Making the Most of Mealtimes (M3): effect of eating occasions and other covariates on energy and protein intake among Canadian older adult residents in long-term care.

BACKGROUND: Food intake varies among long-term care (LTC) residents and, as a result, some residents are at risk for protein-energy malnutrition and its consequences, such as sarcopenia. The present study aimed to determine whether eating occasions, as well as other factors that may vary with eating occasions (e.g. family/volunteer presence), were associated with energy and protein intake at meals and snacks. METHODS: The present study comprised a secondary analysis of the cross-sectional Making the Most of Mealtimes study, including 630 residents (median age 88.00 years, range 62-107 years; 197 males) from 32 Canadian LTC homes. An analysis of variance compared protein and energy intake at meals and snacks. Mixed repeated measures linear regression testing for meal and relevant covariates (e.g. family/volunteer presence) was also conducted. RESULTS: Energy and protein intake was significantly associated with eating occasions (F = 44.31, P < 0.001; F = 12.72, P < 0.001), with the greatest energy intake at breakfast, and the greatest protein intake at dinner. Regression analysis confirmed these findings when considering other factors. Covariates associated with higher intake included: being male (+79 kcal; +3.4 g protein), living on a dementia care unit (+39 kcal; +2.1 g protein) and family/volunteer presence at meals (+58 kcal; +2.5 g protein). Intake was lowest in the oldest age group (-59 kcal; -3.6 g protein) and for those sometimes requiring eating assistance (-36 kcal; -2.0 g protein). CONCLUSIONS: Energy and protein intake appears to be associated with eating occasions. Based on these exploratory findings, LTC homes may consider providing more protein-dense foods at breakfast. Protein and energy dense snacks could also be used more extensively to support intake.

Modified Texture Food Use is Associated with Malnutrition in Long Term Care: An Analysis of Making the Most of Mealtimes (M3) Project.

OBJECTIVE: Modified texture food (MTF), especially pureed is associated with a high prevalence of under-nutrition and weight loss among older adults in long term care (LTC); however, this may be confounded by other factors such as dependence in eating. This study examined if the prescription of MTF as compared to regular texture food is associated with malnutrition risk in residents of LTC homes when diverse relevant resident and home-level covariates are considered. DESIGN: Making the Most of Mealtimes (M3) is a cross-sectional multi-site study. SETTING: 32 LTC homes in four Canadian provinces. PARTICIPANTS: Regular (n= 337) and modified texture food consumers (minced n= 139; pureed n= 68). MEASUREMENTS: Malnutrition risk was determined using the Mini Nutritional Assessment short-form (MNA-SF) score. The use of MTFs, and resident and site characteristics were identified from health records, observations, and standardized assessments. Hierarchical linear regression analyses, accounting for clustering, were performed to determine if the prescription of MTFs is associated with malnutrition risk while controlling for important covariates, such as eating assistance. RESULTS: Prescription of minced food [F(1, 382)=5.01, p=0.03], as well as pureed food [F(1, 279)=4.95, p=0.03], were both significantly associated with malnutrition risk among residents. After adjusting for age and sex, other significant covariates were: use of oral nutritional supplements, eating challenges (e.g., spitting food out of mouth), poor oral health, and cognitive impairment. CONCLUSIONS: Prescription of minced or pureed foods was significantly associated with the risk of malnutrition among residents living in LTC facilities while adjusting for other covariates. Further work needs to consider improving the nutrient density and sensory appeal of MTFs and target modifiable covariates.

Measuring Activity Performance of Continuing Care Residents Using the activPAL: An Exploratory Study.

Few studies have measured the activity patterns of continuing care residents using objective, uniaxial, accelerometers such as the activPAL. This exploratory study described the activity performance of continuing care residents and explored the correlation of activity performance with grip strength, falls and mobility. Data were gathered from 24 continuing care residents. Participants (82.3 ± 5.8 years of age), wore the activPAL an average of 12.60 hours per day (SD = 0.96) and were stepping for a median of 0.47 hours (25th and 75th percentiles = 0.31, 0.81) with a median step count of 1906 steps (25th and 75th percentiles = 1216, 3420). Participants were inactive (sitting/lying/standing) for a mean 11.99 hours (SD = 1.03). No statistically significant correlations were identified between activity performance (active time, inactive time or step count) and grip strength, falls or mobility. Ambulatory older adults in continuing care centres were more sedentary compared to community-dwelling older adults or older adults with cancer.

Engineering mammalian cells for solid-state sensor applications.

A fundamental advance in the development and application of cell- and tissue-based biosensors would be the ability to achieve air-dry stabilization of mammalian (especially human) cells with subsequent recovery following rehydration. The would allow for the preparation of sensors with extended shelf lives, only requiring the addition of water for activation. By understanding and subsequently employing the tactics used by desiccation-tolerant extremophiles, it may be possible to design stabilized mammalian cell-based biosensors. The approaches required to realize this goal are discussed and illustrated with several examples.

An investigation of the action of porcine pancreatic alpha-amylase on native and gelatinised starches.

The action of pancreatic alpha-amylase (EC 3.2.1.1) on various starches has been studied in order to achieve better understanding of how starch structural properties influence enzyme kinetic parameters. Such studies are important in seeking explanations for the wide differences reported in postprandial glycaemic and insulinaemic indices associated with different starchy foodstuffs. Using starches from a number of different sources, in both native and gelatinised forms, as substrates for porcine alpha-amylase, we showed by enzyme kinetic studies that adsorption of amylase to starch is of kinetic importance in the reaction mechanism, so that the relationship between reaction velocity and enzyme concentration [E0] is logarithmic and described by the Freundlich equation. Estimations of catalytic efficiencies were derived from measurements of kcat/Km performed with constant enzyme concentration so that comparisons between different starches were not complicated by the logarithmic relationship between E0 and reaction velocity. Such studies reveal that native starches from normal and waxy rice are slightly better substrates than those from wheat and potato. After gelatinisation at 100 degrees C, kcat/Km values increased by 13-fold (waxy rice) to 239-fold (potato). Phosphate present in potato starch may aid the swelling process during heating of suspensions; this seems to produce a very favourable substrate for the enzyme. Investigation of pre-heat treatment effects on wheat starch shows that the relationship between treatment and kcat/Km is not a simple one. The value of kcat/Km rises to reach a maximum at a pre-treatment temperature of 75 degrees C and then falls sharply if the treatment is conducted at higher temperatures. It is known that amylose is leached from starch granules during heating and dissolves. On cooling, the dissolved starch is likely to retrograde and become resistant to amylolysis. Thus the catalytic efficiency tends to fall. In addition, we find that the catalytic efficiency on the different starches varies inversely with their solubility and we interpret this finding on the assumption that the greater the solubility, the greater is the likelihood of retrogradation. We conclude that although alpha-amylase is present in high activity in digestive fluid, the enzymic hydrolysis of starch may be a limiting factor in carbohydrate digestion because of factors related to the physico-chemical properties of starchy foods.

Phenotypic resistance of Staphylococcus aureus, selected Enterobacteriaceae, and Pseudomonas aeruginosa after single and multiple in vitro exposures to ciprofloxacin, levofloxacin, and trovafloxacin.

The phenotypic resistance of selected organisms to ciprofloxacin, levofloxacin, and trovafloxacin was defined as a MIC of > or =4 microg/ml. The dynamics of resistance were studied after single and sequential drug exposures: clinical isolates of methicillin-susceptible and methicillin-resistant Staphylococcus aureus (MSSA and MRSA), Escherichia coli, Klebsiella pneumoniae, Enterobacter cloacae, Serratia marcescens, and Pseudomonas aeruginosa were utilized. After a single 48-h exposure of a large inoculum to four times the initial MIC for the organism, the frequency of selection of resistant mutants of MSSA was greater for trovafloxacin than levofloxacin (P = 0.008); for E. cloacae, the frequency was highest for ciprofloxacin and lowest for levofloxacin and trovafloxacin; for S. marcescens, the frequency was highest for trovafloxacin and lowest for ciprofloxacin (P = 0.003). The results of serial passage experiments were analyzed both by the Kaplan-Meier product-limited method as well as by analysis of variance of mean inhibitory values. By both methods, MSSA and MRSA expressed mutants resistant to ciprofloxacin after fewer passages than were required for either levofloxacin or trovafloxacin. For the aerobic gram-negative bacilli, two general patterns emerged. Mutants resistant to trovafloxacin appeared sooner and reached higher mean MICs than did mutants resistant to levofloxacin or ciprofloxacin. Mutants resistant to ciprofloxacin appeared later and reached mean MICs lower than the MICs of the other two drugs studied. Even though individual strain variation occurred, the mean MICs were reproduced when the serial passage experiment was repeated using an identical panel of E. coli isolates. In summary, the dynamic selection of fluoroquinolone-resistant bacteria can be demonstrated in experiments that employ serial passage of bacteria in vitro.

Focus on function in geriatric assessment and rehab.

In 1994, the province of Alberta, driven by the need for deficit reduction, began a major restructuring of the provincial health care system. An integral component of this new health structure was accountability for service delivery, including the use of outcome measures to determine service effectiveness. This paper describes the efforts of one program to evaluate the effectiveness of its service delivery, in terms of functional patient outcomes, in the midst of restructuring and budget constraints.

Vancomycin-resistant enterococci in intensive-care hospital settings: transmission dynamics, persistence, and the impact of infection control programs.

Vancomycin-resistant enterococci (VRE) recently have emerged as a nosocomial pathogen especially in intensive-care units (ICUs) worldwide. Transmission via the hands of health-care workers is an important determinant of spread and persistence in a VRE-endemic ICU. We describe the transmission of nosocomial pathogens by using a micro-epidemiological framework based on the transmission dynamics of vector-borne diseases. By using the concept of a basic reproductive number, R0, defined as the average number of secondary cases generated by one primary case, we show quantitatively how infection control measures such as hand washing, cohorting, and antibiotic restriction affect nosocomial cross-transmission. By using detailed molecular epidemiological surveillance and compliance monitoring, we found that the estimated basic reproductive number for VRE during a study at the Cook County Hospital, Chicago, was approximately 3-4 without infection control and 0.7 when infection control measures were included. The impact of infection control was to reduce the prevalence from a predicted 79% to an observed 36%. Hand washing and staff cohorting are the most powerful control measures although their efficacy depends on the magnitude of R0. Under the circumstances tested, endemicity of VRE was stabilized despite infection control measures, by the constant introduction of colonized patients. Multiple stochastic simulations of the model revealed excellent agreement with observed pattern. In conjunction with detailed microbiological surveillance, a mathematical framework provides a precise template to describe the colonization dynamics of VRE in ICUs and impact of infection control measures. Our analyses suggest that compliance for hand washing significantly in excess of reported levels, or the cohorting of nursing staff, are needed to prevent nosocomial transmission of VRE in endemic settings.

Students add value to learning organizations: the Medical University of South Carolina experience.

Students bring fresh ideas, knowledge, and perspective to health care organizations. As students learn how to apply the principles and methods of continuous improvement, they help improve both the quality of health care and the organization's way of improving quality.

The role of "colonization pressure" in the spread of vancomycin-resistant enterococci: an important infection control variable.

OBJECTIVE: The spread of nosocomial multiresistant microorganisms is affected by compliance with infection control measures and antibiotic use. We hypothesized that "colonization pressure" (ie, the proportion of other patients colonized) also is an important variable. We studied the effect of colonization pressure, compliance with infection control measures, antibiotic use, and other previously identified risk factors on acquisition of colonization with vancomycin-resistant enterococci (VRE). METHODS: Rectal colonization was studied daily for 19 weeks in 181 consecutive patients who were admitted to a single medical intensive care unit. A statistical model was created using a Cox proportional hazards regression model including length of stay in the medical intensive care unit until acquisition of VRE, colonization pressure, personnel compliance with infection control measures (hand washing and glove use), APACHE (Acute Physiology and Chronic Health Evaluation) 11 scores, and the proportion of days that a patient received vancomycin or third-generation cephalosporins, sucralfate, and enteral feeding. RESULTS: With survival until colonization with VRE as the end point, colonization pressure was the most important variable affecting acquisition of VRE (hazard ratio [HR], 1.032; 95% confidence interval [C1], 1.012-1.052; P=.002). In addition, enteral feeding was associated with acquisition of VRE (HR, 1.009; 95% CI, 1.000-1.017; P=.05), and there was a trend toward association of third-generation cephalosporin use with acquisition (HR, 1.007; 95% CI, 0.999-1.015; P=.11). The effects of enteral feeding and third-generation cephalosporin use were more important when colonization pressure was less than 50%. Once colonization pressure was 50% or higher, these other variables hardly affected acquisition of VRE. CONCLUSIONS: Acquisition of VRE was affected by colonization pressure, the use of antibiotics, and the use of enteral feeding. However, once colonization pressure was high, it became the major variable affecting acquisition of VRE.

External sources of vancomycin-resistant enterococci for intensive care units.

OBJECTIVE: The incidence of colonization and infection with vancomycin-resistant enterococci (VRE) has increased dramatically in the last 5 yrs, especially in intensive care units (ICUs). We studied VRE-colonization in patients on admission to a medical ICU (MICU) where VRE colonization is endemic. DESIGN: Prospective, descriptive analysis. SETTING: An MICU of a public hospital. PATIENTS: Three hundred and one consecutively admitted patients. MEASUREMENTS AND MAIN RESULTS: Rectal swabs were obtained on admission from all patients. VRE isolates from all colonized patients were genetically fingerprinted by pulsed-field gel-electrophoresis (PFGE). Forty-three (14%) of 301 patients were colonized with VRE on MICU admission. Three (7%) of these 43 patients were admitted directly from the community without prior hospital contact. Risk of colonization on admission was related to the length of stay in the hospital before MICU-admission (odds ratio 4.65 for patients with a stay of at least 3 days) and previous in-hospital use of antibiotics. Of 22 VRE PFGE strain types recognized in the MICU during the study period, four (18%) were introduced by patients admitted directly from the community and ten (45%) were introduced by patients admitted from other hospital wards. CONCLUSIONS: These results show that although ICUs are considered epicenters for antibiotic resistance, sources extraneous to our MICU (e.g., other wards) contributed the majority of VRE strain types in the unit.

A new classification system predicting keratomalacia after trauma in vitamin A deficiency: sodium citrate does not prevent disease progression.

PURPOSE: The purpose of this study was to develop a classification system to predict keratomalacia after trauma in vitamin A-deficient eyes and to determine whether citrate impedes polymorphonuclear leukocyte infiltration into the cornea, thus preventing keratomalacia. METHODS: Preliminary classification studies showed that a 7.0-mm corneal epithelial scrape, before clinical findings of corneal xerosis, did not induce keratomalacia. Primary studies were conducted concurrently on the same animals to develop the classification system and test the effect of citrate in vitamin A deficiency. A 7.0-mm corneal epithelial scrape was performed on vitamin A-deficient eyes in various stages of corneal xerosis and treated as follows. Experiment 1: group 1, 10% citrate drops; group 2, phosphate buffer solution (PBS) drops; experiment II: group 3, drops and subconjunctival injection of 10% citrate; group 4, drops and subconjunctival injection of PBS. RESULTS: Corneal abrasion in eyes with 2+ corneal xerosis yielded keratomalacia in 50% of cases; the remainder healed with xerotic epithelium. Eighty-three percent of eyes with > 2+ xerosis developed keratomalacia after corneal abrasion, whereas only 7.1% of eyes with < 2+ xerosis advanced to this stage. In experiment I, 27% of citrate-treated eyes and 38% of PBS-treated eyes developed keratomalacia (not significant). In experiment II, two of six citrate-treated eyes perforated and one eye developed keratomalacia. One of six control PBS eyes perforated and four developed keratomalacia. CONCLUSION: We correlated the degree of corneal xerosis with the occurrence of keratomalacia after corneal trauma. This led to the development of a classification scale that is of research and clinical significance. Additionally, citrate did not significantly reduce keratomalacia or perforation in the vitamin. A-deficient eye.

Skin colonization with vancomycin-resistant enterococci among hospitalized patients with bacteremia.

To assess the prevalence of skin and rectal colonization by vancomycin-resistant enterococci (VRE) in hospitalized bacteremic patients and to determine the relation between colonization and bacteremia, we compared 14 case patients who had bacteremia due to VRE with 30 control patients who had bacteremia due to other pathogens. Rectal colonization and skin (inguinal area and/or antecubital fossa) colonization with VRE were common among both case patients (100% had rectal colonization, and 86% had skin colonization) and control patients (37% had rectal colonization and 23% had skin colonization). Among patients with rectal colonization, skin colonization was more common when diarrhea or fecal incontinence was present. The bloodstream cleared without appropriate antimicrobial therapy in nine of the 14 patients with bacteremia due to VRE. The high prevalence of skin colonization with VRE may increase the risk of catheter-related sepsis, cross-infection, or blood culture contamination (which may explain the frequent spontaneous resolution of bacteremia due to VRE).

Evaluating the FONE FIM: Part I. Construct validity.

Rasch analysis was used in this paper to evaluate the Motor component of the FONE FIM, the telephone version of the Functional Independence Measure (FIM). For this purpose, 132 patients discharged from an inpatient geriatric assessment and rehabilitation program were assessed by trained research assistants using the FONE FIM. The results at 5 weeks post-discharge were compared to the observation FIMs (OBS FIMs) done at home 6 weeks post-discharge. These patients had an average age of 79 years and presented with multiple, complex medical problems and significant functional decline. The FONE FIM and the OBS FIM were shown to share a strikingly similar item hierarchy, based on Rasch item difficulty measures. Only bladder management and climbing stairs were misfitting items as indicated by item fit statistics. The same 13-item set and 4-point scales were shown to be psychometrically optimal for both the FONE FIM and the OBS FIM based on the person separation index. Further research is required to address the issue of the optimal item set and scale levels from psychometric and clinical perspectives.

Evaluating the FONE FIM: Part II. Concurrent validity & influencing factors.

The "motor" (activities of daily living) component of the FONE FIM, the telephone version of the Functional Independence Measure (FIM) was evaluated in a cohort of 132 patients who had been discharged to home from a geriatric inpatient assessment and rehabilitation program. In the current study, Rasch person ability measures were derived from telephone assessments 5 weeks after discharge and in-home assessments 1 week later. Concordance between the modes was shown to be satisfactory for the Rasch measures based on intraclass correlation coefficients. However, the telephone mode consistently generated lower estimates than did the observational mode. This was due to the fact that the telephone mode underestimated motor function for the majority of patients who were at higher levels of cognition and motor function, but overestimated for patients who were at lower levels of cognition and motor function. At the item level, concordance, as determined by Kappa statistics, was better when the FONE FIM responses came from the patient rather than proxy respondents, and when the assessments were done by more experienced rather than less experienced raters. Based on these findings, a mixed strategy, the telephone mode for patients capable of responding to the FONE FIM and in-home assessments for those who are incapable, is recommended.

Epidemiology of colonisation of patients and environment with vancomycin-resistant enterococci.

BACKGROUND: Vancomycin-resistant enterococci (VRE) have emerged as nosocomial pathogens during the past 5 years, but little is known about the epidemiology of VRE. We investigated colonisation of patients and environmental contamination with VRE in an endemic setting to assess the importance of different sources of colonisation. METHODS: Between April 12, and May 29, 1995, cultures from body sites (rectum, groin, arm, oropharynx, trachea, and stomach) and from environmental surfaces (bedrails, drawsheet, blood-pressure cuff, urine containers, and enteral feed) were obtained daily from all newly admitted ventilated patients in our medical intensive-care unit (MICU). Rectal cultures were obtained from all non-ventilated patients in the MICU. Strain types of VRE were determined by pulsed-field gel electrophoresis. FINDINGS: There were 97 admissions of 92 patients, of whom 38 required mechanical ventilation. Colonisation with VRE on admission was more common in ventilated than in non-ventilated patients (nine [24%] vs three [6%], p < 0.05). Of the nine ventilated patients colonised with VRE on admission, one acquired a new strain of VRE in the MICU. Of the 29 ventilated patients who were not colonised with VRE on admission, 12 (41%) acquired VRE in the MICU. The median time to acquisition of VRE was 5 days (interquartile range 3-8). Of the 13 ventilated patients who acquired VRE, 11 (85%) were colonised with VRE by cross-colonisation. VRE were isolated from 157 (12%) of 1294 environmental cultures. The rooms of 13 patients were contaminated with VRE, but only three (23%) of these patients subsequently acquired colonisation with VRE. Pulsed-field gel electrophoresis of 262 isolates showed 20 unique strain types of VRE. INTERPRETATION: Frequent colonisation with VRE on MICU admission and subsequent cross-colonisation are important factors in the endemic spread of VRE. Persistent VRE colonisation in the gastrointestinal tract and on the skin, the presence of multiple-strain types of VRE, and environmental contamination may all contribute to the spread of VRE.

Work force diversity: nursing perspectives.

All too frequently, diversity is viewed negatively or, at best, neutrally. The challenge of diversity is one of embracing it. The extent to which we are successful in meeting this challenge will determine South Carolina's and America's competitiveness and effectiveness in health care and in the global marketplace. Although much of the focus of this article has been work force diversity within nursing, attention to diversity is applicable within all health services markets, where human resources is the primary conduit for progress. Therefore, elements of this report can be generalized to all health care providers, where racial under-representation, in comparison to the populations served, is present.