Patient-reported experiences of mealtime care and food access in acute and rehabilitation hospital settings: a cross-sectional survey.

BACKGROUND: Nutrition and mealtime interventions can improve nutritional intake amongst hospital inpatients; however, patient-reported experience is rarely considered in their development and evaluation. The present study aimed to measure patient-reported food and mealtime experience to evaluate and inform continuous quality improvement of hospital nutrition care. METHODS: A cross-sectional survey with inpatients in seven acute care and rehabilitation wards was conducted. A 27-item validated questionnaire measured five domains of patient experience: food choices, organisational barriers, feeling hungry, physical barriers to eating and food quality. Responses were summarised descriptively and compared between settings (acute versus rehabilitation), patient demographics (age, gender) and time in hospital. RESULTS: Responses from 143 participants (mean age 67 years, 57% male, 28% rehabilitation, median 6 days into hospitalisation) showed that 10% or fewer respondents reported difficulties with food choices, feeling hungry or food quality. The most common difficulties were opening packets (36%), insufficient menu information provided (29%), being interrupted by staff when eating (28%), being disturbed when eating (27%), being in an uncomfortable position when eating (24%) and difficulty reaching food (21%). There were no significant differences in domain patterns by sex, age group or time in hospital. Organisational barriers were reported less frequently amongst rehabilitation participants compared to acute care (P = 0.01). CONCLUSIONS: This survey highlights areas of positive patient-reported experience with nutrition care and suggests that local improvement efforts should focus on physical assistance needs and organisational barriers, especially in acute care wards. The questionnaire may be useful for informing and evaluating systematic nutrition care improvements.

Experiences of using the i-PARIHS framework: a co-designed case study of four multi-site implementation projects.

BACKGROUND: The integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework is an implementation framework that has been developed and refined over the last 20 years. Its underlying philosophy is that implementing research into healthcare practice is complex, unpredictable and non-linear which therefore requires a flexible and responsive approach to implementation. Facilitation is recognized as the central ingredient of this approach, and i-PARIHS now provides a Facilitation Guide with associated tools. This multiple case study of four implementation projects explored how the i-PARIHS framework has been practically operationalized by diverse implementation project teams. METHODS: A co-design approach was used to elicit the experiences of four implementation project teams who used the i-PARIHS framework to guide their implementation approach. We conducted the established co-design steps of (i) setting up for success, (ii) gathering the experience, and (iii) understanding the experience. In particular we explored teams' approaches to setting up their projects; why and how they used the i-PARIHS framework and what they learnt from the experience. RESULTS: We found both commonalities and differences in the use of i-PARIHS across the four implementation projects: (i) all the projects used the Facilitation Checklist that accompanies i-PARIHS as a starting point, (ii) the projects differed in how facilitation was carried out, (iii) existing tools were adapted for distinct phases: pre-implementation, during implementation, and post-implementation stages; and (iv) project-specific tools were often developed for monitoring implementation activities and fidelity. CONCLUSIONS: We have provided a detailed overview of how current users of i-PARIHS are operationalising the framework, which existing tools they are using or adapting to use, and where they have needed to develop new tools to best utilise the framework. Importantly, this study highlights the value of existing tools from the published i-PARIHS Facilitation Guide and provides a starting point to further refine and add to these tools within a future Mobilising Implementation of i-PARIHS (or "Mi-PARIHS") suite of resources. Specifically, Mi-PARIHS might include more explicit guidance and/or tools for developing a structured implementation plan and monitoring fidelity to the implementation plan, including recording how strategies are tailored to an evolving context.

Geriatric Syndromes in Older Surgical Patients: A Literature Review.

With the ageing of the population, surgical wards are caring for an increased proportion of older patients. Geriatric syndromes are common in older hospitalised medical and hip fracture patients and are important predictors of poor outcomes in these groups, however the extent of presenting and hospital acquired geriatric syndromes in other older inpatients is less clear. This systematic literature review aimed to identify the proportion of patients aged 60 or older, cared for in usual-care surgical wards, who presented with and/or developed geriatric syndromes. Observational studies in English were identified through searches in CINAHL and Medline databases from 1985-2012. Studies of hip fracture patients and those requiring surgical intensive care (eg cardiac surgery) were excluded. The review included 25 studies. The majority of studies reported on the incidence of post-operative delirium, which ranged from 2% to 51% and varied with the type of surgery. The prevalence of depression at pre-admission screening varied from 9% to 29%. No studies reported on functional decline. Estimates of falls, malnutrition, pressure ulcers and urinary incontinence were limited by the small number of studies. These findings indicate the need for further studies to improve the understanding of geriatric syndromes in older surgical patients in usual-care wards.

Estrogen mediates sex differences in stress-induced prefrontal cortex dysfunction.

Many anxiety disorders, as well as major depressive disorder (MDD), are at least twice as prevalent in women as in men, but the neurobiological basis of this discrepancy has not been well studied. MDD is often precipitated by exposure to uncontrollable stress, and is frequently characterized by abnormal or disrupted prefrontal cortex (PFC) function. In animals, exposure to stress has been shown to cause PFC dysfunction, but sex differences in this effect have not been investigated. The present study tested male and female rats on a PFC-dependent working memory task after administration of FG7142, a benzodiazepine inverse agonist that activates stress systems in the brain. Female rats were impaired by lower doses than males during proestrus (high estrogen), but not during estrus (low estrogen). Similarly, ovariectomized females showed increased stress sensitivity only after estrogen replacement. These results suggest that estrogen amplifies the stress response in PFC, which may increase susceptibility to stress-related disorders.

Use of the Memokath for detrusor-sphincter dyssynergia after spinal cord injury--a cautionary tale.

We report on the intraurethral insertion of the Memokath in 24 patients (26 stents) to combat detrusor-sphincter dyssynergia developing after spinal cord injury. Most patients have high tetraplegia for whom self-catheterisation is very difficult, if not impossible. Our results have been disappointing in that 19 stents have had to be removed, mainly because of persisting urinary infection, migration of the stent, or because of failure to improve emptying, usually associated with poor detrusor function. Caution is therefore advised in the use of this stent for detrusor-sphincter dyssynergia and it is not recommended in patients with chronic urinary infection. With better patient selection however, perhaps aided by modifications to stent design, the Memokath may still prove to be a simple and reversible alternative to sphincterotomy in this difficult group of patients.

Genetic population structure of the Greater Bilby Macrotis lagotis, a marsupial in decline.

The Greater Bilby has shown a rapid decline in range during this century and now occupies only a small isolated area in south-western Queensland (QLD) and a larger, but mostly low-density area in the north-western deserts of the Northern Territory (NT) and Western Australia (WA). We have examined variation in the control region of mitochondrial DNA (mtDNA) and at nine microsatellite loci in order to investigate the extent of current and historical subdivision across the species range, and to provide a preliminary assessment of genetic structuring and mating system on a finer scale within the QLD population. Both mtDNA and microsatellite loci had substantial variation within and among populations, with mtDNA divergence being greater between QLD and NT than between NT and WA. The QLD population had two unique and divergent mtDNA lineages, but there was no evidence for strong phylogeographical structure across the range. The available evidence suggests that the bilby should be considered as a single Evolutionarily Significant Unit consisting of multiple Management Units. Augmentation of the remnant QLD population from the NT does not appear necessary at this stage, at least not on genetic grounds. Finer-scale analysis of microsatellite variation for two QLD colonies revealed a deficiency of heterozygotes and significantly greater relatedness within than between colonies. However, structuring was observed only for males; relatedness values for females did not depart from those expected under panmixia. Parentage exclusion analysis for one colony allowed the construction of a partial pedigree which indicated strong polygyny, with one male fathering all but one of the eight offspring assigned. The extent to which fine-scale genetic structuring and differences between sexes is due to sex-biased dispersal vs. effects of mating system remain to be determined.

The quality of life of patients on a waiting list for transurethral resection of the prostate.

We evaluated the quality of life of 50 patients with benign prostatic hypertrophy on a waiting list for transurethral resection of the prostate. The patients had a median age of 68 years (range: 48-84 years) and had been on the waiting list for a median of eight months (range: 2-36 months). Patients were assessed using the Benign Prostatic Hypertrophy Health-Related Quality of Life Survey Questionnaire. All patients had disagreeable urinary symptoms that interfered with their normal activities, for example, 92% of patients were troubled by disturbed sleep. The patients also had worries about the possibility of prostatic cancer (40%) and a perceived deterioration in sexual performance during the preceding year (56%). Eleven of the 14 patients who were re-evaluated one year after a transurethral resection of the prostate were completely free of any bothersome urinary symptoms.

Antibiotic prophylaxis for patients undergoing transurethral resection of the prostate.

OBJECTIVES: To evaluate the prevention of urinary tract infections (UTIs) after transurethral resection of the prostate (TURP) in a prospective randomized study using a quinolone antibiotic (fleroxacin) to compare the efficacy of: (1) a single oral dose, (2) a single intravenous (IV) dose, and (3) an extended regimen consisting of an initial IV dose followed by oral therapy until removal of the urinary catheter, but for less than 6 days. METHODS: We excluded from study patients who received antimicrobial agents within 48 hours of surgery. Single-dose prophylaxis consisted of 400 mg of fleroxacin given either orally or intravenously. The extended regimen consisted of an initial 400 mg IV dose followed by 400 mg oral each day (patients older than 75 years, or with a creatinine clearance less than 40 mL/min, received 200 mg/day). UTI was defined as clinical evidence of infection plus the presence of more than 10 white blood cells (WBC)/mm3 in any urine specimen plus the presence of more than 10(4) cfu/mL in midstream urine specimens or more than 10(2) cfu/mL in catheter specimens. RESULTS: Prior to TURP, 30% (25/84) of the patients had a urethral catheter in situ and 12% (3/25) of these patients had bacteriuria. Only 1 patient developed a UTI and that was 22 days after a TURP (intergroup comparisons, Fisher's exact test greater than 0.05). There were no instances of urosepsis. CONCLUSIONS: A single oral dose of a fluoroquinolone agent provided optimum prophylaxis for patients undergoing TURP.

Central venous thrombophlebitis diagnosed by computerized tomography scanning.

A case is described in which computerized tomography scanning aided in a prompt diagnosis and assessment of an intravenous catheter-induced septic thrombus. Computerized tomography scanning detected gas bubbles within the thrombus, which extended from the right subclavian vein into the superior vena cava, and retrograde propagation of the thrombus into the right internal jugular vein. Computerized tomography scanning also helped in the assessment of the amount of deep tissue swelling present and the competence of the upper respiratory tract.

Clam enterocystoplasty in the neuropathic bladder.

Clam enterocystoplasty has proved to be the most effective treatment for severe detrusor instability resistant to conservative treatment (Bramble, 1982; Mundy and Stephenson, 1985). More recently it has become the procedure of choice in patients with neuropathic bladders with hyper-reflexia or severely impaired compliance, provided that the bladder is of reasonable size and that gross fibrosis and/or diverticular formation of the bladder wall has not occurred. Fifty-nine patients have undergone the clam procedure as part or all of their reconstruction in the past 4 years. Although uncontrolled incontinence was the commonest indication, impaired renal function was the indication in 14 patients and need for undiversion in seven. Currently all but four are voiding satisfactorily or are on intermittent self-catheterisation, though six have significant stress incontinence. The clam procedure is easier, quicker and as satisfactory as substitution cystoplasty in selected cases.