A review of the nutritional challenges experienced by people living with severe mental illness: a role for dietitians in addressing physical health gaps.

People experiencing a severe mental illness (SMI), such as schizophrenia, schizoaffective disorder, bipolar affective disorder or depression with psychotic features, have a 20-year mortality gap compared to the general population. This 'scandal of premature mortality' is primarily driven by preventable cardiometabolic disease, and recent research suggests that the mortality gap is widening. Multidisciplinary mental health teams often include psychiatrists, clinical psychologists, specialist mental health nurses, social workers and occupational therapists, offering a range of pharmacological and nonpharmacological treatments to enhance the recovery of clients who have experienced, or are experiencing a SMI. Until recently, lifestyle and life skills interventions targeting the poor physical health experienced by people living with SMI have not been offered in most routine clinical settings. Furthermore, there are calls to include dietary intervention as mainstream in psychiatry to enhance mental health recovery. With the integration of dietitians being a relatively new approach, it is important to review and assess the literature to inform practice. This review assesses the dietary challenges experienced by people with a SMI and discusses potential strategies for improving mental and physical health.

The effects of vitamin and mineral supplementation on symptoms of schizophrenia: a systematic review and meta-analysis.

BACKGROUND: When used as an adjunctive with antipsychotics, certain vitamins and minerals may be effective for improving symptomatic outcomes of schizophrenia, by restoring nutritional deficits, reducing oxidative stress, or modulating neurological pathways. METHOD: We conducted a systematic review of all randomized controlled trials (RCTs) reporting effects of vitamin and/or mineral supplements on psychiatric symptoms in people with schizophrenia. Random-effects meta-analyses were used to calculate the standardized mean difference between nutrient and placebo treatments. RESULTS: An electronic database search in July 2016 identified 18 eligible RCTs, with outcome data for 832 patients. Pooled effects showed that vitamin B supplementation (including B6, B8 and B12) reduced psychiatric symptoms significantly more than control conditions [g = 0.508, 95% confidence interval (CI) 0.01-1.01, p = 0.047, I 2 = 72.3%]. Similar effects were observed among vitamin B RCTs which used intention-to-treat analyses (g = 0.734, 95% CI 0.00-1.49, p = 0.051). However, no effects of B vitamins were observed in individual domains of positive and negative symptoms (both p > 0.1). Meta-regression analyses showed that shorter illness duration was associated with greater vitamin B effectiveness (p = 0.001). There were no overall effects from antioxidant vitamins, inositol or dietary minerals on psychiatric symptoms. CONCLUSIONS: There is preliminary evidence that certain vitamin and mineral supplements may reduce psychiatric symptoms in some people with schizophrenia. Further research is needed to examine how the benefits of supplementation relate to nutrient deficits and the impact upon underlying neurobiological pathways, in order to establish optimal nutrient formulations for improving clinical outcomes in this population. Future studies should also explore the effects of combining beneficial nutrients within multi-nutrient formulas.

Educational outreach in diabetes to encourage practice nurses to use primary care hypertension and hyperlipidaemia guidelines (EDEN): a randomized controlled trial.

OBJECTIVE: To determine the effectiveness of specialist nurse delivered education in primary care to improve control of hypertension and hyperlipidaemia in patients with diabetes. DESIGN AND SETTING: Practice-level randomized controlled trial, Salford, England. SUBJECTS: From 44 practices, 10 303 subjects presenting in general practice with raised blood pressure (= 140/80 mmHg), raised total cholesterol (= 5.0 mmol/l) or both. INTERVENTIONS: Practices were randomized to receive either the intervention for hyperlipidaemia or for hypertension; practices acted as control for the intervention not received. Specialist nurses arranged a schedule of visits with general practitioners and general practice nurses, reminding them of diabetes protocols and clinical targets. They provided educational materials and protocols used in secondary care for nurse and doctor interventions including stepping up pharmacotherapy when necessary. Practices received a list of patients in their practice who were poorly controlled at their last annual review; new and recalled patients were targeted. OUTCOME MEASURES: At subsequent annual review, blood pressure and total cholesterol values were obtained from the Salford electronic diabetes register for patients from participating practices. RESULTS: Overall, specialist nurse-led educational outreach to primary care was associated with no improvement in patients achieving target after 1 year-odds ratio (OR): 1.03 (95% CI 0.95-1.11; P = 0.52). Similar results were achieved with hyperlipidaemia OR: 1.04 (95% CI 0.88-1.23; P = 0.62) and hypertension OR: 1.01 (95% CI 0.80-1.27; P = 0.93). CONCLUSION: This study provides evidence that the use of specialist nurses to perform educational outreach to improve target adherence to patients with diabetes in primary care is not effective.

The effect of three different doses of tranexamic acid on blood loss after cardiac surgery with mild systemic hypothermia (32 degrees C).

OBJECTIVE: Prophylactic administration of tranexamic acid (TA), an antifibrinolytic agent, decreases bleeding after cardiac surgery with systemic hypothermia (25 degrees C to 29 degrees C). Warmer systemic temperatures during cardiopulmonary bypass (CPB) may reduce bleeding and thus alter the requirement for TA. The effect of three different doses of TA on bleeding after cardiac surgery with mild systemic hypothermia (32 degrees C) is evaluated. DESIGN: Double-blind, prospective, randomized study. SETTING: University hospital. PARTICIPANTS: One hundred fifty adult patients undergoing aortocoronary bypass or valvular cardiac surgery. INTERVENTIONS: Patients received TA, 50 (n = 50), 100 (n = 50), or 150 (n = 50) mg/kg intravenously before CPB with mild systemic hypothermia. MEASUREMENTS AND MAIN RESULTS: Blood loss through chest drains over 6, 12, and 24 hours after surgery and total hemoglobin loss were measured. Autotransfused blood, transfused banked blood and blood products, and coagulation profiles were measured. Analysis of variance on log-transformed data for blood loss and confidence intervals (CIs) of 0.95 were calculated and transformed to milliliters of blood. No patient was re-explored for bleeding. Blood loss at 6 hours was statistically greater in the 50-mg/kg group compared with the other two groups (p = 0.03; p = 0.02). Total hemoglobin loss was statistically greater in the 50-mg/kg group compared with the 150-mg/kg group (p = 0.04). There was no statistical difference in blood tranfusion rate or coagulation profiles among the three groups. However, preoperative hemoglobin level was statistically lower in the 150-mg/kg group compared with the other two groups (p = 0.01). CONCLUSION: Of the three doses of TA studied, the most efficacious and cost-effective dose to reduce bleeding after cardiac surgery with mild hypothermic systemic perfusion is 100 mg/kg.

Improving information management in family practice: testing an adult learning model.

Information management training has been neglected in family practice in the UK in the past. An adult learning model for such training is introduced. A pilot study using the adult learning approach showed improvements in information management processes over the six-month study period. The research project described in this paper compares the effectiveness of on-site training using adult learning methods, written information, and no intervention, in 33 family practices in the UK. Nine of the eleven practices in the on-site training group completed the training sessions and eight provided full data, whereas only one of the eleven practices in the written information group, and only one of the eleven practices in the control group provided full data. Preliminary analysis demonstrates that on-site training practices made considerable changes to the information systems in their practices, and appreciated the importance of high-quality data, both for patient care and reporting requirements. Full comparisons of data quality and information management methods are presented, and an assessment of priority training needs for maximum benefit is made.

Interventions for improving information management in family practice.

Information management training has been neglected in family practice in the UK in the past. An adult learning model for such training is introduced. A pilot study using the adult learning approach showed improvements in information management processes over the six-month study period. The research project described in this paper compares the effectiveness of on-site training using adult learning methods, written information, and no intervention, in 33 family practices in the UK. Nine of the eleven practices in the on-site training group completed the training sessions and provided data, whereas only four of the eleven practices in the written information group provided data, and only three of the eleven practices in the control group did so. Preliminary analysis demonstrates that on-site training practices made considerable changes to the information systems in their practices, and appreciated the importance of high-quality data, both for patient care and reporting requirements. Full comparisons of data quality and information management methods are presented, and an assessment of priority training needs for maximum benefit is made.

Do prescribing formularies help GPs prescribe from a narrower range of drugs? A controlled trial of the introduction of prescribing formularies for NSAIDs.

BACKGROUND: Previous studies have suggested that prescribing formularies may promote rational prescribing. The range of drugs prescribed may be one aspect of rational prescribing. AIM: To determine whether the introduction of prescribing formularies helps general practitioners (GPs) to prescribe from a narrower range of non-steroidal anti-inflammatory drugs (NSAIDs). METHOD: General practices in Lincolnshire were offered help in developing prescribing formularies. Ten practices decided to develop a formulary for NSAIDs. Level 3 PACT data were used to determine whether changes in prescribing had occurred with the introduction of the formulary. Matched controls were used to determine whether similar changes had occurred in other practices. RESULTS: Between April and June 1992, and during the same period in 1993, practices that introduced a formulary for NSAIDs reduced the mean number of different drugs used (14.3 versus 13.1, P = 0.04) and increased the percentage of NSAID-defined daily doses coming from the three most commonly used drugs (70.1% versus 74.8%, P = 0.02). Similar changes were not seen in control practices. CONCLUSION: Following the development of a formulary for NSAIDs, practices prescribed from a narrower range of drugs and focused a greater proportion of their prescribing on their three most commonly used drugs.

Nursing on the Internet.

The Internet is a world-wide network of computers that anyone with the right equipment can join. Users can communicate quickly with other people all over the world and join news groups discussing a wide variety of issues, including nursing topics. The Internet gives access to academic and commercial information, stored in large computers on the World Wide Web.

Prevention of bleeding after cardiopulmonary bypass with high-dose tranexamic acid. Double-blind, randomized clinical trial.

This prospective, double-blind, randomized trial assessed the effectiveness of high-dose tranexamic acid given in the preoperative period on blood loss in patients undergoing cardiopulmonary bypass. One hundred fifty patients scheduled to undergo cardiac operations with cardiopulmonary bypass were randomized into three groups of equal size. The first group received 10 gm of tranexamic acid intravenously over 20 minutes before sternotomy and a placebo infusion over 5 hours. The second group received 10 gm of tranexamic acid over 20 minutes and then another 10 gm infused intravenously over 5 hours. The control group received a placebo bolus and a placebo infusion over 5 hours (0.9% normal saline solution). The blood loss after the operation was measured at 6 hours and 24 hours. The homologous blood and blood products given during and up to 48 hours after operation were recorded. Eighteen percent of the control group patients shed more than 750 ml blood in 6 hours compared with only 2% in both tranexamic acid groups. Patients who shed more than 750 ml blood required 93% more red blood cell transfusions than patients without excessive bleeding. Tranexamic acid (10 gm) given intravenously in the period before cardiopulmonary bypass reduced blood loss over 6 hours by 50% and over 24 hours by 35%. Continued tranexamic acid infusion (10 gm over 5 hours) did not reduce bleeding further. There was no difference in the coagulation profile before operation between patients with and without excessive bleeding. However, coagulation tests done in the postoperative period indicated ongoing fibrinolysis and platelet dysfunction in patients with excessive bleeding.

Prevention of postbypass bleeding with tranexamic acid and epsilon-aminocaproic acid.

In this institution, two antifibrinolytic agents have been in routine use before cardiopulmonary bypass (CPB) to prevent bleeding due to fibrinolysis; epsilon-aminocaproic acid (EACA) or tranexamic acid (TA) are administered as intravenous infusions over 2 hours, from the time of anesthetic induction until the onset of CPB. TA is 10 times more potent and binds more strongly to plasminogen than EACA. Data were collected retrospectively on 411 patients undergoing first-time coronary artery bypass grafting with cardiopulmonary bypass who had received one of four therapy regimens: 10 g of EACA (65 patients), 15 g of EACA (60 patients), 6 g of TA (100 patients), or 10 g of TA (75 patients). Patients who did not receive any drug (91) served as controls. Anesthetic technique and the heparin/protamine protocol did not differ. Blood collected by mediastinal and pleural tubes was autotransfused up to 6 hours postoperatively. Both TA and EACA reduced post-CPB bleeding in the first 24 hours. Ten grams of TA was the most effective, resulting in a 52% and 36% reduction in blood loss over controls at 6 and 24 hours, respectively. Although 10 g of TA was more effective than 6 g of TA in blood loss control for the first 6 hours, the difference was not significant at 24 hours. A significantly lower number of patients in the 10 g TA group received blood products than in control (28% v 49%) patients (P = 0.02). Pretreatment with 10 g of TA prevented excessive (over 750 mL in 6 hours) bleeding after CPB.

The effect of warm heart surgery on postoperative bleeding.

The effects of normothermic systemic perfusion (35 degrees to 37 degrees C; n = 73) were compared with those of moderately hypothermic systemic perfusion (25 degrees to 29 degrees C; n = 73) with respect to blood loss, transfusion requirements, and platelet levels in 146 patients undergoing isolated, primary coronary artery bypass grafting. In addition, most patients were given an antifibrinolytic medication during operation as follows: tranexamic acid (10 gm intravenously; n = 63), epsilon-aminocaproic acid (15 gm intravenously; n = 63), or no drug as a control. (n = 20). Normothermic patients tended to bleed less at 24 hours (warm, 864 +/- 42 ml and cold, 918 +/- 68 ml), but these differences were not statistically significant. Patients receiving either tranexamic acid or epsilon-aminocaproic acid, regardless of perfusion temperature, bled less after 6, 12, and 24 hours than did cold control patients (p less than 0.05). Warm control patients also bled less than did cold control patients after 6 or 12 hours (p less than 0.05), and neither drug further reduced blood loss in these patients. Circulating platelet levels were better preserved in patients receiving either tranexamic acid or epsilon-aminocaproic acid and in patients with warm perfusion and no drug than in cold control patients. Normothermic systemic perfusion, tranexamic acid, and epsilon-aminocaproic acid each reduced postoperative blood loss and preserved platelets.