Success factors and barriers in interprofessional collaboration between dental hygienists and dietitians in community-dwelling older people: Focus group interviews.

INTRODUCTION: Poor nutritional status can impair oral health while poor oral health can influence the individual's dietary intake, which may result in malnutrition. This interaction between nutritional status and oral health in older age requires attention, coordination and collaboration between healthcare professionals. This qualitative study explores dental hygienists' and dietitians' opinions about current collaboration with the aim of identifying success factors and barriers to this interprofessional collaboration. METHODS: Three focus group interviews were held with Dutch dental hygienists and dietitians about nutritional and oral healthcare in community-dwelling older people. RESULTS: In total, 9 dietitians and 11 dental hygienists participated in three online focus group interviews. Dental hygienists and dietitians seldom collaborated or consulted with each other. They struggled with the professional boundaries of their field of expertise and experienced limited knowledge about the scope of practice of the other profession, resulting in conflicting information to patients about nutrition and oral health. Interprofessional education was scarce during their professional training. Organizational and network obstacles to collaborate were recognized, such as limitations in time, reimbursement and their professional network that often does not include a dietitian or dental hygienist. CONCLUSION: Dental hygienists and dietitians do not collaborate or consult each other about (mal)nutrition or oral health in community-dwelling older people. To establish interprofessional collaboration, they need to gain knowledge and skills about nutrition and oral health to effectively recognize problems in nutritional status and oral health. Interprofessional education for healthcare professionals is needed to stimulate interprofessional collaboration to improve care for older people.

Muscle Strength Is Associated With Muscle Mass in Patients With Esophageal Cancer Awaiting Surgery.

BACKGROUND AND PURPOSE: Decreased muscle mass and muscle strength are independent predictors of poor postoperative recovery in patients with esophageal cancer. If there is an association between muscle mass and muscle strength, physiotherapists are able to measure muscle strength as an early predictor for poor postoperative recovery due to decreased muscle mass. Therefore, in this cross-sectional study, we aimed to investigate the association between muscle mass and muscle strength in predominantly older patients with esophageal cancer awaiting esophagectomy prior to neoadjuvant chemoradiation. METHODS: In patients with resectable esophageal cancer eligible for surgery between March 2012 and October 2015, we used computed tomographic scans to assess muscle mass and compared them with muscle strength measures (handgrip strength, inspiratory and expiratory muscle strength, 30 seconds chair stands test). We calculated Pearson correlation coefficients and determined associations by multivariate linear regression analysis. RESULTS AND DISCUSSION: A tertiary referral center referred 125 individuals to physiotherapy who were eligible for the study; we finally included 93 individuals for statistical analysis. Multiple backward regression analysis showed that gender (95% confidence interval [CI], 2.05-33.82), weight (95% CI, 0.39-1.02), age (95% CI, -0.91 to -0.04), left handgrip strength (95% CI, 0.14-1.44), and inspiratory muscle strength (95% CI, 0.08-0.38) were all independently associated with muscle surface area at L3. All these variables together explained 66% of the variability (R) in muscle surface area at L3 (P < .01). CONCLUSIONS: This study shows an independent association between aspects of muscle strength and muscle mass in patients with esophageal cancer awaiting surgery, and physiotherapists could use the results to predict muscle mass on the basis of muscle strength in preoperative patients with esophageal cancer.

Intake of Vegetables, Fruit, and Fish is Beneficial for Age-Related Macular Degeneration.

PURPOSE: What patients should eat to reduce their risk of age-related macular degeneration (AMD) is still unclear. We investigated the effect of a diet recommended by Health Councils on AMD. DESIGN: Prospective population-based cohort study. METHODS: Four thousand two hundred and two participants from the Rotterdam Study ≥55 years of age who were free of AMD at baseline were included and followed up for 9.1 ± 5.8 years. Incident AMD was graded on fundus photographs. Dietary data were collected using a validated 170-item food frequency questionnaire, and food intakes were categorized into food patterns based on guidelines from Health Councils. Associations with incident AMD were analyzed using Cox proportional hazards models that were adjusted for age, sex, total energy intake, smoking, body mass index, hypertension, education, and income. RESULTS: Seven hundred fifty-four people developed incident AMD. Intake of the recommended amounts of vegetables (≥200 g/day), fruit (2×/day), and fish (2×/week) were 30.6%, 54.9%, and 12.5%, respectively. In particular, the intake of fish (2×/week) decreased the risk of incident AMD (hazard ratio 0.76 [95% confidence interval 0.60-0.97]). Intake of the recommended amounts of all 3 food groups was only 3.7%, but adherence to this pattern showed a further reduction of the risk of incident AMD (hazard ratio 0.58 [95% confidence interval 0.36-0.93]). Younger age, higher income, and not smoking were associated with this food pattern, but the risk-lowering effects remained significant after additional adjustment for these factors. CONCLUSION: A diet of 200 grams per day of vegetables, fruit two times per day, and fish two times per week is associated with a significantly reduced risk of AMD.

Estimation of body composition depends on applied device in patients undergoing major abdominal surgery.

BACKGROUND: Bioelectrical impedance analysis (BIA) is a method used to estimate body compartments such as fat-free mass (FFM) and fat mass (FM). Two BIA devices, a single-frequency BIA (SF-BIA) device and a bioimpedance spectroscopy (BIS) approach, were compared to evaluate their reliability and to study whether their estimations resulted in similar classifications of body composition. MATERIALS AND METHODS: In a prospective observational study, body composition was estimated by SF-BIA and BIS in 123 adult patients scheduled for major abdominal surgery. Measurement agreement for the continuous variables FFM and FM were analyzed by using the intraclass correlation coefficient (ICC), the mean differences, and their limits of agreement. Measurement differences were also visualized by Bland-Altman plots. For the dichotomized FFM index (FFMI) and FM index (FMI), interobserver agreement was calculated using Cohen κ statistics; the McNemar test was performed to compare the paired proportions. RESULTS: Agreement for the continuous variables was almost perfect for FM (.86; 95% confidence interval [CI], .80-.90) and substantial for FFM (.78; 95% CI, .70-.84). For the dichotomous variables, the agreement was substantial for FMI (.67; 95% CI, .51-.83) and slight for FFMI (.19; 95% CI, .01-.37). BIS classified a larger proportion having a low FFMI and a high FMI. CONCLUSION: There were good ICCs between SF-BIA and BIS for FFM and FM. However, the mean differences were substantial, whereas the classification of body composition based on FFMI and FMI was influenced by the device. Therefore, BIA devices are not interchangeable.

Handgrip strength by dynamometry does not identify malnutrition in individual preoperative outpatients.

BACKGROUND & AIMS: Low handgrip strength by dynamometry is associated with increased postoperative morbidity, higher mortality and reduced quality of life. The aim of this study was to evaluate the accuracy of four algorithms in diagnosing malnutrition by measuring handgrip strength. METHODS: We included 504 consecutive preoperative outpatients. Reference standard for malnutrition was defined based on percentage involuntary weight loss and BMI. Diagnostic characteristics of the handgrip strength algorithms (Álvares-da-Silva, Klidjian, Matos, Webb) were expressed by sensitivity, specificity, positive and negative predictive value, false positive and negative rate. RESULTS: The prevalence of malnutrition was 5.8%. Although Klidjian showed the highest sensitivity (79%, 95% CI 62%-90%), 6 out of 29 malnourished patients were falsely identified as well-nourished (false positive rate 21%, 95% CI 9%-38%). In contrast, this algorithm showed the lowest positive predictive value (8%, 95% CI 5%-13%). Matos presented the highest positive predictive value; the post-test probability increased to 13% (95% CI 8%-20%). The 1-minus negative predictive value ranged between 3% and 5% for all algorithms. CONCLUSIONS: None of the algorithms derived from handgrip strength measurements was found to have a diagnostic accuracy good enough to introduce handgrip strength as a systematic institutional screening tool to detect malnutrition in individual adult preoperative elective outpatients.

Suboptimal intake of nutrients after esophagectomy with gastric tube reconstruction.

Esophagectomy with gastric tube reconstruction results in a variety of postoperative nutrition-related complaints that can impair nutritional intake and nutritional status. The aim of this study was to determine to what extent patients reached the recommended intake of various nutrients at 6 and 12 months after esophagectomy. It was also analyzed whether a suboptimal intake could be explained by the most clinically significant nutrition-related complaints after esophagectomy. In a prospective cohort study (2002 to 2006), the nutrient intake of 96 patients, recorded in preprinted nutritional diaries, was compared with the recommended energy intake in The Netherlands and Recommended Dietary Allowance of protein and micronutrients. Energy and protein intake remained below recommendations in 24% and 7% of the patients, respectively. Less than 10% of the patients had a sufficient intake of all micronutrients. Folic acid, vitamin D, copper, calcium, and vitamin B-1 were the micronutrients most often reported to have a suboptimal intake. Multivariate logistic regression, corrected for preoperative epigastric pain and energy intake, showed that the number of nutrition-related complaints was not an independent risk factor for the presence of a suboptimal intake of nutrients (adjusted odds ratio=1.11; 95% CI: 0.94 to 1.31; P = 0.22). This study shows that the intake of micronutrients remains below recommendations in the majority of patients 12 months after esophagectomy. This problem requires special attention and care by registered dietitians.

Self-reporting of height and weight: valid and reliable identification of malnutrition in preoperative patients.

BACKGROUND: Preoperative screening for malnutrition has become mandatory in The Netherlands. A sensitive method to diagnose malnutrition would save time and improve effectiveness. METHODS: A prospective cross-sectional study of 488 adult elective preoperative outpatients was performed. The accuracy of self-reported height and weight was compared with measured data and 3 commonly used malnutrition screening tools. Interobserver agreement was calculated by the intraclass correlation coefficient, studied in Bland and Altman plots, and analyzed by using Cohen's κ statistic. Accuracy was expressed in sensitivity, specificity, and false-negative rates. RESULTS: Differences between self-reported and measured data were significant, but clinically irrelevant, because only 1 patient was falsely identified as well nourished. Intraclass correlation coefficient for height, weight, and body mass index was high (.97-.99). Bland-Altman plots showed that the mean ± standard deviation differences and 95% limits of agreement between both methods were as follows: height, .0096 m (±.0262, -.0417 to +.0609 m); weight, -1.28 kg (±2.29, -5.76 to +3.20 kg); body mass index, -.72 kg/m(2) (±1.11, -2.92 to +1.46 kg/m(2)). The κ coefficient was .84 (95% confidence interval, .75-.94). Sensitivity was .97 and specificity was .98. Sensitivity and false-negative rates of self-reported data were better overall compared with the screening tools. CONCLUSIONS: Self-reported data provide highly sensitive information to diagnose malnutrition in preoperative outpatients.

Chylous ascites after pancreaticoduodenectomy: introduction of a grading system.

BACKGROUND: Chylous ascites (CA) is a complication that follows thoracic and abdominal surgery, recognized after provocation by enteral feeding and characterized by its milky appearance from an elevated triglyceride level. The aim of this study was to evaluate incidence, management, and predisposing factors of CA and its impact on outcomes after pancreaticoduodenectomy. STUDY DESIGN: Between 1996 and 2007, 609 consecutive patients underwent pancreaticoduodenectomy. Patients having a drain output with a milky appearance, and with a triglyceride level greater than 1.2 mmol/L, were compared with patients without significant drain production or with a low triglyceride level. Management of CA was reviewed. RESULTS: Sixty-six patients had isolated CA (11%) of any measurable volume, 440 patients (72%) had no CA, and 109 patients (16%) were excluded from analysis. CA was diagnosed on postoperative day 6 (median; interquartile range 5 to 8), generally after introduction of a normal (polymeric low-chain-triglyceride) diet. Female gender (odds ratio, 1.79; 95% CI, 1.05 to 3.03) and chronic pancreatitis at pathology (odds ratio, 2.52; 95% CI, 1.19 to 5.32) were independently associated with development of isolated CA. A low-chain-triglyceride-restricted diet was initiated in 47 patients, 3 were started on total parenteral nutrition, and an expectative approach was followed in 16 patients. CA resolved after 3.5 days (median; interquartile range, 2 to 5). Isolated CA was significantly associated with prolonged hospital stay (p=0.002). CONCLUSIONS: We propose a novel definition and grading system for CA after pancreaticoduodenectomy, according to which the incidence is 9%, with clinically significant CA occurring in 4% (grades B and C). Although female gender and (focal) chronic pancreatitis were associated with development of isolated CA, no predisposing factors that could readily anticipate CA were identified. Isolated CA was associated with prolonged hospital stay.