Change in motivational bias during treatment predicts outcome in anorexia nervosa.

OBJECTIVE: Reward and punishment sensitivity are known to be altered in anorexia nervosa (AN). Most research has examined these constructs separately although motivated behavior is influenced by considering both the potential for reward and risk of punishment. The present study sought to compare the relative balance of reward and punishment sensitivity in AN versus healthy controls (HCs) and examine whether motivational bias is associated with AN symptoms and treatment outcomes. METHODS: Adolescents and adults with AN (n = 262) in a partial hospitalization program completed the Eating Disorders Examination Questionnaire (EDE-Q), Behavioral Inhibition System/Behavioral Activation System (BIS/BAS) scales, and Sensitivity to Punishment/Sensitivity to Reward Questionnaire (SPSRQ) at admission and discharge. HCs (HC; n = 90) completed the BIS/BAS and SPSRQ. Motivational Bias Scores were calculated to reflect the dominance of reward versus punishment sensitivity. RESULTS: Individuals with AN demonstrated significantly greater bias toward punishment sensitivity than HC. In AN, a bias toward punishment was associated with higher EDE-Q Global score at admission. Change in motivational bias during treatment predicted EDE-Q Global scores, but not BMI, at discharge, with greater increases in reward sensitivity or greater decreases in punishment sensitivity during treatment predicting lower eating pathology. Similar findings were observed using the BIS/BAS and SPSRQ. DISCUSSION: Change in motivational bias during treatment is associated with improved outcomes in AN. However, it appears that much of the change in motivational bias can be attributed to changes in punishment sensitivity, rather than reward sensitivity. Future research should examine the mechanisms underlying punishment sensitivity decreases during treatment. PUBLIC SIGNIFICANCE: Sensitivity to reward and punishment may be important treatment targets for individuals with anorexia nervosa (AN). To date, most research has considered reward and punishment sensitivity separately, rather than examining their relationship to each other. We found that the balance of reward and punishment sensitivity (i.e., motivational bias) differs between healthy controls and those with AN and that this bias is associated with eating disorder symptoms and treatment outcome.

Following the Science? Examining the Issuance of Stay-At-Home Orders Related to COVID-19 by U.S. Governors.

Informed by the public health policymaking literature, this study's objective is to identify scientific, political, social, economic, and external factors related to U.S. governors' decisions to issue stay-at-home orders (SAHOs) in response to the first wave of the COVID-19 pandemic. Public health experts advocate for social distancing to slow the spread of infectious diseases, but government mandates to social distance can impose substantial social and economic costs. This study uses event history analysis to investigate the issuance of COVID-19-related gubernatorial SAHOs during a 41-day period in the 50 U.S. states. The findings indicate that scientific, political, and economic factors were associated with the issuance of SAHOs, but that external considerations played the largest role, particularly those related to the timing of other governors' decisions. This study offers evidence about how some U.S. political leaders balance public health concerns against other considerations and, more broadly, how state governments address crisis-level issues.

Anhedonia in Eating Disorders.

Anhedonia is frequently observed among individuals with eating disorders (ED), though its relevance to ED pathology and clinical outcomes remain poorly understood. This chapter will present the latest findings regarding anhedonia in ED, with the majority of data available for anorexia nervosa (AN) and bulimia nervosa (BN). We consider anhedonia from the mechanistic lens of altered reward processing, with attention given to subjective experience, neurotransmitter function, neural correlates, and cognitive performance corresponding to distinct components of reward (i.e., liking, wanting, and learning). Findings from animal models are also highlighted. The chapter concludes with a discussion of implications for treatment and future directions aimed at better understanding anhedonia in ED.

A Longitudinal Preliminary Study of Addiction-Like Responses to Food and Alcohol Consumption Among Individuals Undergoing Weight Loss Surgery.

Reductions in addiction-like food behaviors and increases in alcohol intake have been reported after weight loss surgery. However, no studies have tracked these measures in combination and prospectively. In this preliminary study, 27 participants underwent bariatric surgery (Roux-en-Y gastric bypass (RYGB) (n = 10) and sleeve gastrectomy (SG) (n = 6)), dietary weight loss (n = 6), or no treatment (n = 5). Participants were weighed, completed the Yale Food Addiction Scale (YFAS), and reported alcohol intake frequency before intervention and at 4 and 24 months after baseline. At 24 months, only the surgery group showed significant reductions in BMI. Between baseline and 24 months, YFAS scores decreased (p = .006) and alcohol intake increased in the surgery group (p = .005). Significant changes were not observed in the diet or no treatment groups.

Assessment of executive functioning in binge-eating disorder independent of weight status.

OBJECTIVE: Executive functioning (EF) problems may serve as vulnerability or maintenance factors for Binge-Eating Disorder (BED). However, it is unclear if EF problems observed in BED are related to overweight status or BED status. The current study extends this literature by examining EF in overweight and normal-weight BED compared to weight-matched controls. METHOD: Participants were normal-weight women with BED (n = 23), overweight BED (n = 32), overweight healthy controls (n = 48), and normal-weight healthy controls (n = 29). The EF battery utilized tests from the National Institutes of Health (NIH) Toolbox and Delis-Kaplan Executive Function System (D-KEFS). RESULTS: After controlling for years of education and minority status, overweight individuals performed more poorly than normal-weight individuals on a task of cognitive flexibility requiring generativity (p < .01), and speed on psychomotor performance tasks (p = .01). Normal-weight and overweight BED performed worse on working memory tasks compared to controls (p = .04). Unexpectedly, normal-weight BED individuals out-performed all other groups on an inhibitory control task (p < .01). No significant differences were found between the four groups on tasks of planning. DISCUSSION: Regardless of weight status, BED is associated with working memory problems. Replication of the finding that normal-weight BED is associated with enhanced inhibitory control is needed.

The importance of body image concerns in overweight and normal weight individuals with binge eating disorder.

Body image concerns in binge eating disorder (BED) have been examined almost exclusively in overweight individuals with BED. The current study extends past research by including overweight and normal weight BED and non-BED groups to assess the multifactorial construct of body image using subscales of the Eating Disorder Examination 16.0 (EDE-16.0) and a Body Comparison Task. Independent of weight status and when controlling for age and race, women with BED are distinguished from those without BED by significantly greater overvaluation of shape and weight on the EDE-16.0 and significantly reduced weight satisfaction after a Body Comparison Task. Both BED diagnosis and weight status were independently associated with Weight Concern and Shape Concern subscales on the EDE-16.0. Taken together, these data provide further support for the consideration of body image concerns in the diagnostic criteria for BED.

Binge-eating disorder may be distinguished by visuospatial memory deficits.

OBJECTIVE: Binge eating disorder (BED), characterized by recurrent episodes of loss of control overeating, is highly comorbid with overweight and obesity. Both loss of control eating and higher body mass index have been associated with poor memory. The current study sought to clarify the relationships between BED, weight and memory. Specifically, visual memory was examined, given evidence of impaired visuospatial abilities in overweight individuals and little research on visual memory in BED. METHOD: Overweight and normal-weight women with BED and matched healthy controls were administered the Rey Complex Figure Test. RESULTS: Planned contrasts revealed that normal-weight healthy controls performed better than all other groups on the immediate and delayed recall portions of the task. Performance on the immediate recall portion was better among normal-weight individuals than overweight individuals, and performance on both the immediate and delayed recall portions was better among individuals without BED than those with BED. No differences between groups were seen on the copy or recognition trials. CONCLUSIONS: Visual memory appears to be impaired among overweight participants and both normal and overweight participants with BED. This finding was specific to retrieval. Replication of this finding in BED using different measures of memory is needed.

WITHDRAWN: Nutrition support for bone marrow transplant patients.

BACKGROUND: This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES: To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH METHODS: Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA: RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS: Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS: In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS: In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Insights revealed by rodent models of sugar binge eating.

Binge eating is seen across the spectrum of eating disorder diagnoses as well as among individuals who do not meet diagnostic criteria. Analyses of the specific types of foods that are frequently binged upon reveal that sugar-rich items feature prominently in binge-type meals, making the effects of binge consumption of sugar an important focus of study. One avenue to do this involves the use of animal models. Foundational and recent studies of animal models of sugar bingeing, both outlined here, lend insight into the various neurotransmitters and neuropeptides that may participate in or be altered by this behavior. Further, several preclinical studies incorporating sugar bingeing paradigms have explored the utility of pharmacological agents that target such neural systems for reducing sugar bingeing in an effort to enhance clinical treatment. Indeed, the translational implications of findings generated using animal models of sugar bingeing are considered here, along with potential avenues for further study.

Exercise for falls prevention in Parkinson disease: a randomized controlled trial.

OBJECTIVE: To determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, i.e., poor balance, reduced leg muscle strength, and freezing of gait, in people with Parkinson disease. METHODS: Two hundred thirty-one people with Parkinson disease were randomized into exercise or usual-care control groups. Exercises were practiced for 40 to 60 minutes, 3 times weekly for 6 months. Primary outcomes were fall rates and proportion of fallers during the intervention period. Secondary outcomes were physical (balance, mobility, freezing of gait, habitual physical activity), psychological (fear of falling, affect), and quality-of-life measures. RESULTS: There was no significant difference between groups in the rate of falls (incidence rate ratio [IRR] = 0.73, 95% confidence interval [CI] 0.45-1.17, p = 0.18) or proportion of fallers (p = 0.45). Preplanned subgroup analysis revealed a significant interaction for disease severity (p < 0.001). In the lower disease severity subgroup, there were fewer falls in the exercise group compared with controls (IRR = 0.31, 95% CI 0.15-0.62, p < 0.001), while in the higher disease severity subgroup, there was a trend toward more falls in the exercise group (IRR = 1.61, 95% CI 0.86-3.03, p = 0.13). Postintervention, the exercise group scored significantly (p < 0.05) better than controls on the Short Physical Performance Battery, sit-to-stand, fear of falling, affect, and quality of life, after adjusting for baseline performance. CONCLUSIONS: An exercise program targeting balance, leg strength, and freezing of gait did not reduce falls but improved physical and psychological health. Falls were reduced in people with milder disease but not in those with more severe Parkinson disease. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that for patients with Parkinson disease, a minimally supervised exercise program does not reduce fall risk. This study lacked the precision to exclude a moderate reduction or modest increase in fall risk from exercise. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).

Predictors of Adherence to a Falls Prevention Exercise Program for People with Parkinson's Disease.

BACKGROUND: Long-term benefits of exercise for people with Parkinson's disease (PD) require regular and sustained participation. This study aimed to investigate predictors of adherence to a minimally supervised exercise program designed to reduce falls in people with PD. METHOD: People with idiopathic PD who participated in the exercise arm of a randomized, controlled trial were included. Exercises were prescribed three times per week for 6 months. Adherence was defined as the percentage of prescribed sessions participants reported as having undertaken. Potential predictors of adherence included baseline measures of demographic variables, disease severity and duration, falls and fear of falling, pain, self-reported health and quality of life, cognition, physical activity levels, freezing of gait, functional mobility and balance, and knee extensor strength. RESULTS: The 108 participants included undertook a mean of 72% (standard deviation: 38%) of prescribed sessions. Participants had higher levels of adherence if they had shorter disease duration, less bodily pain, and better self-reported health and quality of life. A multivariate model (including disease duration, severity of bodily pain, self-reported physical well-being, the Frontal Assessment Battery, the Short Physical Performance Battery, and maximum walking time) explained 9% of the variance in exercise adherence, with shorter disease duration and less pain the strongest predictors (both predictors standardized ß = -0.2; P = 0.04). CONCLUSION: Disease duration and pain are likely to negatively influence exercise participation in people with PD. Given that most of the variance in adherence is unexplained, further work is required to determine other predictors of adherence to long-term exercise programs.

GS 455534 selectively suppresses binge eating of palatable food and attenuates dopamine release in the accumbens of sugar-bingeing rats.

Binge eating palatable foods has been shown to have behavioral and neurochemical similarities to drug addiction. GS 455534 is a highly selective reversible aldehyde dehydrogenase 2 inhibitor that has been shown to reduce alcohol and cocaine intake in rats. Given the overlaps between binge eating and drug abuse, we examined the effects of GS 455534 on binge eating and subsequent dopamine release. Sprague-Dawley rats were maintained on a sugar (experiment 1) or fat (experiment 2) binge eating diet. After 25 days, GS 455534 was administered at 7.5 and 15 mg/kg by an intraperitoneal injection, and food intake was monitored. In experiment 3, rats with cannulae aimed at the nucleus accumbens shell were maintained on the binge sugar diet for 25 days. Microdialysis was performed, during which GS 455534 15 mg/kg was administered, and sugar was available. Dialysate samples were analyzed to determine extracellular levels of dopamine. In experiment 1, GS 455534 selectively decreased sugar intake food was made available in the Binge Sugar group but not the Ad libitum Sugar group, with no effect on chow intake. In experiment 2, GS 455534 decreased fat intake in the Binge Fat group, but not the Ad libitum Fat group, however, it also reduced chow intake. In experiment 3, GS 455534 attenuated accumbens dopamine release by almost 50% in binge eating rats compared with the vehicle injection. The findings suggest that selective reversible aldehyde dehydrogenase 2 inhibitors may have the therapeutic potential to reduce binge eating of palatable foods in clinical populations.

Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings.

BACKGROUND: Given the prevalence of under-nutrition and reports of inadequate nutritional management of patients in hospitals and the community, nutritional screening may play a role in reducing the risks of malnutrition. Screening programmes can invoke costs to health systems and patients. It is therefore important to assess the effectiveness of nutritional screening programmes. OBJECTIVES: To examine the effectiveness of nutritional screening in improving quality of care (professional practice) and patient outcomes compared with usual care. SEARCH METHODS: We searched the following databases: CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL up to June 2012 to find relevant studies. SELECTION CRITERIA: Randomised controlled studies, controlled clinical trials, controlled before-after studies and interrupted time series studies assessing the effectiveness of nutritional screening were eligible for inclusion in the review. We considered process outcomes (for example patient identification, referral to dietitian) and patient outcomes (for example mortality, change in body mass index (BMI)). Participants were adult patients aged 16 years or over. We included studies conducted in different settings, including hospitals, out-patient clinics, primary care or long term care settings. DATA COLLECTION AND ANALYSIS: We independently assessed the risk of bias and extracted data from the included studies. Meta-analysis was considered but was not conducted due to the discrepancies between the studies. The studies were heterogeneous in their design, setting, intervention and outcomes. We analysed the data using a narrative synthesis approach. MAIN RESULTS: After conducting initial searches and screening the titles and abstracts of the identified literature, 77 full text papers were retrieved and read. Ultimately three studies were included. Two controlled before-after studies were conducted in hospital settings (one in the UK and one in the Netherlands) and one cluster randomised controlled trial was conducted in a primary care setting (in the USA).The study conducted in primary care reported that physicians were receptive to the screening intervention, but the intervention did not result in any improvements in the malnutrition detection rate or nutritional intervention rate. The two studies conducted in hospitals had important methodological limitations. One study reported that as a result of the intervention, the recording of patients' weight increased in the intervention wards. No significant changes were observed in the referral rates to dietitians or care at meal time. The third study reported weight gains and a reduction in hospital acquired infection rate in the intervention hospital. They found no significant differences in length of stay, pressure sores, malnutrition and treatment costs per patient between the two hospitals. AUTHORS' CONCLUSIONS: Current evidence is insufficient to support the effectiveness of nutritional screening, although equally there is no evidence of no effect. Therefore, more high quality studies should be conducted to assess the effectiveness of nutritional screening in different settings.

The effects of an exercise program on fall risk factors in people with Parkinson's disease: a randomized controlled trial.

This randomized controlled trial with blinded assessment aimed to determine the effect of a 6-month minimally supervised exercise program on fall risk factors in people with Parkinson's disease (PD). Forty-eight participants with PD who had fallen or were at risk of falling were randomized into exercise or control groups. The exercise group attended a monthly exercise class and exercised at home three times weekly. The intervention targeted leg muscle strength, balance, and freezing. The primary outcome measure was a PD falls risk score. The exercise group had no major adverse events and showed a greater improvement than the control group in the falls risk score, which was not statistically significant (between group mean difference = -7%, 95% CI -20 to 5, P = 0.26). There were statistically significant improvements in the exercise group compared with the control group for two secondary outcomes: Freezing of Gait Questionnaire (P = 0.03) and timed sit-to-stand (P = 0.03). There were statistically nonsignificant trends toward greater improvements in the exercise group for measures of muscle strength, walking, and fear of falling, but not for the measures of standing balance. Further investigation of the impact of exercise on falls in people with PD is warranted.

Nutrition support for bone marrow transplant patients.

BACKGROUND: This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES: To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH STRATEGY: Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA: RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS: Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS: In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS: In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Exercise therapy for prevention of falls in people with Parkinson's disease: a protocol for a randomised controlled trial and economic evaluation.

BACKGROUND: People with Parkinson's disease are twice as likely to be recurrent fallers compared to other older people. As these falls have devastating consequences, there is an urgent need to identify and test innovative interventions with the potential to reduce falls in people with Parkinson's disease. The main objective of this randomised controlled trial is to determine whether fall rates can be reduced in people with Parkinson's disease using exercise targeting three potentially remediable risk factors for falls (reduced balance, reduced leg muscle strength and freezing of gait). In addition we will establish the cost effectiveness of the exercise program from the health provider's perspective. METHODS/DESIGN: 230 community-dwelling participants with idiopathic Parkinson's disease will be recruited. Eligible participants will also have a history of falls or be identified as being at risk of falls on assessment. Participants will be randomly allocated to a usual-care control group or an intervention group which will undertake weight-bearing balance and strengthening exercises and use cueing strategies to address freezing of gait. The intervention group will choose between the home-based or support group-based mode of the program. Participants in both groups will receive standardized falls prevention advice. The primary outcome measure will be fall rates. Participants will record falls and medical interventions in a diary for the duration of the 6-month intervention period. Secondary measures include the Parkinson's Disease Falls Risk Score, maximal leg muscle strength, standing balance, the Short Physical Performance Battery, freezing of gait, health and well being, habitual physical activity and positive and negative affect schedule. DISCUSSION: No adequately powered studies have investigated exercise interventions aimed at reducing falls in people with Parkinson's disease. This trial will determine the effectiveness of the exercise intervention in reducing falls and its cost effectiveness. This pragmatic program, if found to be effective, has the potential to be implemented within existing community services. TRIAL REGISTRATION: The protocol for this study is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12608000303347).

Hospital and non-hospital costs for fall-related injury in community-dwelling older people.

OBJECTIVES: This study determined the cost of fall-related health care in a cohort of community-dwelling people. METHODS: 578 people aged 75 years and over were monitored for falls and related health-care costs for one year. RESULTS: The mean cost per injurious fall was $1600 (year 2000 dollars). Hospital costs accounted for 67% of the total cost, even though only 4% of injurious falls required hospital admission. The cost of non-hospital health care was also substantial. CONCLUSION: This study highlights the economic burden of falls and the importance of injury prevention strategies.

Nutrition support for bone marrow transplant patients.

BACKGROUND: This is an update of the original Cochrane review published in Issue 2, 2002. Bone marrow transplantation involves administration of toxic chemotherapy and infusion of marrow cells. After treatment, patients can develop poor appetite, mucositis and gastrointestinal failure, leading to malnutrition. To prevent this, parenteral nutrition (PN) support is often first choice but is associated with increased risk of infection. Enteral nutrition (EN) is an alternative, as is addition of substrates. OBJECTIVES: To determine efficacy of EN or PN support for patients receiving bone marrow transplant. SEARCH STRATEGY: Search of The Cochrane Library, MEDLINE, EMBASE and CINAHL in November 2000 and subsequently June 2006. SELECTION CRITERIA: RCTs that compared one form of nutrition support with another, or control, for bone marrow transplant patients. DATA COLLECTION AND ANALYSIS: Twenty nine studies were identified. Data were collected on participants' characteristics; adverse effects; neutropaenia; % change in body weight; graft versus host disease; and survival. MAIN RESULTS: In two studies (82 participants) glutamine mouthwash reduced number of days patients were neutropenic (6.82 days, 95%CI (1.67 to 11.98) P = 0.009) compared with placebo. Three studies reported (103 participants) that patients receiving PN with glutamine had reduced hospital stay, 6.62 d (95%CI 3.47 to 9.77, P = 0.00004) compared with patients receiving standard PN. However, in the update a further study was added (147 participants) which altered the pooled results: duration in hospital may be increased for those who receive PN with additional glutamine - 0.22 days (95%CI (1.29 to 1.72). Two other studies reported that (73 participants) patients receiving PN plus glutamine had reduced incidence of positive blood cultures (OR 0.23, 95%CI 0.08 to 0.65, P = 0.006) compared to those receiving standard PN. However, a study from the update (113 participants in total) showed the odds of having a positive blood culture have increased but are still less likely if the patient receives PN with glutamine compared to standard PN (OR 0.46, 95%CI 0.20 to 1.04). When patients were given PN versus IV hydration, (25 participants) patients receiving PN had a higher incidence of line infections (OR 21.23, 95%CI 4.15 to 108.73, P = 0.0002) compared to those receiving standard IV fluids. The update identified one study which recognised that (55 participants) those who received IV were likely to spend less time in hospital, 3.30 days (95%CI -0.38 to 6.98, P = 0.08), although this result was not significant. As reported in the original review there remains no evaluable data to properly compare PN with EN. AUTHORS' CONCLUSIONS: In this update an additional study that compared PN and Glutamine versus standard PN showed that the certain benefits of parenteral nutrition with added glutamine compared to standard PN for reducing hospital stay are no longer definite. When PN with glutamine is compared with standard PN, patients may not leave hospital earlier, but do have reduced incidence of positive blood cultures, than those receiving standard PN. Where possible use of intravenous fluids and oral diet should be considered as a preference to parenteral nutrition, however, in the event of a patient suffering severe gastrointestinal failure even with a trial of enteral feeding, PN with the addition of glutamine could be considered.

Cultural aspects of working with students enrolled in a school-based health center.

School-based health centers provide accessible quality health services to culturally diverse student populations. Numerous challenges exist in providing culturally competent services in a school setting. This article presents models of culturally competent care, practice recommendations, and practical resources in an attempt to improve the provision of culturally competent services. In addition, one school health center's initiative to outreach culturally diverse students into health careers is highlighted.

The effect of an individualized fall prevention program on fall risk and falls in older people: a randomized, controlled trial.

OBJECTIVES: To determine whether an individualized falls prevention program comprising exercise, visual, and counseling interventions can reduce physiological falls risk and falls in older people. DESIGN: Randomized, controlled trial of 12 months' duration. SETTING: Falls Clinic, Royal North Shore Hospital, Sydney, Australia. PARTICIPANTS: Six hundred twenty people aged 75 and older recruited from a health insurance company membership database. INTERVENTIONS: Participants in the extensive intervention group (EIG) received individualized interventions comprising exercise and strategies for maximizing vision and sensation; the minimal intervention group (MIG) received brief advice; and the control group (CG) received no intervention. MEASUREMENTS: Accidental falls, vision, postural sway, coordinated stability, reaction time, lower limb muscle strength, sit-to-stand performance, and physiological profile assessment (PPA) falls risk scores. RESULTS: At the 6-month follow-up, PPA falls risk scores were significantly lower in the EIG than in the CG. EIG subjects assigned to the extensive exercise intervention group showed significant improvements in tests of knee flexion strength and sit-to-stand times but no improvements in balance. EIG subjects assigned to the extensive visual intervention group showed significant improvements in tests of visual acuity and contrast sensitivity. The rate of falls and injurious falls within the trial period were similar in the three groups. CONCLUSION: The individualized intervention program reduced some falls risk factors but did not prevent falls. The lack of an effect on falls may reflect insufficient targeting of the intervention to an at-risk group.