Compliance of acute and long stay geriatric patients with nutritional supplementation.

BACKGROUND: Nutritional supplements are prescribed to improve nutritional status, and reduce hospital stays in manourised hospital patients. Clinical benefits are dependant on compliance, the level of which remains unclear. AIMS: To assess compliance levels with oral nutritional supplementation and determine methods to improve compliance. METHODS: Compliance was observed over 10 days by measuring total supplements prescribed and weighing wastage remaining after use. Areas for improvement were identified and implemented for 6 months. Specifically, a distinct supplement administration round was established and those patients requiring assistance with supplement consumption were identified with signage above their beds. Compliance was re-assessed in a sub sample of patients. RESULTS: Thirty seven elderly patients (mean age 85 years; 57% female) prescribed nutritional supplements were studied. Mean compliance was significantly greater in males than females (85.7% vs 74%) and acute wards compared to longstay (89.5% vs. 74.2 Compliance with supplements was significantly greater following intervention (mean 74.2% vs. 93%, p < 0.0001). CONCLUSION: Compliance with nutritional supplementation is variable among institutionalized geriatric patients. Timing of supplementation dispensation and improving staff vigilance can positively affect compliance.

Central administration of the neurotensin receptor antagonist SR48692 attenuates vacuous chewing movements in a rodent model of tardive dyskinesia.

Tardive dyskinesia is a movement disorder that develops in 20-30% of patients treated with chronic neuroleptics. Whilst the pathogenesis of tardive dyskinesia remains unclear, altered expression of neuropeptides in the basal ganglia has been implicated in its emergence. The peptide neurotensin is expressed in both dopamine D1 receptor-bearing neurons of the direct striatonigral pathway and dopamine D2 receptor-bearing neurons of the indirect striatopallidal pathway. Increased levels of striatal neurotensin messenger RNA (mRNA) are reported following chronic neuroleptic therapy. Chronic treatment with the typical antipsychotic haloperidol elicits neurotensin immunoreactivity in a large number of striatopallidal and a modest number of striatonigral projection neurons, whilst treatment with the potent dopamine releaser, methamphetamine, induces intense neurotensin immunoreactivity in striatonigral projection neurons. In order to determine whether increased levels of striatal neurotensin mRNA in the direct striatonigral or the indirect striatopallidal pathway play a more influential role in the development of tardive dyskinesia, we explored the effects of a specific neurotensin antagonist in a rodent model (vacuous chewing movements [VCMs] induced by chronic neuroleptics). Three groups of animals received injections of fluphenazine decanoate (25 mg/kg) or its vehicle sesame oil every 3 weeks for at least 18 weeks. They were then surgically implanted with bilateral guide cannulae aimed at the striatum, the substantia nigra pars reticulata, or the globus pallidus respectively. After recovery, animals were infused with 2-[(1-(7-chloro-4-quinolinyl)-5-(2,6-imethoxyphenyl)pyrazol-3-yl)carbonylamino]tricyclo(3.3.1.1.(3.7))decan-2-carboxylic acid (SR48692; 0.25, 0.50, and 1.0 nmol/microl), or its vehicle (10% dimethyl sulfoxide [DMSO] in saline) and observed for 60 min. Intra-striatal, intra-nigral or intra-pallidal infusion of SR48692 attenuated neuroleptic-induced VCMs. These findings lend further support to a role for neurotensin in the development of VCMs but do not clarify which pathway plays a more important role. Thus, treatments that reduce or prevent the effects of increased neurotensin expression and release may be useful in the management of tardive dyskinesia.

Blockade of nigral and pallidal opioid receptors suppresses vacuous chewing movements in a rodent model of tardive dyskinesia.

Chronic neuroleptic treatment leads to the development of tardive dyskinesia in 20-30% of patients. While the pathogenesis of tardive dyskinesia remains elusive, altered opioid peptide function in striatal projection pathways of the basal ganglia has been implicated. Using a rodent model of vacuous chewing movements induced by chronic neuroleptic administration, we investigated regional involvement of opioid transmission in tardive dyskinesia. We examined the role of dynorphin in the direct striatonigral pathway by infusing nor-binaltorphimine, a selective kappa opioid receptor antagonist, into the substantia nigra pars reticulata. As well, infusions of naloxone (a non-specific opioid receptor antagonist), D-Phe-Cys-Tyr-D-Trp-Orn-Thr-Pen-Thr amide (CTOP; a mu opioid receptor antagonist) or naltrindole (a delta opioid receptor antagonist) into the globus pallidus were used to establish the contribution of the striatopallidal pathway. Chronic fluphenazine treatment (25 mg/kg i.m. every 3 weeks for 18 weeks) resulted in a robust increase in vacuous chewing movements. Infusion of nor-binaltorphimine (5.0 nmol) into the substantia nigra pars reticulata significantly attenuated vacuous chewing movements. Infusion of naloxone (0.5 and 2.0 nmol) into the globus pallidus also significantly attenuated vacuous chewing. Infusion of naltrindole into the globus pallidus blocked vacuous chewing at all doses administered (0.5, 1.0, 2.0 nmol) while CTOP was only effective at the two higher doses. From these results we suggest that increases in dynorphin in the direct striatonigral pathway and enkephalin in the indirect striatopallidal pathway following chronic neuroleptic administration are both likely to contribute to tardive dyskinesia.

Reusable biopsy forceps: a prospective evaluation of cleaning, function, adequacy of tissue specimen, and durability.

BACKGROUND: Recent studies have indicated that reusable biopsy forceps remain contaminated after reprocessing and can only be used a mean of 12 to 25 times without malfunction. Because this contradicts traditional endoscopic practice, our study investigated the ability to sterilize a type of commercially available biopsy forceps and prospectively evaluated their function in vivo until malfunction and/or breakage. METHODS: Thirty reusable biopsy forceps were studied, 15 of which were contaminated for 5 trials each with 10(6) Bacillus stearothermophilus, and 15 of which were prospectively evaluated clinically over an 18-month period (9/98-3/00). Contaminated forceps were reprocessed by using a standard protocol and placed in a sterile bag containing soy broth. The latter was passed through a 0.2 micron filter and was subsequently cultured. In vivo data included biopsy site, size, adequacy, problems obtaining a biopsy specimen, and reasons for ultimate forceps failure. RESULTS: After contamination, all biopsy forceps yielded a heavy growth of B stearothermophilus. No forceps, including 5 that were piecemeal dismantled with a wire cutter, had residual bacteria after reprocessing. In the in vivo study, 1507 biopsy sessions were undertaken in 1339 procedures. Forceps were categorized as new or like-new in 1259 of 1339 (94%) procedures, some loss of function but usable in 72 of 1339 (5.4%), and inadequate function or broken at use in 8 of 1339 (0.6%). Histologically, 1501 specimen sets were adequate (99.6%) and mean specimen size was 2.7 +/- 0.1 mm. Mechanical problems were noted in only 38 of 1507 (3%) sessions to include such things as sticky forceps, and the mean number of uses to malfunction or breakage was 91 +/- 15 (SEM) (range 19-132). CONCLUSIONS: This reusable biopsy forceps can be sterilized and used a mean of 91 times with adequate tissue sampling. Mechanical problems were minor to time of breakage. Contingent on acquisition and reprocessing costs as well as the number of procedures performed, this reusable forceps has the potential for significant cost savings.

Evaluation of liver histology, ALT elevation, and HCV RNA titer in patients with chronic hepatitis C.

OBJECTIVE: Hepatic histological evaluation is currently the gold standard to determine the degree of liver injury in chronic hepatitis C. It is unclear whether degree of serum ALT elevation or quantitative hepatitis C virus (HCV) RNA can predict level of histological damage. METHODS: Fifty nine biopsies from 44 patients with chronic hepatitis C were reviewed. The amount of liver damage was quantified using the Histology Activity Index (HAI) and was compared with serum ALT and, in 26 biopsies, quantitative HCV RNA (branched DNA amplification, Quantiplex, Chiron). RESULTS: A statistically significant linear relationship was noted between degree of ALT elevation and amount of liver injury based on HAI score (p < 0.05) although this relationship was not statistically strong (rs = 0.4900). No significant correlation was noted between serum ALT and HCV RNA titer (rs = 0.4044) or between quantitative HCV RNA titer and HAI score (rs = 0.3506). No individual component of the HAI correlated with ALT or HCV RNA. CONCLUSIONS: Although there is a correlation between serum ALT and degree of hepatic injury based on HAI score, this relationship is weak and probably of no clinical use. There is no significant correlation between HCV RNA and serum ALT or HCV RNA and degree of hepatic injury in individual patients. Hepatic histological evaluation continues to be required for clinical assessment of patients with chronic hepatitis C.

A 22-year-old man with a liver mass and markedly elevated serum alpha fetoprotein.

Our patient presented with a large liver mass, an extremely elevated AFP level, and an almost certain diagnosis of HCC. However, extensive evaluation and biopsies failed to demonstrate malignancy, and the available evidence strongly suggests that the patient has an adult polycystic disease without renal involvement, and that the mass was the result of hemorrhage and degenerative changes in one of his cysts. Polycystic diseases can involve only one lobe, as it appears in this case. Only about 10-15% of patients with polycystic disease have symptoms due to the liver disease, while 30-50% have associated renal disease. Thus, our patient is unusual in several respects. However, his liver mass has decreased in size, he feels well, and his biochemical abnormalities have returned to normal. Despite a classic presentation for HCC, this case underscores the necessity for a thorough evaluation, especially for patients without major risk factors for hepatocellular carcinoma.