What do people with inflammatory bowel disease want to know about diet? The dietary information needs of people with inflammatory bowel disease and perceptions of healthcare providers

BACKGROUND

Inflammatory bowel disease (IBD) is an incurable illness of the gastrointestinal tract. Its relapsing-remitting nature negatively impacts physical health and quality of life. Food and eating are key concerns for people with this illness. To provide holistic person-centred care, healthcare providers (HCPs) need to meet patients' dietary information needs. However, there is a paucity of literature describing these in any meaningful detail. The present study aimed to explore the perceived dietary information needs of individuals with IBD, the perceptions of HCPs and enablers and barriers to communication.

METHODS

Online and face-to-face semi-structured interviews with 13 HCPs and 29 people with IBD were conducted. The framework method aided thematic analysis of de-identified interview recordings.

RESULTS

The cyclical nature of IBD contextualised the five themes. Both individuals with IBD and HCPs articulated similar ideas viewed from different perspectives: (1) living with IBD is exasperating and unique to the individual; (2) individuals with IBD desire dietary information; (3) diet manipulation is used to exert control on a disease with unpredictable nature; (4) people with IBD and HCPs have different views on the role of diet; and (5) doctors are perceived as gatekeepers to accessing dietetics care.

CONCLUSIONS

A lack of dietary guidance at diagnosis negatively impacts the patient's journey with food and eating. The present study supports a paradigm shift towards holistic person-centred care for consistent access to dietetics services to meet the needs of people with IBD.

A scoping review of the dietary information needs of people with inflammatory bowel disease

AIMS

This review aimed to explore and describe the dietary information needs of individuals with inflammatory bowel disease and sources of information.

METHODS

A scoping review of English language articles and grey literature, using electronic databases with a predefined search strategy was undertaken. Data were synthesised based on the identified variables (e.g. dietary information needs and sources of dietary information) corresponding to the aims of this review.

RESULTS

Forty-six studies were included, reporting data from 7557 people with inflammatory bowel disease, of which 58.6% had Crohn's disease and 60.1% were males. Dietary information was rated very important and appeared to be influenced by the disease course. The need to discuss it is heightened at important stages, namely diagnosis and relapse. Dietary information was described broadly and included advice about foods to avoid and dietary advice for symptoms management. No major differences were noted in the dietary information needs of people with Crohn's disease compared to ulcerative colitis. The main sources of dietary information were the gastroenterologist (36%-98%), the internet (9%-60%) and non-dietetic professionals (84.7%).

CONCLUSION

This review highlights limited literature describing the dietary information needs of people with inflammatory bowel disease. Importantly, the limited access to specialised dietary advice for this cohort is concerning. Future studies are required to explore not only the nuances in the needs of those with active disease and in remission, but to further understand issues of access to specialised dietary advice to provide holistic person-centred care desired by this cohort.

Lifestyle Interventions, Kidney Disease Progression, and Quality of Life: A Systematic Review and Meta-analysis

Rationale & Objective

Poor dietary patterns and low physical activity levels are important lifestyle-related factors that contribute to negative health outcomes in individuals with chronic kidney disease (CKD). Previous systematic reviews have not explicitly focused on these lifestyle factors, nor undertaken meta-analyses of any effects. We aimed to evaluate the effect of lifestyle interventions (such as diet, exercise, and other lifestyle-related interventions) on the risk factors for and progression of CKD and the quality of life.

Study Design

Systematic review and meta-analysis.

Setting & Study Populations

Individuals aged 16 years or older with CKD stages 1 to 5 not requiring kidney replacement therapy.

Selection Criteria for Studies

Randomized controlled trials of interventions.

Data Extraction

Kidney function, albuminuria, creatinine, systolic blood pressure, diastolic blood pressure, body weight, glucose control, and quality of life.

Analytical Approach

A random-effects meta-analysis with evidence certainty assessed using GRADE.

Results

Seventy-eight records describing 68 studies were included. Twenty-four studies (35%) were dietary interventions, 23 (34%) exercise, 9 (13%) behavioral, 1 (2%) hydration, and 11 (16%) multiple component. Lifestyle interventions resulted in significant improvements in creatinine (weighted mean difference [WMD], -0.43 mg/dL; 95% CI, -0.74 to -0.11; P = 0.008); 24-hour albuminuria (WMD, -53 mg/24 h; 95% CI, -56 to -50; P < 0.001); systolic blood pressure (WMD, -4.5 mm Hg; 95% CI, -6.7 to -2.4; P < 0.001); diastolic blood pressure (WMD, -2.2 mm Hg; 95% CI, -3.7 to -0.8; P = 0.003); and body weight (WMD, -1.1 kg; 95% CI, -2.0 to -0.1; P = 0.025). Lifestyle interventions did not result in significant changes in the estimated glomerular filtration rate (0.9 mL/min/1.73 m²; 95% CI, -0.6 to 2.3; P = 0.251). However, narrative synthesis indicated that lifestyle intervention resulted in improvements in the quality of life.

Limitations

Certainty of the evidence was rated very low for most outcomes, primarily owing to the risk of bias and inconsistency. No meta-analysis was possible for quality-of-life outcomes because of variations in measurement tools.

Conclusions

Lifestyle interventions seem to positively affect some risk factors for progression of CKD and quality of life.

Accounting for vaccines specificities in the Joint Clinical Assessment (JCA): a proposal for guiding principles

Issue/problem

Vaccines are an important public health intervention protecting the population against infectious diseases. The value of vaccines is broad ranging from individual to societal as achieving community immunity protects the unvaccinated, minimizes the risk of outbreaks, reduces the emergence of antimicrobial resistance, and leads to broader societal benefits.

Description of the problem

Vaccines’ market access processes are characterized by the development of recommendations by NITAGs followed by the assessment of health technology assessment (HTA) bodies in less than half of 27 EU member states. Despite that HTA for therapeutic drugs is well established, there is very limited experience in applying HTA methodologies to vaccines, especially for clinical assessments, as HTA methods and frameworks are traditionally geared toward therapeutics. However, following the adoption of the EU regulation on HTA, Joint Clinical Assessments (JCAs) of vaccines are expected.

Results

To support a discussion on how to account for vaccine specificities in the JCA, Vaccines Europe has performed a project which aimed at developing a proposal for high-level guiding principles on processes and methodologies for clinical HTA for vaccines. The proposal is informed by findings of literature reviews on currently applied processes, methods, and clinical assessment frameworks of vaccines as well as the outcomes of an advisory board with scientific experts.

Lessons

A proposal for high-level guiding principles for clinical HTA for vaccines is being developed based on both evidence and the advice from scientific experts which focuses on processes (e.g., horizon scanning, early advice, consideration of vaccine-specific expertise) and methods (e.g., unmet need, safety, efficacy/effectiveness, real-world evidence and technical characteristics of the technology). Lastly, the implementation of vaccines specificities in JCA represents a call for action.

Prevalence and features of delirium in older patients admitted to rehabilitation facilities: a multicenter study

BACKGROUND

Delirium is thought to be common across various settings of care; however, still little research has been conducted in rehabilitation.

AIM

We investigated the prevalence of delirium, its features and motor subtypes in older patients admitted to rehabilitation facilities during the three editions of the "Delirium Day project".

METHODS

We conducted a cross-sectional study in which 1237 older patients (age ≥ 65 years old) admitted to 50 Italian rehabilitation wards during the three editions of the "Delirium Day project" (2015 to 2017) were included. Delirium was evaluated through the 4AT and its motor subtype with the Delirium Motor Subtype Scale.

RESULTS

Delirium was detected in 226 patients (18%), and the most recurrent motor subtype was mixed (37%), followed by hypoactive (26%), hyperactive (21%) and non-motor one (16%). In a multivariate Poisson regression model with robust variance, factors associated with delirium were: disability in basic (PR 1.48, 95%CI: 1.17-1.9, p value 0.001) and instrumental activities of daily living (PR 1.58, 95%CI: 1.08-2.32, p value 0.018), dementia (PR 2.10, 95%CI: 1.62-2.73, p value < 0.0001), typical antipsychotics (PR 1.47, 95%CI: 1.10-1.95, p value 0.008), antidepressants other than selective serotonin reuptake inhibitors (PR 1.3, 95%CI: 1.02-1.66, p value 0.035), and physical restraints (PR 2.37, 95%CI: 1.68-3.36, p value < 0.0001).

CONCLUSION

This multicenter study reports that 2 out 10 patients admitted to rehabilitations had delirium on the index day. Mixed delirium was the most prevalent subtype. Delirium was associated with unmodifiable (dementia, disability) and modifiable (physical restraints, medications) factors. Identification of these factors should prompt specific interventions aimed to prevent or mitigate delirium.

The association between low skeletal muscle mass and delirium: results from the nationwide multi-centre Italian Delirium Day 2017

Introduction

Delirium and sarcopenia are common, although underdiagnosed, geriatric syndromes. Several pathological mechanisms can link delirium and low skeletal muscle mass, but few studies have investigated their association. We aimed to investigate (1) the association between delirium and low skeletal muscle mass and (2) the possible role of calf circumference mass in finding cases with delirium.

Methods

The analyses were conducted employing the cross-sectional “Delirium Day” initiative, on patient 65 years and older admitted to acute hospital medical wards, emergency departments, rehabilitation wards, nursing homes and hospices in Italy in 2017. Delirium was diagnosed as a 4 + score at the 4-AT scale. Low skeletal muscle mass was operationally defined as calf circumference ≤ 34 cm in males and ≤ 33 cm in females. Logistic regression models were used to investigate the association between low skeletal muscle mass and delirium. The discriminative ability of calf circumference was evaluated using non-parametric ROC analyses.

Results

A sample of 1675 patients was analyzed. In total, 73.6% of participants had low skeletal muscle mass and 24.1% exhibited delirium. Low skeletal muscle mass and delirium showed an independent association (OR: 1.50; 95% CI 1.09–2.08). In the subsample of patients without a diagnosis of dementia, the inclusion of calf circumference in a model based on age and sex significantly improved its discriminative accuracy [area under the curve (AUC) 0.69 vs 0.57, p < 0.001].

Discussion and conclusion

Low muscle mass is independently associated with delirium. In patients without a previous diagnosis of dementia, calf circumference may help to better identify those who develop delirium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01950-8.

Validation of an electronic food intake tool and its usability and efficacy in the healthcare setting

BACKGROUND

Accurate dietary intake data are critical to nutrition care planning. Commonly used food record charts (FRC) are paper-based, time consuming, require nutrient analysis estimations, and may provide limited accuracy. The present study aimed to validate Mobile Intake® (MI) (an electronic food intake tool incorporating the five-point visual scale and providing automatic nutrient analysis) for usability and efficacy in quantifying dietary intake in the healthcare setting.

METHODS

Two research stages within two tertiary hospitals included: (1) examining criterion validity and efficiency of dietary intake quantification using FRC and MI compared to the gold standard weighed food record (WFR) in a controlled environment and (2) comparing efficiency and effectiveness of FRC and MI in usual care conditions.

RESULTS

In Stage 1, dietary intake was calculated (n = 90) with a significant difference across all methods (FRC, MI and WFR) for energy (p = 0.04), but not between MI and WFR (p = 1.00). The time taken for MI (40 s) was significantly less than FRC (174 s) and WFR (371 s) (p < 001). In Stage 2, dietary intake was determined (n = 210) using FRC and MI. Sufficient data to complete dietary analysis were available for 35% of meals from FRC compared to 98% from MI. Calculated mean daily energy intake (4764 ± 1432 kJ vs. 6636 ± 2519 kJ, p = 0.002) and mean daily protein intake (62.9 ± 12.7 g vs. 78.5 ± 22.2 g, p = 0.007) were significantly lower with FRC compared to MI. Average time to complete MI was 14.4 seconds.

CONCLUSIONS

MI demonstrates efficacy as an accurate measure of dietary intake compared to WFR, as well as usability, providing faster, more accurate and comprehensive real-time intake data in practice than FRC.

Poor Diet Quality in Children with Cancer During Treatment

Background: With improved long-term health outcomes and survivorship, the long-term nutritional management of childhood cancer survivors, from diagnosis to long-term follow-up, has become a priority. The aim of this study was to examine the diet quality of children receiving treatment for cancer. Methods: Participants were parents of children with cancer who were receiving active treatment and not receiving supplementary nutrition. A 24-h dietary recall assessed food and nutrient intake. Serves of food group intakes and classification of core and discretionary items were made according to the Australian Dietary Guidelines and compared with age and sex recommendations. Results: Sixty-four parents participated (75% female). Most children were not consuming adequate intake of vegetables (94% of patients), fruit (77%), and milk/alternatives (75%). Of the vegetables that were consumed, half were classified as discretionary foods (e.g., chips/fries). Nearly half (49%) of children exceeded recommendations for total sugar intake and 65% of patients had an excessive sodium intake. Discussion: Children receiving cancer treatment are consuming diets of reasonable quantity, but poor quality. Information provided during treatment should focus on educating parents on a healthy diet for their child, the importance of establishing healthy eating habits for life, and strategies to overcome barriers to intake during treatment.

Reference to nutrition in medical accreditation and curriculum guidance: a comparative analysis

Objective

Poor diet is a leading cause of death worldwide. Doctors are well placed to provide dietary advice, yet nutrition remains insufficiently integrated into medical education. Enforcement of curriculum or accreditation requirements such as nutrition requires relevant regulatory frameworks. The aim of this review was to identify nutrition content or requirements for nutrition education in accreditation standards or formal curriculum guidance for medical education internationally.

Design

Non-systematic comparative analysis.

Data sources

An internet search using the Google Search engine, the WHO Directory of Medical Schools and Foundation for Advancement of International Medical Education and Research Directory of Organizations that Recognise/Accredit Medical Schools was conducted through September 2020 to identify government and organisational reports as well as publications from regulatory and professional bodies relevant to medical education.

Eligibility criteria

Eligible publications included (A) accreditation standards, (B) competency standards or a framework, (C) curricula, and (D) assessment content.

Data extraction and synthesis

We stratified findings by country or region and both preregistration and postregistration education. Findings were synthesised based on the existence of nutrition content or requirements for nutrition education within systems used to guide medical education internationally.

Results

This review found that despite an emphasis on meeting the needs of the community and the demands of the labour market, only 44% of accreditation and curriculum guidance included nutrition. Nutrition remains inadequately represented in accreditation and curriculum guidance for medical education at all levels internationally. Accreditation standards provide a mandated framework for curricula and inclusion of nutrition in accreditation frameworks provides an incentive for the integration of nutrition into medical education.

Conclusions

This review is a call to action for the medical profession including government, health agencies and educational and accreditation entities. The inclusion of nutrition in medical education has appeared throughout medical education literature for more than five decades, yet without consensus standards there is little likelihood of uniform adoption.

Perspective: Why Whole Grains Should Be Incorporated into Nutrient-Profile Models to Better Capture Nutrient Density

Healthy eating patterns, as described by dietary guidelines, typically favor whole grains, low-fat dairy, vegetables, fruit, legumes, and nuts and seeds. Nutrient-profiling (NP) models capture nutrient density of individual foods and can inform healthier food choices. Although whole grains are prominently featured in most dietary guidelines, they are not included in most NP models. Healthy foods, as identified by most NP models, are those that contain limited amounts of energy, saturated fat, total or added sugar, and sodium. As global dietary guidance turns to foods and food groups as opposed to individual nutrients, future nutrient-density metrics may need to do the same. Potential methods to incorporate whole grains into the overall concept of nutrient density and into selected NP models are outlined in this review. Incorporating whole grains into the Nutri-Score, Health Star Rating, or the Nutrient Rich Food index will require further analyses of dietary nutrient density in relation to health outcomes across diverse population subgroups. We present the rationale for how the inclusion of whole grains in NP models can assist in the implementation of dietary guidance.

Whole Grains and Consumer Understanding: Investigating Consumers' Identification, Knowledge and Attitudes to Whole Grains

Whole grains may assist in reducing risk of non-communicable disease, but consumption is limited in many countries. In Australia, the reasons for poor consumption are not well understood. The aim of this study was to investigate consumers' knowledge, attitudes and identification of whole grains, incorporating an exploration of factors influencing consumption, promotion and provision. An online semi-structured questionnaire was used to gather responses from 735 participants (61% complete responses). Although 92% of respondents consumed grains, only 8% reported an intake consistent with age and gender recommendations. Refined pasta and rice were the most frequently purchased grain foods followed by wholemeal/whole grain bread. Of whole grain foods, bread and breakfast cereals were consumed more frequently. However, overall, participants did not prioritise consumption of whole grains. Despite this, 93% of participants had seen food packaging information drawing attention to whole grain content, with a high proportion describing whole grain as less processed (72%) or high in dietary fibre (67%). Two-thirds were aware of health benefits but stated that if they had further information, they would be more likely to swap to whole grain. Further education, increasing exposure, accessibility and extensive promotion of whole grain health benefits are required to facilitate whole grain consumption. Furthermore, removing the negative stigma associated with carbohydrate foods, including grains, will be necessary to improve consumption.

Whole grain consumption and human health: an umbrella review of observational studies

Whole grains have been associated with a number of health benefits. We systematically reviewed existing meta-analyses of observational studies and evaluated the level of evidence for their putative effects based on pre-selected criteria. Of the 23 included studies, we found convincing evidence of an inverse association between whole grain consumption and risk of type-2 diabetes and colorectal cancer; possible evidence of decreased risk of colon cancer and cardiovascular mortality with increased whole grain intake, as well as increased risk of prostate cancer. Limited or insufficient evidence was available for all other outcomes investigated. Overall findings are encouraging for a positive effect of whole grain consumption on certain diseases, especially highly prevalent metabolic diseases, however, uncertainty of some negative associations deserves further attention.

Consumer Understanding and Culinary Use of Legumes in Australia

While health benefits of legume consumption are well documented, intake is well below recommendations in many Western cultures, and little is known regarding culinary use and consumer understanding of these foods. This study aimed to investigate consumption, knowledge, attitudes, and culinary use of legumes in a convenience sample of Australians. An online computer-based survey was used to gather data and demographic characteristics. Respondents (505 individuals answered in full or in part) were regular consumers of legumes (177/376 consumed legumes 2–4 times weekly). Chickpeas, green peas, and kidney beans were most often consumed, and were made into most commonly Mexican, then Indian and Middle Eastern meals. Consumers correctly identified protein and dietary fibre (37%) as key nutritional attributes. For non-consumers (7%; 34/463), taste, a lack of knowledge of how to prepare and include legumes, and the time taken to prepare, along with family preferences, hindered consumption. Participants identified the food category as “beans” rather than “legumes”, and this may have implications for dietary guidance at an individual and policy level. Addressing barriers to consumption, perhaps through food innovation, emphasizing positive health attributes, and clarification within dietary guidelines, are important considerations for increasing consumption of legumes.

Comparing Whole Grain with Cereal Fibre – Associations to Markers of Cardiovascular Disease Risk in the UK National Diet and Nutrition Survey and the Australian Health Survey (P08-079-19)

Objectives

Whole grain intake is associated with lower risk of cardiovascular disease (CVD) and related risk factors. Cereal fibre content of whole grains may be responsible, although it is not clear to what extent. Inconsistent definitions of whole grains used within previous studies, such as including bran as a whole grain source, confound findings and limit the ability to separate the two exposures. We compared how intakes of whole grain and cereal fibre were separately associated with markers of CVD risk in adult participants within the UK National Diet and Nutrition Survey (NDNS) and the Australian Health Survey (AHS).

Methods

Cross-sectional analyses of the NDNS Rolling Programme 2008–14 and the 2011–13 AHS examined associations between whole grain and cereal fibre intakes and markers of CVD risk using multivariate linear regression analysis. Whole grain was defined as containing the endosperm, germ and bran components in the expected proportions, and food composition databases were used to estimate intakes.

Results

Within the NDNS, participants in the highest quartile (Q4) of whole grain intake had lower waist-hip ratio (Q1 0.872; Q4 0.857; P = 0.04), HbA1c (Q1 5.66%; Q4 5.47%; P = 0.01) and homocysteine (Q1 9.95 µmol/L; Q4 8.76 µmol/L; P = 0.01) compared to participants in the lowest quartile (Q1) after adjustment for cereal fibre intake. Participants in the highest tertile of whole grain intake within the AHS had lower waist circumferences (P = 0.03), HbA1c (P = 0.03) and fasting blood glucose (P = 0.048) compared to non-whole grain consumers after adjustment for cereal fibre intake. Cereal fibre intake, when analysed separately, was inversely associated with waist-hip ratio (P = 0.03) and homocysteine (P = 0.002) in the NDNS, and BMI (P < 0.0001) and waist circumference (P = 0.0008) in the AHS.

Conclusions

Similar inverse associations between whole grain and cereal fibre intakes to multiple markers of CVD risk suggest cereal fibre may play a role in protective associations of whole grains. However, whole grain associations often remained significant after adjustment for cereal fibre intake, suggesting additional constituents may be relevant. Future research should ensure use of consistent definitions when examining health associations of whole grains and their specific constituents.

Funding Sources

Nil funding.

Moderation of a foodservice assessment artefact in nutrition and dietetics programs

AIM

Foodservice is a key component of dietetics education and practice internationally yet benchmarks for competency are limited. This study sought to review and moderate an assessment artefact of foodservice work integrated learning (WIL) to develop a shared understanding of one tool which may be used in a suite of evidence to demonstrate competence.

METHODS

The foodservice curricula and assessment artefacts were described for the foodservice program at each of four participating universities. An assessment artefact from WIL, the report, was identified as an indicator of foodservice competence common to each program. Each university provided four purposively sampled WIL reports, assessed in duplicate by two academics from other participating universities using the corresponding university assessment rubric. Collated assessment results, along with the original assessment, were presented back to assessors. A semi-structured group discussion explored variations in assessment results, factors influencing decisions, and potential changes needed for assessment documentation.

RESULTS

There was variation in assessment outcomes between independent assessors. In some instances assessors did not consistently deliver the same assessment outcome, nor rank students in sequential order of performance. This variation was less where an absolute ranking of satisfactory/unsatisfactory was applied. The assessor discussion revealed three key concepts: importance of understanding the project scope; challenges which influence assessment decision making; importance of understanding the broader program of assessment.

CONCLUSIONS

Assessment inconsistencies emphasise the importance of multiple assessors and assessment artefacts across a programmatic assessment model, and the need for a clear understanding of competence in nutrition and dietetics.

Key Characteristics of Public Health Interventions Aimed at Increasing Whole Grain Intake: A Systematic Review

OBJECTIVE

To identify characteristics of successful public health interventions aimed at increasing whole grain consumption.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analyses framework, guided by higher-quality interventions with greatest effect size, was adopted to conduct a systematic literature review.

RESULTS

Of 8,500 initial records, only 8 interventions with demonstrated reach (up to national populations) and effectiveness (increasing consumption 8-27 g/d) were eligible for synthesis. Their characteristics included multiple stakeholder involvement, specified target intakes in dietary guidelines, manufacturer codes of practice, product reformulation, evidence-based educational resources, social media, and community events with tasting and preparation opportunities. Empowerment of food service providers was also linked to success.

CONCLUSIONS AND IMPLICATIONS

Successful interventions require multifaceted strategies across multiple aspects of the food system, underpinned by multiple stakeholder partnerships. Uniform capture of interventions using an online, searchable, public domain resource may provide a strategy to enable health professionals globally to plan local interventions across cultural settings, drawing on best practice guidelines developed from interventions with demonstrated reach and effectiveness.

Inhibition of Fibrinolysis and Fibrinogenolysis in Man: Comparison of ε-Aminocaproic Acid and Kallikrein Inhibitor

Inhibitor of kallikrein and trypsin (KI) extracted from bovine parotis was compared with ε-aminocaproic acid (EACA): both substances inhibit fibrinolysis induced with streptokinase. EACA is a strong inhibitor of fibrinolysis in concentrations higher than 0, 1 mg per ml plasma. The same amount and higher concentrations are not able to inhibit completely the proteolytic-side reactions of fibrinolysis (fibrinogenolysis, diminution of factor V, rise of fibrin-polymerization-inhibitors). KI inhibits well proteolysis of plasma components in concentrations higher than 2,5 units per ml plasma. Much higher amounts of KI are needed to inhibit fibrinolysis as demonstrated by our in vivo and in vitro tests.

Combination of the two substances for clinical use is suggested. Therapeutic possibilities are discussed.

The Influence of Fibrin Stabilizing Factor on the Growth of Fibroblats in vitro and Wound Healing

Congenital deficiency of Fibrin Stabilizing Factor (FSF) is the cause of both pathological haemostasis and poor wound healing. Experiments with fibroblast cultures were carried out to characterize the latter. Growth of the cultures in the patient’s plasma was quantitatively and qualitatively inferior as compared with the growth in normal control plasma, which contained FSF. Only by addition of normal plasma and purified FSF the poor cell growth was corrected. The necessity of fibrin present in the first stage of wound healing and possible modes of action of FSF in haemostasis and wound healing are discussed.

A Re-Appraisal of the Role of Blood Coagulation and Platelets in the Generalized Shwartzman Phenomenon

The role of intravascular coagulation in the production of the generalized Shwartzman phenomenon has been evaluated. The administration of endotoxin to animals prepared with Thorotrast results in activation of the coagulation mechanism with the resultant deposition of fibrinoid material in the renal glomeruli. Anticoagulation prevents alterations in the state of the coagulation system and inhibits development of the renal lesions. Platelets are not primarily involved. Platelet antiserum produces similar lesions in animals prepared with Thorotrast, but appears to do so in a manner which does not significantly involve intravascular coagulation.

The production of adrenal cortical hemorrhage, comparable to that seen in the Waterhouse-Friderichsen syndrome, following the administration of endotoxin to animals that had previously received ACTH does not require intravascular coagulation and may not be a manifestation of the generalized Shwartzman phenomenon.

Strategic leadership will be essential for dietitian eHealth readiness: A qualitative study exploring dietitian perspectives of eHealth readiness

AIM

To explore dietitians' perspectives on the eHealth readiness of Australian dietitians, and to identify strategies to improve eHealth readiness of the profession.

METHODS

Dietitians who met the criteria for nutrition informatics experts participated in semi-structured interviews between June 2016 and March 2017. The interviews were recorded and transcribed verbatim. Thematic analysis using coding was undertaken until consensus was reached by the researchers regarding key themes, topics and exemplar quotes.

RESULTS

Interviews with 10 nutrition informatics experts revealed 25 discussion topics grouped into four main themes: benefits of eHealth for dietitians; risks of dietitians not being involved in eHealth; dietitians are not ready for eHealth; and strategies to improve eHealth readiness. The strategies identified for improving eHealth readiness included: collaboration and representation, education, offering of incentives and mentoring, as well as development of a national strategy, organisational leaders, nutrition informatics champions and a supportive environment.

CONCLUSIONS

These findings suggest that dietitians may not be ready for eHealth. Strategic leadership and the actioning of other identified strategies will be imperative to preparing dietitians for eHealth to ensure the profession can practice effectively in the digital age, optimise nutrition care and support research for eHealth. If dietitians do not engage in eHealth, others may take their place, or dietitians may be forced to use eHealth in ways that are not the most effective for practice or maximising patient outcomes.

A framework for eHealth readiness of dietitians

AIM

To develop a framework for assessing the eHealth readiness of dietitians.

METHODS

Using an inductive approach, this research was divided into three stages: 1. a systematic literature review to identify models or frameworks on eHealth readiness; 2. data synthesis to identify eHealth readiness themes and develop a framework; and 3. semi-structured interviews with Australian nutrition informatics experts to gain consensus and validate the framework.

RESULTS

Two hundred and forty one unique citations were identified, of which twenty four met the research criteria and were included in the review and subsequent synthesis. Common eHealth readiness themes or dimensions were extracted from the literature, and five key dimensions were identified that were relevant to dietitian eHealth readiness: access, standards, attitude, aptitude and advocacy. A framework diagram was designed and discussed during semi-structured interviews with ten nutrition informatics experts to inform the final framework. The result of this research was an inductively developed Framework for eHealth Readiness of Dietitians (FeRD).

DISCUSSION

The FeRD builds on existing theories and models, and provides a conceptual model for developing eHealth readiness evaluation tools to examine, measure and drive strategies to better prepare dietitian professionals for eHealth.

eHealth readiness of dietitians

BACKGROUND

The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia.

METHODS

Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys.

RESULTS

The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions.

CONCLUSIONS

Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

Neuropathological Problems Arising from Prefrontal Leucotomy

The neuropathological problems which arise from prefrontal leucotomy may be conveniently divided into three groups.

The first group is concerned with the analysis of the anatomical and possible other factors which may influence the prospect of recovery. This group is naturally of the greatest practical interest to the psychiatrist and, for this reason, will require our foremost attention.

Anatomical Comments on Psychosurgical Procedures

There has recently been a plethora of new methods of psychosurgery. This has, we believe, created considerable bewilderment in the minds both of the clinical psychiatrists who have to decide which of the methods to choose and of the neurosurgeons who have to practise them. The aim of the present paper is to clarify and disentangle the situation as far as this can be done from the anatomical angle.

Exploring approaches to dietetic assessment of a common task across different universities through assessment moderation

BACKGROUND

Assessment presents one of the greatest challenges to evaluating health professional trainee performance, as a result of the subjectivity of judgements and variability in assessor standards. The present study aimed to test a moderation procedure for assessment across four independent universities and explore approaches to assessment and the factors that influence assessment decisions.

METHODS

Assessment tasks designed independently by each of the four universities to assess student readiness for placement were chosen for the present study. Each university provided four student performance recordings for moderation. Eight different academic assessors viewed the student performances and assessed them using the corresponding university assessment instrument. Assessment results were collated and presented back to the assessors, together with the original university assessment results. Results were discussed with assessors to explore variations. The discussion was recorded, transcribed, thematically analysed and presented back to all assessors to achieve consensus on the emerging major learnings.

RESULTS

Although there were differences in absolute scores, there was consistency (12 out of 16 performances) in overall judgement decisions regarding placement readiness. Proficient communication skills were considered a key factor when determining placement readiness. The discussion revealed: (i) assessment instruments; (ii) assessor factors; and (iii) the subjectivity of judgement as the major factors influencing assessment.

CONCLUSIONS

Assessment moderation is a useful method for improving the quality of assessment decisions by sharing understanding and aligning standards of performance.

New Horizons for the Study of Dietary Fiber and Health: A Review

Dietary fibre has been consumed for centuries with known health benefits, but defining dietary fibre is a real challenge. From a functional perspective, dietary fibre is described as supporting laxation, attenuating blood glucose responses and assisting with cholesterol lowering. The problem is different types of dietary fibre have different effects, and new effects are increasingly observed, such as the influence on gut microbiota. Thus, a single definition may need to be described in more generic terms. Rather than being bound by a few functional definitions, we may need to embrace the possibilities of new horizons, and derive a working definition of dietary fibre based on a set of conceptual principles, rather than the limited definitions we have to date. To begin this process, a review of individual fibre types and their physiological effects would be helpful. Dietary fibre is a complex group of substances, and there is a growing interest in specific effects linked to fibre type. Different fractions of dietary fibre have different physiological properties, yet there is a paucity of literature covering the effects of all fibres. This paper describes a range of individual fibre types and identifies gaps in the literature which may expose new directions for a working definition of dietary fibre.

CYT003, a TLR9 agonist, in persistent allergic asthma - a randomized placebo-controlled Phase 2b study

BACKGROUND

New treatment options are required for patients with asthma not sufficiently controlled with inhaled therapies. In a Phase 2a trial, CYT003, a Toll-like receptor-9 agonist immunomodulator, improved asthma control during inhaled glucocorticosteroid reduction in patients with allergic asthma. This double-blind Phase 2b study assessed the efficacy and safety of CYT003 in patients with persistent moderate-to-severe allergic asthma not sufficiently controlled on standard inhaled glucocorticosteroid therapy with/without long-acting beta-agonists (LABAs).

METHODS

Overall, 365 patients received seven doses of subcutaneous CYT003 (0.3, 1, or 2 mg) or placebo as add-on therapy to conventional controller medication. Change from baseline in Asthma Control Questionnaire (ACQ) score was the primary outcome; secondary outcomes included change in forced expiratory volume, Mini Asthma Quality of Life Questionnaire, and safety.

RESULTS

All groups, including placebo, showed a clinically important improvement in ACQ score; however, there was no significant difference between the CYT003 and placebo groups at week 12 (least-squares mean difference 0.3 mg: -0.027 [95% confidence interval -0.259 to 0.204]; 1 mg: 0.097 [-0.131 to 0.325]; 2 mg: 0.081 [-0.148 to 0.315]). No significant differences were seen in secondary outcomes. CYT003 was well tolerated; the most common treatment-emergent adverse events were injection site reactions. Due to lack of efficacy, the study was prematurely terminated at the end of the treatment phase with no further follow-up.

CONCLUSIONS

Toll-like receptor-9 agonism with CYT003 showed no additional benefit in patients with insufficiently controlled moderate-to-severe allergic asthma receiving standard inhaled glucocorticosteroid therapy with or without LABAs.

Energy and protein intake increases with an electronic bedside spoken meal ordering system compared to a paper menu in hospital patients

BACKGROUND AND AIMS

Electronic bedside spoken meal ordering systems (BMOS) have the potential to improve patient dietary intakes, but there are few published evaluation studies. The aim of this study was to determine changes in the dietary intake and satisfaction of hospital patients, as well as the role of the Nutrition Assistant (NA), associated with the implementation of an electronic BMOS compared to a paper menu.

METHODS

This study evaluated the effect of a BMOS compared to a paper menu at a 210-bed tertiary private hospital in Sydney during 2011-2012. Patient dietary intake, patient satisfaction and changes in NA role were the key outcomes measured. Dietary intake was estimated from observational recordings and photographs of meal trays (before and after patient intake) over two 48 h periods. Patient satisfaction was measured through written surveys, and the NA role was compared through a review of work schedules, observation, time recordings of patient contact, written surveys and structured interviews.

RESULTS

Baseline data were collected across five wards from 54 patients (75% response rate) whilst using the paper menu service, and after BMOS was introduced across the same five wards, from 65 patients (95% response rate). Paper menu and BMOS cohorts' demographics, self-reported health, appetite, weight, body mass index, dietary requirements, and overall foodservice satisfaction remained consistent. However, 80% of patients preferred the BMOS, and importantly mean daily energy and protein intakes increased significantly (paper menu versus BMOS): 6273 kJ versus 8273 kJ and 66 g versus 83 g protein; both p < 0.05. No additional time was required for the NA role, however direct patient interaction increased significantly (p < 0.05), and patient awareness of the NA and their role increased with the BMOS.

CONCLUSIONS

The utilisation of a BMOS improved patient energy and protein intake. These results are most likely due to an enhancement of existing NA work processes, enabling more NA time with patients, facilitating an increase in patient participation and satisfaction with the service.

Über den Katabolismus von Hamamelose [2-C(Hydroxymethyl)-ᴰ-ribose] / On the Catabolism of Hamamelose [2-C-(hydroxymethyl)-ᴰ-ribose]

Free hamamelose [2-C- (hydroxymethyl) -ᴰ-ribose] occurs in almost all higher plants, but except a reduction to the corresponding sugar alcohol (hamamelitol) , no metabolism of this branched chain hexose could be detected in plants until now. Therefore we tried to find microorganisms which would allow us to study the catabolism of hamamelose. A strain of Pseudomonas (“H 1”), showing dependence between growth and hamamelose concentration in the medium (Fig. 1), was isolated from soil on which Primula clusiana was grown (this plant contains large amounts of hamamelose and hamamelitol). However, this organism needs citrate besides hamamelose for growth.

When “H 1” was incubated in a phosphate buffer containing only 14C-labelled hamamelose, hamamelonic acid was the sole radioactive product formed (Tables 2, 3, 4).

As no further degradation of hamamelonic acid by “H 1” could be detected, we conclude that this organism uses hamamelose as a hydrogen source only. Thus it becomes reasonable that “H 1” needs an additional carbon source (citrate) for growth.