Improving the nutritional intake of hospital patients: how far have we come? A re-audit.

BACKGROUND: Malnutrition affects up to 33.6% of hospitalised patients, with consequences that are detrimental for both patients and healthcare providers. In 2015, an audit demonstrated inadequate nutritional provision and consumption by hospitalised patients, comprising a major risk factor for malnutrition. This re-audit evaluates whether patients are meeting recommended energy and protein standards and estimated individual requirements, subsequent to food service improvements since 2015. METHODS: Patients (n = 111) were included from a South West hospital, and Malnutrition Universal Screening Tool scores (MUST) categorised patients as 'nutritionally well' (MUST 0) or 'nutritionally vulnerable' (MUST ≥ 1). Individual energy and protein requirements were estimated using weight-based equations. Nutritional intakes were assessed via 24-h dietary recall and compared against the British Dietetic Association's Nutrition and Hydration Digest standards, as well as estimated individual requirements. RESULTS: In total, the Digest standards for energy and protein were met by 35% and 63% of patients respectively, which is an increase of 19% and 36% since 2015. 'Nutritionally well' patients were more likely to meet nutrient standards for protein (62%) than estimated individual requirements (30%) (P ≤ 0.001). 'Nutritionally vulnerable' patients were more likely to meet estimated individual requirements for energy (60%) than the Digest standards (30%) (P = 0.047). CONCLUSIONS: The proportion of patients meeting the Digest standards has increased considerably following numerous food service changes. Nutritional training for housekeepers, energy/protein-dense snacks and drinks, and fortified dietary items may further increase nutritional intakes. Additionally, as a result of discrepancies between the Digest standards and individual estimated requirements, more research is required to identify the most appropriate auditing standards that reflect best practice.

Are energy and protein requirements met in hospital?

BACKGROUND: Malnutrition is a problem within hospitals, which impacts upon clinical outcomes. The present audit assesses whether a hospital menu meets the energy and protein standards recommended by the British Dietetic Association's (BDA) Nutrition and Hydration Digest and determines the contribution of oral nutrition supplements (ONS) and additional snacks. METHODS: Patients in a UK South West hospital were categorised as 'nutritionally well' or 'nutritionally vulnerable' in accordance with their Malnutrition Universal Screening Tool score. Energy and protein content of food selected from the menu ('menu choice'), menu food consumed ('hospital intake') and total food consumed including snacks ('overall intake') were calculated and compared with the standards. RESULTS: In total, 93 patients were included. For 'nutritionally well' patients (n = 81), energy and protein standards were met by 11.1% and 33.3% ('menu choice'); 7.4% and 22.2% ('hospital intake'); and 14.8% and 28.4% ('overall intake'). For 'nutritionally vulnerable' patients (n = 12), energy and protein standards were met by 0% and 8.3% ('menu choice'); 0% and 8.3% ('hospital intake'); and 8.3% and 16.7% ('overall intake'). Ten percent of patients consumed ONS. Patients who consumed hospital snacks (34%) were more likely to meet the nutrient standards (P ≤ 0.001). CONCLUSIONS: The present audit demonstrated that most patients are not meeting the nutrient standards recommended by the BDA Nutrition and Hydration Digest. Recommendations include the provision of energy/protein-dense snacks, as well as menu, offering ONS where clinically indicated, in addition to training for staff. A food services dietitian is ideally placed to lead this, forming a vital link between patients, caterers and clinical teams.

A qualitative study of the meaning of oral health and self-care for 40 Dunedin residents living on lower incomes.

BACKGROUND AND OBJECTIVES: This project extends studies of oral health cultures for lower income families by identifying the participants' meaning of oral health self-care, barriers to its attainment, and suggestions for its improvement. METHODS: Forty open-ended interviews were conducted with Dunedin residents purposively selected from a variety of ages, backgrounds and ethnicities. Transcribed interviews were analysed thematically. RESULTS: Five key themes emerged: (1) oral health understandings for self and wider family groups; (2) the complexity of understanding cost in relation to oral self-care; (3) oral self-care tools and daily oral health routines; (4) relationships with oral health workers and the meaning of good and bad care provision; and (5) the State's involvement in oral health. CONCLUSIONS: Participants valued good oral health and were knowledgeable about it, but cost was the primary barrier to care.

Production of human chorionic gonadotrophin by a hepatoblastoma resulting in precocious puberty.

A two year old boy presented with precocious puberty associated with hepatoblastoma. Serum concentrations of beta human chorionic gonadotrophin and alpha-fetoprotein were raised. An aggressive chemotherapeutic regimen resulted in useful palliation and interesting changes in the beta human chorionic gonadotrophin and alpha-fetoprotein concentrations. In contrast to a previous report, the ultrastructure of the tumour showed frequent Golgi apparatus but no other electron dense membrane bound vesicles.

Artificial pneumothorax can be used to prevent lung toxicity in chest wall radiotherapy.

We report two patients in whom an artificial pneumothorax was induced to reduce the risk of radiation pneumonitis and fibrosis after treatment for chest wall tumours. The procedure was well tolerated; the only complication observed was a single episode of syncope following over-inflation. High doses of radiation were given to large chest wall fields with no clinical or radiological evidence of pneumonitis or fibrosis, either during or after treatment. The available literature on the use of artificial pneumothorax with radiation is reviewed, and the technique of induction is described.

Detection of amphetamine and methamphetamine-type materials in pharmaceutical and biological fluids by fluorometric labeling.

A rapid and sensitive method for detecting amphetamine and methamphetamine in drug preparations and biological fluids has been developed. Amphetamine and methamphetamine in pharmaceutical and clandestine drug preparations can be easily screened from other contaminating drugs and readily identified by their fluorescence, with subsequent separation accomplished by TLC. The same general procedure can also be used to detect amphetamine and methamphetamine in human urine at concentrations of 0.1 mug/ml.

Cervical cancer: changing trends in the Wellington region.

AIM: To identify changes in patient and tumour characteristics of women with carcinoma of the cervix treated through the Wellington Regional oncology unit between 1975-89. METHODS: The medical records of the patients treated between 1985-9 were reviewed. The age and stage of disease was noted in each case and results compared with the previous two 5-year cohorts. RESULTS: Over the 15 year period there was no obvious reduction in the incidence of cervical cancer. There was a significant trend towards women presenting with earlier stage disease. In the 1985-9 cohort, patients less than 40 years old were significantly more likely to present with earlier stage disease, and there was no detectable difference between the incidence of cervical cancer in Maori and nonMaori. CONCLUSIONS: The results indicate that cervical screening has not yet made an impact on the incidence of cervical cancer in the greater Wellington region, and possible reasons for this are discussed.

Managing serum phosphate in haemodialysis patients: time for an innovative approach?

BACKGROUND/OBJECTIVES: Hyperphosphataemia, a common biochemical abnormality in chronic kidney disease, poses significant management challenges. This study aims to determine whether the reasons for this are multifactorial; including poor dietary knowledge, poor adherence to a low phosphate diet and phosphate-binding medications and the impact of age on these parameters. SUBJECTS/METHODS: In order to compare serum phosphate and other associated parameters to the UK Renal Association Clinical Practice Guidelines 2010 an audit and service evaluation questionnaire was carried out in May 2011 on 130 haemodialysis outpatients attending the Plymouth Dialysis Unit. RESULTS: Fifty-three percent of patients had serum phosphate within the target range of 1.1-1.7 mmol/l, 77% and 85% had serum calcium and parathyroid hormone within target ranges, respectively. Younger patients (18-45 years) were significantly less likely to have serum phosphate within range χ(2) (2, n=124)=18.77, P<0.001. Despite better knowledge of their own phosphate levels (P=0.005), phosphorus-rich foods (P<0.001), symptoms of hyperphosphataemia (P<0.001) and increased use of Renal Patient View (P=0.002), <65 years old had significantly higher phosphate levels than those >65 years (P<0.001). No significant associations were found between phosphate control and the following factors: gender, timing of dialysis shift, years on dialysis or dialysis adequacy. CONCLUSIONS: In this population, despite better knowledge, younger patients have worse phosphate control than older patients. Using the same dietary education techniques may not be suitable for all ages, more innovative approaches supported by skilled health professionals are needed to motivate and engage with younger patients to promote self-management and adherence.

Hepatic fibrosis and cirrhosis in the Fontan circulation: a detailed morphological study.

AIMS: To describe the histological features of the liver in patients with a Fontan circulation. METHODS: Specimens from liver biopsies carried out as part of preoperative assessment prior to extracardiac cavopulmonary conversion of an older style Fontan were examined and scored semi-quantitatively for pertinent histological features. To support the use of the scoring, biopsy specimens were also ranked by eye for severity to allow correlation with assigned scores. RESULTS: Liver biopsy specimens from 18 patients with a Fontan circulation were assessed. All specimens showed sinusoidal fibrosis. In 17 cases there was at least fibrous spur formation, with 14 showing bridging fibrosis and 2 showing frank cirrhosis. In 17 cases at least some of the dense or sinusoidal fibrosis was orcein positive, although a larger proportion of the dense fibrous bands were orcein positive compared with the sinusoidal component. All specimens showed marked sinusoidal dilatation, and 14 showed bile ductular proliferation; 1 showed minimal iron deposition, and 1 showed mild lobular lymphocytic inflammation. There was no cholestasis or evidence of hepatocellular damage. Similar appearances were observed in 2 patients with severe tricuspid regurgitation. DISCUSSION: The histological features of the liver in patients with a Fontan circulation are similar to those described in cardiac sclerosis. Sinusoidal dilatation and sinusoidal fibrosis are marked in the Fontan series. The presence of a significant amount of orcein negative sinusoidal fibrosis suggests there may be a remediable component, although the dense fibrous bands are predominantly orcein positive, suggesting chronicity and permanence. No inflammation or hepatocellular damage is evident, suggesting that fibrosis may be mediated by a non-inflammatory mechanism.

Hepatocyte inclusions of alpha 1-antichymotrypsin in a patient with partial deficiency of alpha 1-antichymotrypsin and chronic liver disease.

We present a case of chronic liver disease with selective and exclusive hepatocyte endoplasmic reticulum storage of alpha 1-antichymotrypsin in the form of granules, detected by specific immunohistochemistry at the light microscopy level and corresponding to material found in dilated endoplasmic reticulum of hepatocytes by electron microscopy. The patient had intermediate deficiency of alpha 1-antichymotrypsin. Thus, the hepatocyte accumulation of alpha 1-antichymotrypsin may indicate the presence of an export block resembling that of a closely-related protein, namely PiZ alpha 1-antitrypsin. It is proposed that hepatocyte storage of alpha 1-antichymotrypsin may be an expression of an inborn error of metabolism bearing the characteristics of endoplasmic reticulum storage diseases such as PiZ alpha 1-antitrypsin deficiency and hereditary hypofibrinogenaemia.

Modification of biological responses to interleukin-1 by agents that perturb signal transduction pathways.

In this study we have examined the effect of agents known to perturb certain signal transduction pathways on the biological responses of target cells to stimulation with interleukin-1 (IL-1). In the murine thymoma cell line EL4, IL-1 stimulation results in the secretion of interleukin-2 (IL-2), which was subsequently measured by proliferation of an IL-2-dependent cell line. Agents that elevated intracellular cAMP blocked or partially blocked IL-1 induction of IL-2 secretion, whereas agents that activated protein kinase C (PKC) resulted in a synergistic enhancement. Both pertussis and cholera toxins also inhibited IL-1-induced IL-2 secretion, although probably by acting at different levels. IL-1 simulation of human and murine fibroblasts resulted in release of prostaglandin E2. This response was inhibitable by pertussis toxin but not by cholera toxin, whereas co-stimulation of the fibroblasts with IL-1 and phorbol ester resulted in a synergistic response. Murine fibroblasts could also be stimulated to proliferate by IL-1, and this response was also inhibitable by pertussis toxin. These findings are consistent with coupling of the IL-1 receptor to a signalling pathway via a pertussis toxin substrate.

Interleukin-10 expression and function in experimental murine liver inflammation and fibrosis.

Kupffer cells (KC) play a central role in the initiation and perpetuation of hepatic inflammation, which, if uncontrolled, can result in tissue damage, fibrosis, and cirrhosis. Interleukin-10 (IL-10) can inhibit a range of macrophage functions. We hypothesized that the transcription, synthesis, and release of IL-10 may influence the development of liver injury. Rat KC were activated in vitro with lipopolysaccharide (LPS), and expression of IL-10 mRNA compared with IL-13 and IL-1beta by reverse-transcription polymerase chain reaction (RT-PCR). The effects of pretreatment with recombinant IL-10 (rIL-10) on KC phagocytosis, production of superoxide (SO), and tumor necrosis factor (TNF-) were examined by fluorescent activated cell sorter (FACS), reduction of ferricytochrome C, and bioassay, respectively. Rats were administered intraperitoneal carbon tetrachloride (CCl4), and expression of IL-10 mRNA and protein in vivo compared with IL-13 and IL-1beta by RT-PCR and immunoblotting. Results were correlated with histological inflammatory changes. Finally, IL-10 gene-deleted (IL-10-/-) mice and wild-type (WT) controls were administered intraperitoneal CCl4 biweekly for up to 70 days, and the development of inflammation and fibrosis compared by scoring histological changes. IL-10 mRNA was up-regulated early, both in KC in vitro and in whole liver in vivo, concurrent with that of IL-1beta. IL-10 was able to inhibit KC production of both SO and TNF- in vitro, and this was achieved more effectively than IL-4 or IL-13; no such effects were seen on KC phagocytosis. After 70 days of treatment with CCl4, IL-10-/- mice showed significantly more severe fibrosis and exhibited higher hepatic TNF- levels than WT controls. These results suggest that IL-10 synthesized during the course of liver inflammation and fibrosis may modulate KC actions, and influence subsequent progression of fibrosis.

Evaluation of a transgenic mouse model for alpha-1-antitrypsin (AAT) related liver disease.

We have attempted to produce a transgenic mouse model of the neonatal liver disease associated with the human PIZ allele. Analysis of a number of transgenic mouse lines carrying either a normal human PIM gene construct or the mutant Z is reported. Using isoelectric focusing analysis of plasma from transgenic mice, we have shown that the human AAT proteins produced in mice are processed in a similar way to their counterparts in humans. By comparing the level of M and Z mRNA in liver with the levels of M and Z proteins in plasma we have inferred that, as in humans, the mutant protein tends to accumulate within the hepatocyte. Accumulation of Z protein has also been demonstrated by immunocytochemistry. Two of the M transgenic lines produce such high levels of the human protein that it, like the Z protein, accumulates as globules. Histological features of livers from 116 mice of different ages and genotypes were examined: 37 non-transgenic, 62 Z transgenic (23 low expressing and 39 high expressing) and 17 M transgenic mice, all high expressing. Cirrhosis or fibrosis was not seen in any animal and we were unable to find any evidence for neonatal liver disease. Some necrosis was seen in all genotypes and this increased significantly with age with one Z line showing significantly more frequent necrosis than any other group. This line, the highest expressing Z line, was back crossed onto 7 different genetic backgrounds but no major differences between the back crosses with respect to liver disease were observed. The mouse model we have developed is compared with other transgenic Z mouse models; none of these is representative of human neonatal liver disease. Our view is that the transgenic animals generated in these experiments may be most useful for investigating the liver manifestations that almost invariably occur in ZZ adults. Alteration of additional factors other than accumulation of Z protein, for example inactivation of the endogenous mouse genes or some environmental challenge, might produce a mouse model with more relevance to neonatal liver disease.