Small-bore feeding tubes placed with an electromagnetic imaging device leads to cost avoidance and decreased time to initiation of enteral nutrition.

BACKGROUND: The Cortrak Enteral Access System (CEAS) was previously approved by the United States Food and Drug Administration (FDA) to be used in lieu of radiographic confirmation imaging for feeding tubes placed by trained clinicians. Following an institutional protocol change in 2016, our registered dietitians had the option to forgo radiographic confirmation imaging for tubes placed using the CEAS. Our research aimed to determine the difference in the number of radiographic confirmation images for feeding tubes placed using the CEAS between preprotocol and postprotocol environments and the associated cost avoidance after the institutional policy change. METHODS: We retrospectively reviewed data from 506 tube placements (n = 253 per protocol environment) in adult patients with diverse diagnoses admitted to various in-patient care units. RESULTS: There was a significant reduction in the mean number of radiographic images per tube placement (preprotocol = 1.10 [95% CI, 1.05-1.15]; postprotocol = 0.36 [95% CI, 0.30-0.41]; P < 0.001), leading to a cost avoidance of $67,282.80 for the 253 tube placements and a potential cost avoidance of $279,236 over the 5-year postprotocol environment. Additionally, the mean time to initiation of enteral nutrition was significantly reduced by 2.65 h in the postprotocol environment (P < 0.001). CONCLUSION: Our findings suggest that using the CEAS can reduce the number of radiographic images, provide cost avoidance, and improve nutrition outcomes. However, updated 2022 FDA regulatory changes to the use of the CEAS for tube confirmation lead to an uncertain future for this practice because of safety concerns.

The Collaborative Care Model: Realizing healthcare values and increasing responsiveness in the pharmacy workforce.

Healthcare values are fairly ubiquitous across the globe, focusing on caring and respect, patient health, excellence in care delivery, and multi-stakeholder collaboration. Many individual pharmacists embrace these core values. However, their ability to honor these values is significantly determined by the nature of the system in which they work. The paper starts by presenting the prevailing pharmacist workforce model, the 'Atomistic' Model, in Scotland, in which core roles are typically separated into hierarchically disaggregated jobs focused on one professional 'pillar': Clinician/Practice Provider; Educator; Leader/Manager; and Researcher. This skills-segregation yields a workforce of individuals working in isolation rather than collaborating, lacking a shared purpose. Key strategic flaws include suboptimal responsiveness to population needs, inconsistency/inequity of care, erosion of professional agency, and lower job satisfaction. It is conjectured that this results from a lack of congruence between values, professional ethos, and organizational structure. 'Atomism' culminates in a syndrome of widespread professional-level cognitive dissonance. The paper contrasts this with an emerging workforce vision, the Collaborative Care Model. This new model defines a systems-first-approach, built on the principle that all jobs must include all four professional 'pillars'. Vertical skills integration, involving education and task sharing, supports sustainability and succession planning. Horizontal skills integration (across practice, leadership/management, education, and research) is included to improve responsiveness to population need and individual professional agency. The working conditions, supportive ethos, and career structure needed to make the model work are described. Moral and workforce theory are used to justify why the model may be more effective for population health, delivering greater job satisfaction for individuals and ultimately helping systematically realize healthcare values. Finally, the paper sketches the first steps needed to implement the model at the national level, starting with the operationalization of new multi-'pillar' professional curricula across the career spectrum. Potential challenges also are discussed.

Human total, basal and activity energy expenditures are independent of ambient environmental temperature.

Lower ambient temperature (Ta) requires greater energy expenditure to sustain body temperature. However, effects of Ta on human energetics may be buffered by environmental modification and behavioral compensation. We used the IAEA DLW database for adults in the USA (n = 3213) to determine the effect of Ta (-10 to +30°C) on TEE, basal (BEE) and activity energy expenditure (AEE) and physical activity level (PAL). There were no significant relationships (p > 0.05) between maximum, minimum and average Ta and TEE, BEE, AEE and PAL. After adjustment for fat-free mass, fat mass and age, statistically significant (p < 0.01) relationships between TEE, BEE and Ta emerged in females but the effect sizes were not biologically meaningful. Temperatures inside buildings are regulated at 18-25°C independent of latitude. Hence, adults in the US modify their environments to keep TEE constant across a wide range of external ambient temperatures.

Use of Natural Spoken Language With Automated Mapping of Self-reported Food Intake to Food Composition Data for Low-Burden Real-time Dietary Assessment: Method Comparison Study.

BACKGROUND: Self-monitoring food intake is a cornerstone of national recommendations for health, but existing apps for this purpose are burdensome for users and researchers, which limits use. OBJECTIVE: We developed and pilot tested a new app (COCO Nutritionist) that combines speech understanding technology with technologies for mapping foods to appropriate food composition codes in national databases, for lower-burden and automated nutritional analysis of self-reported dietary intake. METHODS: COCO was compared with the multiple-pass, interviewer-administered 24-hour recall method for assessment of energy intake. COCO was used for 5 consecutive days, and 24-hour dietary recalls were obtained for two of the days. Participants were 35 women and men with a mean age of 28 (range 20-58) years and mean BMI of 24 (range 17-48) kg/m2. RESULTS: There was no significant difference in energy intake between values obtained by COCO and 24-hour recall for days when both methods were used (mean 2092, SD 1044 kcal versus mean 2030, SD 687 kcal, P=.70). There were also no significant differences between the methods for percent of energy from protein, carbohydrate, and fat (P=.27-.89), and no trend in energy intake obtained with COCO over the entire 5-day study period (P=.19). CONCLUSIONS: This first demonstration of a dietary assessment method using natural spoken language to map reported foods to food composition codes demonstrates a promising new approach to automate assessments of dietary intake.

Effectiveness of an Energy Management Training Course on Employee Well-Being: A Randomized Controlled Trial.

PURPOSE: Programs focused on employee well-being have gained momentum in recent years, but few have been rigorously evaluated. This study evaluates the effectiveness of an intervention designed to enhance vitality and purpose in life by assessing changes in employee quality of life (QoL) and health-related behaviors. DESIGN: A worksite-based randomized controlled trial. SETTING: Twelve eligible worksites (8 randomized to the intervention group [IG] and 4 to the wait-listed control group [CG]). PARTICIPANTS: Employees (n = 240) at the randomized worksites. INTERVENTION: A 2.5-day group-based behavioral intervention. MEASURES: Rand Medical Outcomes Survey (MOS) 36-item Short-Form (SF-36) vitality and QoL measures, Ryff Purpose in Life Scale, Center for Epidemiologic Studies questionnaire for depression, MOS sleep, body weight, physical activity, diet quality, and blood measures for glucose and lipids (which were used to calculate a cardiometabolic risk score) obtained at baseline and 6 months. ANALYSIS: General linear mixed models were used to compare least squares means or prevalence differences in outcomes between IG and CG participants. RESULTS: As compared to CG, IG had a significantly higher mean 6-month change on the SF-36 vitality scale ( P = .003) and scored in the highest categories for 5 of the remaining 7 SF-36 domains: general health ( P = .014), mental health ( P = .027), absence of role limitations due to physical problems ( P = .026), and social functioning ( P = .007). The IG also had greater improvements in purpose in life ( P < .001) and sleep quality (index I, P = .024; index II, P = .021). No statistically significant changes were observed for weight, diet, physical activity, or cardiometabolic risk factors. CONCLUSION: An intensive 2.5-day intervention showed improvement in employee QoL and well-being over 6 months.

Health Care of Sexual Minority Women.

Sexual minority women may be invisible in health care settings unless practitioners ask every patient about sexual attractions/behaviors and identity. Sexual minority women need to feel comfortable and able to share information about their sexual identity, partners, and lives. No medical diagnoses are found more commonly in sexual minority women, but problems such as overweight/obesity, increased tobacco and alcohol use, increased mental health problems, and a past history of childhood sexual abuse are common. These factors intertwine when treating sexual minority women.

Understanding operator stent choice in the catheterization laboratory using a pre-procedure survey: Opportunities for quality improvement.

OBJECTIVES: We sought to characterize how the perceived risk of early dual antiplatelet therapy (DAPT) discontinuation is incorporated into operator decision-making regarding stent choice, using a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation. BACKGROUND: Understanding which factors influence operator decision-making regarding stent choice during percutaneous coronary intervention (PCI) could help identify areas for quality improvement. METHODS: We retrospectively identified 1202 patients who underwent PCI from July 2008 to January 2013 at the Durham Veterans Affairs Medical Center. We excluded patients without a complete pre-procedure survey within 14days of PCI, repeat procedures on the same patient and those who received both drug-eluting stents (DES) and bare-metal stents (BMS) or no stent during PCI, leaving 864 patients. The primary outcome was the independent association of "yes" responses to survey items with the odds of DES use during PCI. RESULTS: Of 864 patients, 661 received DES and 203 received BMS. A "yes" response to "planned major surgery or dental work in the next year" (OR 0.20, 95% CI 0.11-0.36, p<0.001), "recent bleeding event or bleeding diathesis" (OR 0.31, 95% CI 0.14-0.68, p=0.003) or "currently taking Coumadin" (OR 0.39, 95% CI 0.19-0.78, p=0.007) was independently associated with lower odds of DES use. CONCLUSIONS: Responses to 3 items on a simple pre-procedure survey screening for clinical variables that may lead to early DAPT discontinuation were independently associated with stent type used during PCI, suggesting the importance of these factors in an operator's stent choice.

Association of nutrition club membership with markers of health: a cross sectional study.

BACKGROUND: Nutrition clubs (NC) operate in community settings and provide members with nutrition education and meal replacements for weight management. NC are owned and operated by distributors of Herbalife products. There are over 6200 NC in the US, but there has been no independent assessment of the association of these NC with biomarkers of health. METHODS: We conducted a cross-sectional pilot study to compare the health status of 100 NC members to 100 community-matched controls (CC) in the greater Boston area. Each CC was matched to a NC member for community of residence (zip code), age category, gender, BMI category, race/ethnicity, education level (category), and readiness to make health changes. Measures obtained included cardio-metabolic risk factors, body composition, markers of nutritional status, reported health status, dietary intake, physical activity, sleep and depression. RESULTS: Participants were predominantly female (64%) and Hispanic (73%). NC members had significantly lower fasting insulin (P < 0.001) and lower HbA1c (P = 0.008), higher levels of 25 hydroxy-vitamin D (P = 0.001), and vitamin E:cholesterol ratio (P < 0.001), and lower prevalence of metabolic syndrome (P = 0.02) compared to CC. In addition, most of the NC members (99%) were satisfied with Herbalife NC membership for themselves and their families. A higher percentage of NC members (86%) compared to CC (32%) reported being in much better or somewhat better health compared to a year ago (P < 0.001); and they reported significantly better physical health (P = 0.03), and fewer sleep problems (P = 0.03). CONCLUSION: Herbalife NC membership was positively associated with perceived health and measured cardiometabolic benefits. However, causality cannot be inferred from these findings.

Body-composition changes in the Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy (CALERIE)-2 study: a 2-y randomized controlled trial of calorie restriction in nonobese humans.

Background: Calorie restriction (CR) retards aging and increases longevity in many animal models. However, it is unclear whether CR can be implemented in humans without adverse effects on body composition.Objective: We evaluated the effect of a 2-y CR regimen on body composition including the influence of sex and body mass index (BMI; in kg/m2) among participants enrolled in CALERIE-2 (Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy), a multicenter, randomized controlled trial.Design: Participants were 218 nonobese (BMI: 21.9-28.0) adults aged 21-51 y who were randomly assigned to 25% CR (CR, n = 143) or ad libitum control (AL, n = 75) in a 2:1 ratio. Measures at baseline and 12 and 24 mo included body weight, waist circumference, fat mass (FM), fat-free mass (FFM), and appendicular mass by dual-energy X-ray absorptiometry; activity-related energy expenditure (AREE) by doubly labeled water; and dietary protein intake by self-report. Values are expressed as means ± SDs.Results: The CR group achieved 11.9% ± 0.7% CR over 2-y and had significant decreases in weight (-7.6 ± 0.3 compared with 0.4 ± 0.5 kg), waist circumference (-6.2 ± 0.4 compared with 0.9 ± 0.5 cm), FM (-5.4 ± 0.3 compared with 0.5 ± 0.4 kg), and FFM (-2.0 ± 0.2 compared with -0.0 ± 0.2 kg) at 24 mo relative to the AL group (all between-group P < 0.001). Moreover, FFM as a percentage of body weight at 24 mo was higher, and percentage of FM was lower in the CR group than in the AL. AREE, but not protein intake, predicted preservation of FFM during CR (P < 0.01). Men in the CR group lost significantly more trunk fat (P = 0.03) and FFM expressed as a percentage of weight loss (P < 0.001) than women in the CR group.Conclusions: Two years of CR had broadly favorable effects on both whole-body and regional adiposity that could facilitate health span in humans. The decrements in FFM were commensurate with the reduced body mass; although men in the CR group lost more FFM than the women did, the percentage of FFM in the men in the CR group was higher than at baseline. CALERIE was registered at clinicaltrials.gov as NCT00427193.

Effectiveness of Workplace Weight Management Interventions: a Systematic Review.

A systematic review was conducted of randomized trials of workplace weight management interventions, including trials with dietary, physical activity, environmental, behavioral, and incentive-based components. Main outcomes were defined as change in weight-related measures. Keywords related to weight management and workplace interventions were used to search relevant databases, and 23 eligible studies were reviewed in detail using a data extraction form and quality assessment checklist. The trials were conducted mainly in the USA and Europe, with four additional countries represented. Interventions were mostly multicomponent and were implemented in both sexes and in a range of employment categories. Intervention effectiveness appeared unrelated to region of the world and was highest in 6-12-month trials. The results ranged widely from clinically significant 8.8-kg weight loss in one trial to less effective than the control treatment in others. Some workplace interventions achieve clinically significant benefits, and further studies are needed to replicate those results in wider sociocultural and geographical contexts.

Changes in children's meal orders following healthy menu modifications at a regional U.S. restaurant chain.

OBJECTIVE: To examine changes in children's meal orders, price, and revenue following the implementation of a healthier children's menu in a full-service restaurant chain. METHODS: In April 2012, the healthier menu was implemented, featuring more meals meeting nutrition standards, healthy side dishes by default, and removal of French fries and soda (which could be substituted). Orders (n = 352,192) were analyzed before (September 2011 to March 2012; PRE) and after (September 2012 to March 2013; POST) implementation. RESULTS: Children's meal prices increased by $0.79 for breakfasts and $0.19 for non-breakfast meals from PRE to POST. Revenue continued to increase post-implementation. Orders of healthy meals, strawberry and vegetable sides, milk, and juice increased, and orders of French fries and soda decreased (P < 0.0001). Orders at POST were more likely to include healthy sides (P < 0.0001) and substitutions (P < 0.0001) and less likely to include a la carte sides (P < 0.0001) and desserts (P < 0.01), versus PRE. Total calories ordered by children accepting all defaults decreased (684.2 vs. 621.2; P < 0.0001) and did not change for those not accepting defaults (935.0 vs. 942.9; P = 0.57). CONCLUSIONS: Healthy children's menu modifications were accompanied by healthier ordering patterns, without removing choice or reducing revenue, suggesting that they can improve child nutrition while restaurants remain competitive.

Primary care of women who have sex with women. Recommendations from the research.

Research on women who have sex with women has increased in the last decade. Attention has been brought to this group of women through the IOM report, which noted a lack of research related to their care. Most of the research has not been published in nursing literature. This article reviews this literature with recommendations for primary care practice.

Low Levels of Energy Expenditure in Childhood Cancer Survivors: Implications for Obesity Prevention.

Childhood cancer survivors are at an increased risk of obesity but causes for this elevated risk are uncertain. We evaluated total energy expenditure in childhood cancer survivors using the doubly labeled water method in a cross-sectional study of 17 survivors of pediatric leukemia or lymphoma (median age, 11.5 y). Mean total energy expenditure was 2073 kcal/d, which was nearly 500 kcal/d lower than estimated energy requirements with recommended levels of physical activity. This energy gap is likely to contribute to the risk of obesity in this population and future trials are needed to assess implications and potential treatment strategies.

Improving patient outcomes through registered dietitian order writing.

Traditionally, registered dietitians (RD) have not had order writing privileges in most patient-care facilities and rely on physicians to implement their recommendations. Research has demonstrated that this model results in a high percentage of RD recommendations not being ordered. Timely nutrition interventions are important due to the prevalence of malnutrition in the hospital setting and when RD recommendations are implemented, important outcomes are improved. In addition, several studies have demonstrated that when RDs have order writing privileges, which allows more assurance that an intervention will occur and timely interventions, improved outcomes, such as improved nutrition status, better management of electrolytes and glycemic control, reaching goal calories sooner, reduction in inappropriate parenteral nutrition use, cost savings, and less error with electronic order entry. The process for implementation and outcomes of an RD order writing program at 1 large, urban, tertiary medical center is described. The program has been successful, but the implementation process required multiple years and ongoing monitoring through data collection to ensure success. RDs interested in order writing privileges must consider federal and state regulations, their individual scope of practice (relevant training and competency assessment), and how to obtain approval from the appropriate hospital governing committees. RDs who obtain order writing privileges must understand "with privilege comes responsibility" and should plan to conduct outcomes research to promote the value and acceptance of RD order writing by regulatory agencies at all levels and hospital leaders, for instance physicians and administrators.

Treatment of vitamin D deficiency: divergence between clinical practice and expert advice.

BACKGROUND: Current recommendations for the treatment of vitamin D deficiency vary from calciferol 800 IU per day to loading doses of vitamin D followed by maintenance therapy of up to 2000 IU per day. OBJECTIVE: To assess the preparations and doses of vitamin D used to load and maintain patients with serum 25-hydroxyvitamin D (25OHD) <25 nmol/l. METHODS: We examined all requests for serum 25OHD over a 12-month period, from September 2009 to 2010 in southwest Scotland. We wrote to all 33 general practices asking whether they usually started replacement therapy with a loading dose and/or recommended over-the-counter maintenance preparations. We accessed the Emergency Care Summary for all patients with serum 25OHD <25 nmol/l to determine whether they had been prescribed maintenance therapy. RESULTS: Serum 25OHD was requested in 1162 patients. Levels were <25 nmol/l in 282 (24%) patients, only 173 (61%) of whom were receiving vitamin D replacement therapy 3-15 months after diagnosis. Only four (1.4%) were prescribed a loading dose. One hundred and fifty-three (54%) were treated with cholecalciferol or ergocalciferol and 19 (7%) with alfacalcidol or calcitriol. The median dose of chole/ergocalciferol was 800 IU per day, usually in combination with 1200 mg calcium per day. CONCLUSIONS: We have shown a divergence between clinical practice and even the most conservative expert advice for vitamin D replacement therapy. Possible explanations are conflicting advice on treatment and difficulty obtaining suitable vitamin D preparations, particularly high dose vitamin D and vitamin D without calcium, in the UK.

Design and conduct of the CALERIE study: comprehensive assessment of the long-term effects of reducing intake of energy.

BACKGROUND: In a robust and consistent manner, sustained caloric restriction (CR) has been shown to retard the aging process in a variety of animal species. Nonhuman primate studies suggest that CR may have similar effects in longer-lived species. The CALERIE (Comprehensive Assessment of the Long-term Effects of Reducing Intake of Energy) research program is the first systematic investigation of CR in nonobese human beings. In the phase 2 study, it is hypothesized that 2 years of sustained CR, involving a 25% reduction of ad libitum energy intake, results in beneficial effects similar to those observed in animal studies. This article presents the design and implementation of this study. METHODS: The study is a multicenter, parallel-group, randomized controlled trial. A sample of 225 participants (22.0 ≤ body mass index [BMI] < 28.0 kg/m(2)) is being enrolled with 2:1 allocation to CR. RESULTS: An intensive dietary and behavioral intervention was developed to achieve 25% CR and sustain it over the 2 years. Adherence is monitored using a doubly labeled water technique. Primary outcomes are resting metabolic rate and core temperature, and are assessed at baseline and at 6-month intervals. Secondary outcomes address oxyradical formation, cardiovascular risk markers, insulin sensitivity and secretion, immune function, neuroendocrine function, quality of life and cognitive function. Biologic materials are stored in a central repository. CONCLUSIONS: An intricate protocol has been developed to conduct this study. Procedures have been implemented to safeguard the integrity of the data and the conclusions drawn. The results will provide insight into the detrimental changes associated with the human aging process and how CR mitigates these effects.

Outcomes of establishing an acute assessment unit in the general medical service of a tertiary teaching hospital.

OBJECTIVE: To evaluate the impact of an acute assessment unit (AAU) on length of hospital stay (LOS), emergency department (ED) waiting times, direct discharge rate, unplanned readmission rate and all-cause hospital mortality of general medical patients. DESIGN AND SETTING: Retrospective comparison of data for general medical patients admitted to a tertiary teaching hospital in Adelaide, South Australia, before and after the establishment of an AAU (reference years, 2003 [before] and 2006 [after]). MAIN OUTCOME MEASURES: Mean LOS, ED waiting times and all-cause hospital mortality during calendar years 2003 (pre-establishment) and 2006 (post-establishment). RESULTS: Following the establishment of an AAU, the mean LOS shortened (from 6.8 days in 2003 to 5.7 days in 2006; P < 0.001) despite a 50.5% increase in the number of admissions (from 2652 to 3992). The number of admitted patients waiting in the ED more than 8 hours for a hospital bed decreased (from 28.7% to 17.9%; P < 0.001), as did the number waiting more than 12 hours (from 20.2% to 10.4%; P < 0.001). The rates of unplanned readmission within 7 and 28 days did not change. The all-cause hospital mortality for general medical admissions was 4.6% in 2003 v 3.7% in 2006 (P = 0.056). CONCLUSION: The establishment of an AAU within the general medical service coincided with decreases in both LOS and ED waiting times, despite a 50% increase in admissions. This structural reform in the process of acute medical care may have contributed to the improvement in these key health care performance indices without compromising the quality of patient care.

Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique?

BACKGROUND: Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation. METHODS: Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups. RESULTS: No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays. CONCLUSIONS: No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.