Mediterranean diet based intervention in pregnancy to improve maternal and fetal outcomes: Methodological challenges and lessons learned from the multicentre ESTEEM study.

INTRODUCTION: Evaluating complex dietary interventions such as Mediterranean diet in pregnancy presents unique methodological challenges. We present the challenges and the lessons learned from a multicentre randomised trial (ESTEEM) on Mediterranean-based dietary intervention in pregnancy. METHODS: We recruited pregnant women who met our predefined inclusion criteria and randomised those with metabolic risk factors to the Mediterranean-based dietary intervention or routine antenatal care. We evaluated the effect of the ESTEEM intervention on composite maternal and fetal outcomes. CHALLENGES AND SOLUTIONS: The main challenges were encountered in recruiting to ESTEEM, delivering the intervention, engaging clinical staff, assessing adherence and choosing the outcome measures. The large sample size coupled with the slow recruitment rate forced us to extend the recruitment period by 4 months. The limitation in available resources was overcome by opening sites in a step-wise approach. Engaging healthcare providers was promoted by embedding the recruitment and the follow-up activities into current clinical practice, and promoting research skills training. We delivered the intervention early on in the pregnancy to promote the dietary effect on healthy placentation and reduce metabolic risk factors. Participants and their families were actively involved in the dietary intervention to improve adherence through a series of group teaching sessions. A user-friendly short dietary questionnaire was developed and validated to assess adherence to the intervention. The trial composite primary outcome was chosen in consensus based on input from a panel of experts. CONCLUSION: The ESTEEM experience offers an insight into future pragmatic nutritional studies in pregnancy. TRIAL REGISTRATION NUMBER: NCT02218931.

Transfusion-related acute lung injury in patients with burns.

Transfusion-related acute lung injury (TRALI) has not been systematically described in patients with burn injury, and the characterization of TRALI in patients with pre-existing acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) also is lacking. Our aim was to identify TRALI in burn patients and to attempt to characterize transfusion (TXN)-related pulmonary deterioration in burn patients with pre-existing ALI or ARDS. We undertook a retrospective review of mechanically ventilated and transfused burn patients at an adult regional burn center between January 1, 2003, and January 5, 2005. A blinded intensivist independently rated pre- and post-TXN chest radiographs (CXRs). There were 25 patients (age 51 +/- 19 years, %TBSA burns 30 +/- 19, full thickness %BSA 17 +/- 19, with a 24% incidence of smoke inhalation) who received 124 TXNs. New ALI developed within 6 hours after four TXNs. In one TXN, there were no other precipitating causes (eg, infection, inhalation injury), suggesting possible TRALI (incidence 0.8%). Existing ALI or ARDS was present before 63 (51%) of the TXNs. Definite worsening of the CXR and deterioration in the PaO2/FiO2 ratio (18% +/- 4%) within 6 hours of TXN occurred after six transfusions. In two of the TXNs, there were no other precipitating causes, suggesting possible TXN-related pulmonary deterioration (incidence 3.2%). Vigilance must be maintained for TRALI in burn patients. For patients with existing ALI or ARDS, we suggest that worsening of the CXR and reduction in the PaO2/FiO2 ratio by 20% or more within 6 hours of transfusion should be investigated for possible TRALI with appropriate donor investigations.

Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomized controlled trial.

OBJECTIVE: Olanzapine is the most commonly prescribed atypical antipsychotic medication in Australia. Research reports an average weight gain of between 4.5 and 7 kg in the 3 months following its commencement. Trying to minimize this weight gain in a population with an already high prevalence of obesity, mortality and morbidity is of clinical and social importance. This randomized controlled trial investigated the impact of individual nutrition education provided by a dietitian on weight gain in the 3 and 6 months following the commencement of olanzapine. METHOD: Fifty-one individuals (29 females, 22 males) who had started on olanzapine in the previous 3 months (mean length of 27 days +/- 20) were recruited through Peninsula Health Psychiatric Services and were randomly assigned to either the intervention (n = 29) or the control group (n = 22). Individuals in the intervention group received six 1 hour nutrition education sessions over a 3-month period. Weight, waist circumference, body mass index (BMI) and qualitative measures of exercise levels, quality of life, health and body image were collected at baseline at 3 and 6 months. RESULTS: After 3 months, the control group had gained significantly more weight than the treatment group (6.0 kg vs 2.0 kg, p < or = 0.002). Weight gain of more than 7% of initial weight occurred in 64% of the control group compared to 13% of the treatment group. The control group's BMI increased significantly more than the treatment group's (2 kg/m(2)vs 0.7 kg/m(2), p < or = 0.03). The treatment group reported significantly greater improvements in moderate exercise levels, quality of life, health and body image compared to the controls. At 6 months, the control group continued to show significantly more weight gain since baseline than the treatment group (9.9 kg vs 2.0 kg, p < or = 0.013) and consequently had significantly greater increases in BMI (3.2 kg/m(2)vs 0.8 kg/m(2), p < or = 0.017). CONCLUSION: Individual nutritional intervention provided by a dietitian is highly successful at preventing olanzapine-induced weight gain.

Integrating mental illness prevention into community-based undergraduate education.

Including preventive models of health care in undergraduate education is essential as the nursing profession moves increasingly to community-based care. Traditionally, mental health curricula have focused primarily on psychopathology. This article presents current research in the attachment and temperament literature, which provides sound evidence for the need to synthesize prevention of mental illness concepts into undergraduate education. A curriculum model that integrates concepts from psychiatry and public health to prepare nursing students to promote mental health is described.