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.

Predicting self- and other-directed violence among discharged psychiatric patients: the roles of anger and psychopathic traits.

BACKGROUND: We examined the extent to which trait anger and psychopathic traits predicted post-discharge self-directed violence (SDV) and other-directed violence (ODV) among psychiatric patients. METHOD: Participants were 851 psychiatric patients sampled from in-patient hospitals for the MacArthur Violence Risk Assessment Study (MVRAS). Participants were administered baseline interviews at the hospital and five follow-up interviews in the community at approximately 10-week intervals. Psychopathy and trait anger were assessed with the Psychopathy Checklist: Screening Version (PSC:SV) and the Novaco Anger Scale (NAS) respectively. SDV was assessed during follow-ups with participants and ODV was assessed during interviews with participants and collateral informants. Psychopathy facets and anger were entered in logistic regression models to predict membership in one of four groups indicating violence status during follow-up: (1) SDV, (2) ODV, (3) co-occurring violence (COV), and (4) no violence. RESULTS: Anger predicted membership in all three violence groups relative to a non-violent reference group. In unadjusted models, all psychopathy facets predicted ODV and COV during follow-up. In adjusted models, interpersonal and antisocial traits of psychopathy predicted membership in the ODV group whereas only antisocial traits predicted membership in the COV group. CONCLUSIONS: Although our results provide evidence for a broad role for trait anger in predicting SDV and ODV among discharged psychiatric patients, they suggest that unique patterns of psychopathic traits differentially predict violence toward self and others. The measurement of anger and facets of psychopathy during discharge planning for psychiatric patients may provide clinicians with information regarding risk for specific types of violence.

A double-blind placebo controlled trial of simvastatin for the treatment of dyslipidaemia in renal allograft recipients.

BACKGROUND: With current techniques, renal failure patients are now able to regain near-normal health following renal transplantation. However, the development of premature cardiovascular disease is a major problem. Dyslipidaemia may be an important contributor to this. The use of lipid lowering agents in renal allograft recipients has been limited by potential interaction of these agents with the now widely used immunosuppressive agent, cyclosporine. AIM: This study was designed to investigate efficacy and safety of simvastatin in subjects taking either cyclosporine or azothioprine post renal transplantation. METHODS: Fifty-one subjects (32 females, 19 males -- mean age 51 +/- 12.5 yr) who were at least 1 yr post transplant, had creatinine < or = 2.5 mmol/L and a total cholesterol > or = 6 mmol/L were enrolled in a prospective, double-blind, placebo-controlled study. After an initial 10-wk dietary period, the last 4 wk on placebo, subjects were randomised to receive either 5 mg simvastatin/d for 6 wk followed by 10 mg simvastatin/d for 6 wk, or matching placebo. After this 12-wk double-blind phase, there was an open-label phase when all subjects were treated with 10 mg simvastatin/d for a period of 36 wk. RESULTS: Compared to placebo, 5 mg simvastatin/d significantly decreased total cholesterol by 20% (p < 0.01), low-density lipoprotein cholesterol (LDL cholesterol) by 29% (p < 0.01), and Apolipoprotein B (ApoB) by 26% (p < 0.01). Increasing simvastatin to 10 mg/d did not lead to further significant changes. But high-density lipoprotein cholesterol (HDL cholesterol) increased by 9% (p < 0.01) and Apolipoprotein A1 (ApoA1) by 7% (p < 0.01) only on 10 mg simvastatin/d. During the open-label phase, subjects previously randomised to placebo achieved similar significant changes to their lipoprotein profile. The benefits achieved from simvastatin were maintained to the end of the study. There were three withdrawals from the study, all from the simvastatin/ cyclosporine group. Two subjects had musculoskeletal pain and 1 had abdominal pain. Minor adverse events were similar in both the simvastatin- and placebo-treated groups. CONCLUSION: Low-dose simvastatin is an effective and well-tolerated agent in the treatment of dyslipidaemia in renal allograft recipients.

Hip Dislocation in a High School Football Player.

A group of experts met during the annual meeting of the American College of Sports Medicine in Dallas to discuss a case.

Decreased plasma protein binding of phenytoin in patients on valproic acid.

1 Plasma protein binding of phenytoin and of valproic acid were measured in ten epileptic patients on this drug combination. Ten other epileptics not on valproic acid served as controls. All patients had normal kidney function. 2 The measured free fraction of phenytoin among the patients on valproic acid ranged from 12.5 to 23.2% and after recalculation to a plasma albumin level of 45 g/l from 12.5 to 20.0 (median 15.4%). This differed significantly (P = 0.002, Mann- Whitney U-test) from the control patients where the normalized values ranged from 9.9 to 13.9% with a median value of 11.8%. 3 The measured free fractions of phenytoin and of valproic acid showed a significant correlation which, however, was due to the quantitative relation between the degree of binding of both these drugs and the concentration of plasma albumin. There was no discernable relation in this material between the free concentration of valproic acid and the free fraction of phenytoin. 4 It is concluded that patients on combined treatment with phenytoin and valproic acid have an unpredictably raised free fraction of phenytoin. This drug interaction therefore can complicate the important plasma level monitoring of phenytoin in epileptic patients unless the free concentration of this drug can be analysed or estimated.