What impact do self-referral and direct access pathways for patients have on health inequalities?

BACKGROUND: There is increasing interest in self-referral and direct access as alternatives pathways to care to improve patient access to specialist services. The impact of these pathways on health inequalities is unknown. OBJECTIVES: The purpose of this systematic review is to explore the impact of self-referral and direct access pathways on inequalities in health care use. DESIGN: Three databases (Ovid Medline, Embase, Web of Science) and grey literature were systematically searched for articles from January 2000 to February 2023, reporting on self-referral and direct access pathways to care. Title and abstracts were screened against eligibility criteria to identify studies that evaluated the impact on health inequalities. Data were extracted from eligible studies after full text review and a quality assessment was performed using the ROBINS-I tool. RESULTS: The search strategy identified 2948 articles. Nineteen records were included, covering seven countries and six healthcare services. The impact of self-referral and direct access on inequalities was mixed, suggesting that the relationship is dependent on patient and system factors. Typically self-referral pathways and direct access pathways tend to widen health inequalities. White, younger, educated women from less deprived backgrounds are more likely to self-refer, exacerbating existing health inequalities. CONCLUSIONS: Self-referral pathways risk widening health inequalities. Further research is required to understand the context-dependent mechanisms by which this can occur, explore ways to mitigate this and even narrow health inequalities, as well as understand the impact on the wider healthcare system.

Effect of increased water intake on uropathogenic bacterial activity of underhydrated menstruating young adult women: A randomized crossover trial.

Background: Females are prone to urinary tract infections (UTIs) due to estrogen fluctuations affecting vaginal flora. While menstruating, increased fluid consumption to support urination frequency and void volume may be important, as the urethra and urinary tract are more predisposed to bacteria, particularly UTI pathogens. Aim: This study aimed to investigate the impact of hydration on urinary tract health during menstruation among underhydrated premenopausal women. Methods: Thirteen females participated in a 60-day 2 × 2 randomized crossover trial to evaluate the effectiveness of consuming ≥2.2 L of total beverage fluid intake, with 1.9 L being water, (intervention, INT) and maintaining habitual fluid intake (control, CON) on two subsequent menses. Participants completed fluid and urination diaries at days 2 and 5 after the onset of bleeding (day 1) to determine the fluid amount consumed and urination frequency. Urine concentration was assessed in afternoon (days 2 and 5) and uropathogenic bacterial activity in first-morning (days 3 and 6) urinations. General linear models assessed differences in bacterial and hydration outcomes. Results: The intervention led to a 62% mean total fluid increase, INT 3.0 ± 1.1 L and CON 1.9 ± 0.9 L, p < 0.001, η2 = 0.459. Urination frequency was greater and urine concentration less in the INT to CON, all ps < 0.05, η2 range = 0.023-0.019. Only four cultures detected uropathogenic bacteria, with no patterns between conditions or days, making it difficult to determine the intervention's effectiveness. Conclusion: Fluid intake increased, and hydration status improved. No differences in uropathogenic bacterial activity were seen between the hydration and control conditions.

The health effects of soy: A reference guide for health professionals.

Soy is a hotly debated and widely discussed topic in the field of nutrition. However, health practitioners may be ill-equipped to counsel clients and patients about the use of soyfoods because of the enormous, and often contradictory, amount of research that has been published over the past 30 years. As interest in plant-based diets increases, there will be increased pressure for practitioners to gain a working knowledge of this area. The purpose of this review is to provide concise literature summaries (400-500 words) along with a short perspective on the current state of knowledge of a wide range of topics related to soy, from the cholesterol-lowering effects of soy protein to the impact of isoflavones on breast cancer risk. In addition to the literature summaries, general background information on soyfoods, soy protein, and isoflavones is provided. This analysis can serve as a tool for health professionals to be used when discussing soyfoods with their clients and patients.

Lipid Profiles of College Female Student-Athletes Participating at Different Competition Levels of Organized Sport.

College-aged women are not meeting weekly moderate-to-vigorous physical activity to support lipids protecting against cardiovascular disease onset. Participating in organized sport could assist in physical activity engagement and maintenance while positively impacting lipids predicting cardiovascular disease. However, women may be discouraged from participating in sports if they perceive benefits to be mostly seen at the higher competition levels, thus hindering seeking sports involvement at lesser-intensity levels. A total of N = 78 female athletes participating at the National Collegiate Athletic Association (n = 21), National Junior College Athletic Association (n = 29), and student club (n = 28) completed a personal characteristics questionnaire and provided blood samples to compare physical activity involvement and lipid health profiles. Linear regression modeling was used to assess how the independent variables (i.e., sport level, age, systolic blood pressure, race/ethnicity, sport/physical activity involvement hours per week, and years playing sports) on the dependent variables [i.e., total cholesterol, high density lipid (HDL), and total cholesterol-HDL ratio]. Total sample cholesterol 165.7 ± 34.0, HDL 62.8 ± 15.03, and total cholesterol-HDL ratio 2.8 ± 0.6 were all within a healthy recommendation range, along with per sport level. NJCAA sport level significantly predicted lower total cholesterol, p = 0.043, while identifying as Black significantly predicted higher total cholesterol, p = 0.008. Similarly, identifying as Black significantly predicted higher HDL, p = 0.021. Furthermore, increased systolic blood pressure significantly predicted higher total cholesterol-HDL ratios, p = 0.014. Organized sports participation may help meet physical activity requirements, support healthy lipid profiles, and ward off cardiovascular disease development in female college students regardless of competition level.

Lung parenchymal calcifications in a child with cystic fibrosis.

We describe a 6-year-old girl with homozygous p.Phe508del cystic fibrosis with severe multi-lobar bronchiectasis and obstructive lung disease who was found to have prominent parenchymal calcifications in the right middle lobe on a computed tomography scan of the chest. Histopathology from the calcified area of lung biopsy showed fibrous tissue with chronic inflammation with CD3+ T-lymphocytes and macrophages with no granulomas. Dystrophic calcification was seen within this necrotic debris.

Comparison of Plate Waste between Vegetarian and Meat-Containing Meals in a Hospital Setting: Environmental and Nutritional Considerations.

Vegetarian diets can satisfy nutritional requirements and have lower environmental impacts than those containing meat. However, fruits and vegetables are wasted at higher rates than meat. Reducing both food waste (FW) and the environmental impacts associated with food production is an important sustainability goal. Therefore, the aim of this study was to examine potential tradeoffs between vegetarian meals' lower impacts but potentially higher FW compared to meat-containing meals. To examine this, seven consecutive days of plate FW data from Loma Linda University Medical Center (LLUMC) patients were collected and recorded from 471 meals. Mean total FW and associated greenhouse gas emissions (GHGE) were higher among meat-containing meals (293 g/plate, 604 g CO2-eq/plate) than vegetarian meals (259 g/plate, 357 g CO2-eq/plate) by 34 g (p = 0.05) and 240 g CO2-eq (p < 0.001), respectively. Statistically significant differences were observed in both FW and associated GHGE across major food categories, except fruit, when comparing vegetarian and meat-containing meals. Overall, vegetarian meals were preferable to meat-containing meals served at LLUMC both in terms of minimizing FW and lowering environmental impacts. Other institutions serving vegetarian meal options could expect similar advantages, especially in reduced GHGE due to the high CO2 embodied in meat.

No Significant Differences in Muscle Growth and Strength Development When Consuming Soy and Whey Protein Supplements Matched for Leucine Following a 12 Week Resistance Training Program in Men and Women: A Randomized Trial.

There are conflicting reports regarding the efficacy of plant versus animal-derived protein to support muscle and strength development with resistance training. The purpose of this study was to determine whether soy and whey protein supplements matched for leucine would comparably support strength increases and muscle growth following 12 weeks of resistance training. Sixty-one untrained young men (n = 19) and women (n = 42) (18-35 year) enrolled in this study, and 48 completed the trial (17 men, 31 women). All participants engaged in supervised resistance training 3×/week and consumed 19 grams of whey protein isolate or 26 grams of soy protein isolate, both containing 2 g (grams) of leucine. Multi-level modeling indicated that total body mass (0.68 kg; 95% CI: 0.08, 1.29 kg; p < 0.001), lean body mass (1.54 kg; 95% CI: 0.94, 2.15 kg; p < 0.001), and peak torque of leg extensors (40.27 Nm; 95% CI: 28.98, 51.57 Nm, p < 0.001) and flexors (20.44 Nm; 95% CI: 12.10, 28.79 Nm; p < 0.001) increased in both groups. Vastus lateralis muscle thickness tended to increase, but this did not reach statistical significance (0.12 cm; 95% CI: -0.01, 0.26 cm; p = 0.08). No differences between groups were observed (p > 0.05). These data indicate that increases in lean mass and strength in untrained participants are comparable when strength training and supplementing with soy or whey matched for leucine.

Reply to "Limitations of the Digestible Indispensable Amino Acid Score (DIAAS) and Choice of Statistical Reporting. Comment on "A Comparison of Dietary Protein Digestibility, Based on DIAAS Scoring, in Vegetarian and Non-Vegetarian Athletes." Nutrients 2019, 11, 3106".

We appreciate the critique of our paper (Ciuris et al [...].

A Comparison of Dietary Protein Digestibility, Based on DIAAS Scoring, in Vegetarian and Non-Vegetarian Athletes.

Vegetarian diets provide an abundance of nutrients when carefully planned. However, vegetarian diets may have lower protein quality compared to omnivorous diets, a reflection of less favorable amino acid profiles and bioavailability. Hence, the current recommended dietary allowance for protein may not be adequate for some vegetarian populations. The purpose of this study was to determine dietary protein quality using the DIAAS (Digestible Indispensable Amino Acid Score) method in vegetarian and omnivore endurance athletes. DIAAS scores reflect the true ileal digestibility of the indispensable amino acids that are present in food items, and these scores can be used to compute the available protein in diet plans. Thirty-eight omnivores and 22 vegetarians submitted seven-day food records that were analyzed for nutrient content, and DIAAS scores were computed by diet group. Average available protein (g) was compared along with participants' lean body mass and strength (quantified using the peak torque of leg extension). DIAAS scores and available protein were higher for omnivorous versus vegetarian athletes (+11% and +43%, respectively, p < 0.05). Omnivorous participants had significantly higher lean body mass than vegetarian participants (+14%), and significant correlations existed between available protein and strength (r = 0.314) and available protein and lean body mass (r = 0.541). Based upon available protein, as determined through the DIAAS, vegetarian athletes in this study would need to consume, on average, an additional 10 g protein daily to reach the recommended intake for protein (1.2 g/kg/d). An additional 22 g protein daily would be needed to achieve an intake of 1.4 g/kg/d, the upper end of the recommended intake range.

Plant-Based Diets: Considerations for Environmental Impact, Protein Quality, and Exercise Performance.

Plant-based diets provide well-established physical and environmental health benefits. These benefits stem in part from the degree of restriction of animal-derived foods. Historically, meat and other animal-derived proteins have been viewed as an integral component of athletes' diets, leading some to question the adequacy of vegetarian or vegan diets for supporting athletic performance. The purpose of this review is to examine the impact of plant-based diets on human physical health, environmental sustainability, and exercise performance capacity. Based on currently available literature, it is unlikely that plant-based diets provide advantages, but do not suffer from disadvantages, compared to omnivorous diets for strength, anaerobic, or aerobic exercise performance. However, plant-based diets typically reduce the risk of developing numerous chronic diseases over the lifespan and require fewer natural resources for production compared to meat-containing diets. As such, plant-based diets appear to be viable options for adequately supporting athletic performance while concurrently contributing to overall physical and environmental health. Given the sparse literature comparing omnivore, vegetarian, and vegan athletes, particularly at the elite level, further research is warranted to ascertain differences that might appear at the highest levels of training and athletic performance.

No Difference Between the Effects of Supplementing With Soy Protein Versus Animal Protein on Gains in Muscle Mass and Strength in Response to Resistance Exercise.

Much attention has been given to determining the influence of total protein intake and protein source on gains in lean body mass (LBM) and strength in response to resistance exercise training (RET). Acute studies indicate that whey protein, likely related to its higher leucine content, stimulates muscle protein synthesis to a greater extent than proteins such as soy and casein. Less clear is the extent to which the type of protein supplemented impacts strength and LBM in long-term studies (≥6 weeks). Therefore, a meta-analysis was conducted to compare the effect of supplementation with soy protein to animal protein supplementation on strength and LBM in response to RET. Nine studies involving 266 participants suitable for inclusion in the meta-analysis were identified. Five studies compared whey with soy protein, and four studies compared soy protein with other proteins (beef, milk, or dairy protein). Meta-analysis showed that supplementing RET with whey or soy protein resulted in significant increases in strength but found no difference between groups (bench press: χ2 = 0.02, p = .90; squat: χ2 = 0.22, p = .64). There was no significant effect of whey or soy alone (n = 5) on LBM change and no differences between groups (χ2 = 0.00, p = .96). Strength and LBM both increased significantly in the "other protein" and the soy groups (n = 9), but there were no between-group differences (bench: χ2 = 0.02, p = .88; squat: χ2 = 0.78, p = .38; and LBM: χ2 = 0.06, p = .80). The results of this meta-analysis indicate that soy protein supplementation produces similar gains in strength and LBM in response to RET as whey protein.

Cardiorespiratory Fitness and Peak Torque Differences between Vegetarian and Omnivore Endurance Athletes: A Cross-Sectional Study.

In spite of well-documented health benefits of vegetarian diets, less is known regarding the effects of these diets on athletic performance. In this cross-sectional study, we compared elite vegetarian and omnivore adult endurance athletes for maximal oxygen uptake (VO2 max) and strength. Twenty-seven vegetarian (VEG) and 43 omnivore (OMN) athletes were evaluated using VO2 max testing on the treadmill, and strength assessment using a dynamometer to determine peak torque for leg extensions. Dietary data were assessed using detailed seven-day food logs. Although total protein intake was lower among vegetarians in comparison to omnivores, protein intake as a function of body mass did not differ by group (1.2 ± 0.3 and 1.4 ± 0.5 g/kg body mass for VEG and OMN respectively, p = 0.220). VO2 max differed for females by diet group (53.0 ± 6.9 and 47.1 ± 8.6 mL/kg/min for VEG and OMN respectively, p < 0.05) but not for males (62.6 ± 15.4 and 55.7 ± 8.4 mL/kg/min respectively). Peak torque did not differ significantly between diet groups. Results from this study indicate that vegetarian endurance athletes' cardiorespiratory fitness was greater than that for their omnivorous counterparts, but that peak torque did not differ between diet groups. These data suggest that vegetarian diets do not compromise performance outcomes and may facilitate aerobic capacity in athletes.