consulting for any of the 33 symptoms in the older cohort, and for just 3 symptoms in the younger cohort. These data do not support the most widely suggested explanation for gender differences in consulting, that once symptoms are perceived, women have a higher propensity to consult a general practitioner with the symptom than men.

Morbidity and Irish Catholic descent in Britain: an ethnic and religious minority 150 years on

Ethnic and religious minorities often suffer disadvantages both in socio-economic status and in health. Data from the West of Scotland Twenty-07 study suggest some differences in morbidity between those descended from Irish Catholic migrants of the great emigration from 1840 onwards and others. Catholic religion of at least one parent or at birth is used here as a proxy measure to indicate Irish Catholic descent, on the basis of estimates of sensitivity and specificity in the local area. Higher proportions of "Catholics" are in manual social classes. Differences between "Catholics" and "non-Catholics" in one or more age cohorts are observed for the following aspects of health and physical development: general and physical health (self-assessed health, number of symptoms, accidents), psychological distress (depression, anxiety, number of psychosomatic symptoms), impairments and disabilities (sight, hearing, wearing dentures, disability), and physical measures (height, waist-to-hip ratio, lung function). Furthermore, for all aspects except hearing, wearing dentures and number of psychosomatic symptoms, significant differences remain after accounting for sex and social class. For each measure where a difference is observed, it is those respondents with a Catholic parent or who were born Catholic who experience poorer health or physical development. This suggests that those of Irish Catholic descent are at some disadvantage compared with the rest of the population, with respect to health as well as social class, 150 years after the start of the main migration.

Mycobacterium kansasii infection in a patient presenting with porphyria cutanea tarda

Mycobacterium kansasii, an atypical mycobacterium, is an uncommon cause of cutaneous and joint disease in immunocompetent patients. We report an unusual case of infection with this organism in a patient who initially presented with porphyria cutanea tarda (PCT), and who was noted also to have a crusted ulcer over the middle phalanx and swelling of the proximal interphalangeal joint of the right middle finger. The cutaneous ulcer healed with minocycline, but the joint disease required a combination of rifampicin and ethambutol before a therapeutic response was obtained.

Putting feeding back into the hands of patients

At the Behavioral Health Unit of Baton Rouge General Medical Center, the author and registered dietitians of the Clinical Nutrition Department developed "utensil-less" diets for patients with acute psychiatric conditions. Initially, the diet was developed for patients with dementia; however, the staff quickly realized that the diet would be appropriate for patients with many acute psychiatric disorders, or for those patients with physical limitations. The "Dementia Diet" includes five nutritionally balanced, small meals each day, consisting of finger foods such as sandwiches, vegetable sticks, fruit slices, and other items that patients can eat on their own without feeding assistance or utensils (Figure). After introducing the diet on the Behavioral Health Unit, the staff found that 7 of 10 patients on the diet improved their food intake and gained weight. Not only were nutritional needs met, but mealtimes became more enjoyable for the patients, families, and staff (Table). Unit safety advanced, and most importantly, quality of life and self-esteem were cultivated by helping adult patients regain some of their independence associated with meal times.