Search

A supportive practice climate is demonstrated to improve patient outcomes, health care provider well-being, and workforce stability. Midwives are an integral component to improving maternal health care; however, there has been limited research into the qualities and measurement of a supportive practice climate for midwives.The Midwifery Practice Climate Scale is a self-report instrument designed to measure midwives' perceptions of their work environments. We tested the scale's validity and reliability in multiphase, national cross-sectional survey of the full roster of certified nurse-midwives and certified midwives practicing in the United States. To test structural validity and reliability testing, 2 subsamples of 330 participants were randomly extracted from the sample of 2887 for exploratory and confirmatory factor analyses and internal consistency determination. Convergent validity was tested in the remaining sample of 1673 respondents.Exploratory factor analysis revealed 2 5-subscale structures consistent with the loading values and theoretical structure. Confirmatory factor analysis revealed a mediocre fit of the models identified in the exploratory analysis. Consequently, items were systematically reviewed for redundancy, skew, and generalizability and 24 items were removed from the scale. The resulting structure is a 10-item scale comprising 2 subscales: Practice Leadership and Participation and Support for the Midwifery Model of Care. The revised Midwifery Practice Climate Scale was a good fit with the data demonstrating adequate construct validity (χThese findings indicate that the Midwifery Practice Climate Scale accurately and reliably measures the midwives' perceptions of their practice environment. The next steps include determining the scale's sensitivity to change and assessing the relationship with maternal health outcomes.

OBJECTIVE: Despite their promise for increasing treatment precision, Personalized Trials (i.e., N-of-1 trials) have not been widely adopted. We aimed to ascertain patient preferences for Personalized Trials. STUDY DESIGN AND SETTING: We recruited 501 adults with ≥2 common chronic conditions from Harris Poll Online. We used Sawtooth Software to generate 45 plausible Personalized Trial designs comprised of combinations of 8 key attributes (treatment selection, treatment type, clinician involvement, blinding, time commitment, self-monitoring frequency, duration, cost) at different levels. Conditional logistic regression was used to assess relative importance of different attributes using a random utility maximization model. RESULTS: Overall, participants preferred Personalized Trials with no costs vs. $100 cost (utility difference 1.52 [standard error 0.07], p

Chronic radiation enteritis (RE) has been reported in up to 20% of patients receiving pelvic radiotherapy and can lead to intestinal failure (IF), accounting for 3.9% of new registrants for home parenteral nutrition (HPN) in the UK annually. Our aim is to report nutritional and survival outcomes for patients with RE referred to a national IF unit. A retrospective study of all new admissions over a 13-year period at the Intestinal Failure Centre, Manchester, UK. Data are presented as median (range). Twenty-three (3.8%) of 611 patients were admitted with IF secondary to RE. The primary site of malignancy was genitourinary in 17 (74%) patients. Radiotherapy was administered 9.5 (1–42) years previously. Patients underwent 2 (1–5) laparotomies prior to intestinal failure unit (IFU) admission. Twelve (52%) patients were admitted with intestinal obstruction and 11 (48%) with intractable weight loss and/or high output fistulae/stomas. Additional conditions contributing to IF were noted in 11 (48%) patients. Twenty-two (96%) patients had 2 (1–5) laparotomies prior to IFU referral. At discharge, 5 (22%) patients resumed oral diet without the need for artificial nutrition support, 3 (13%) required enteral feeding and 13 (56%) commenced HPN. The 10-year survival of the patient cohort was 48.2%. Surgical intervention is infrequently required, whereas the majority of patients with IF secondary to RE require long-term HPN. The judicious use of surgery in selected patients, coupled with an aggressive medical strategy to detect and treat contributing factors, and optimal enteral feeding may allow a modest proportion of patients with IF secondary to RE to achieve independence from PN.

Aims: This study was undertaken to report indications and practice of home enteral nutrition (HEN) in Europe. Methods: A questionnaire on HEN practice was sent to 23 centres from Belgium (B), Denmark (D), France (F), Germany (G), Italy (I), Poland (P), Spain (S) and the United Kingdom (UK). This involved adult patients newly registered in HEN programme from 1 January 1998 to 31 December 1998. Results: A total of 1397 patients (532 women, 865 men) were registered. The median incidence of HEN was 163 patients/million inhabitants/year (range: 62–457). Age distribution was 7.5%, 16–40 years; 37.1%, 41–65 years; 34.5%, 66–80 years and 20.9% >80 years. The chief underlying diseases were a neurological disorder (49.1%), or head and neck cancer (26.5%); the main reason for HEN was dysphagia (84.6%). A percutaneous endoscopic gastrostomy (58.2%) or a naso-gastric tube (29.3%) were used to infuse commercial standard or high energy diets (65.3%), or fibre diets (24.5%); infusion was cyclical (61.5%) or bolus (34.1%). Indications and feeds were quite similar throughout the different centres but some differences exist concerning the underlying disease. There was greater variation in the choice of tubes and mode of infusion. In F, G, I, S, and UK, costs of HEN are fully funded. In B, D, and P patients have to pay part or all of the charges. Conclusions: In Europe, HEN was utilised mainly in dysphagic patients with neurological disorders or cancer, using a standard feed via a PEG. However, there were important differences among the countries in the underlying diseases treated, the routes used, the mode of administration and the funding.

Summary Five patients with primary antibody deficiency were investigated because of intermittent but persistent diarrhoea of several years duration despite immunoglobulin replacement therapy. We found no evidence of Giardia lambia or other intestinal pathogens to explain their gastrointestinal symptoms. All five had definite radiological evidence of small bowel Crohn's disease and three had histological specimens available with abnormalities consistent with Crohn's disease. One patient had a non-caseating granuloma in an oral ulcer. A second patient with stricturing disease in the small bowel had a mucosal inflammatory infiltrate with non-caseating granulomas. A third had transmural inflammation but no granulomas. All five patents were diagnosed as having Crohn's disease and have responded symptomatically to steroid therapy.

The prevalence of coronary artery disease (CAD) among South Asians (SAs) significantly exceeds that of Caucasians. South Asians also suffer from more premature, clinically aggressive and angiographically extensive (3-vessel) disease. The role of conventional CAD risk factors (CCRFs) remains controversial.We sought to determine if the CCRF burdens of SA immigrants differed from Caucasians. We also sought to determine whether angiographic CAD was more extensive among SAs and whether SA ethnicity was an independent predictor of 3-vessel disease.We reviewed the CCRFs and angiograms of 520 SAs and 219 Caucasians consecutively referred with stable angina pectoris or acute coronary syndrome.Three-vessel CAD was significantly more common among SAs than Caucasians (32.5% vs 22.4%; P = .006). Diabetes mellitus (DM), age and male sex independently predicted 3-vessel disease. South Asian ethnicity showed a trend toward predicting 3-vessel disease (P = .06). The frequency of DM (55% vs 31.1%; P.001), hypertension (77.5% vs 68.5%; P = .01), obesity (63.1% vs 44.3%; P.001) and dyslipidemia (75.6% vs 61.6%; P.001) were significantly greater among SAs; however, smoking was significantly more common among Caucasians (44.3% vs 21.3%; P.001). Compared to Caucasians, SAs were significantly younger at the time of presentation for coronary angiography (58.5 vs 61.1 yrs; P = .001).SAs referred for coronary angiography with stable angina and acute coronary syndromes are younger, have significantly higher rates of 3-vessel disease, as well as higher rates of DM, hypertension, obesity and dyslipidemia than Caucasians. Aggressive screening, prevention and treatment may be warranted in this population.

The prevalence of coronary artery disease (CAD) among migrant Indian populations exceeds that of Caucasians. Migrant Indians also suffer from more premature, clinically aggressive and angiographically extensive, (i.e., 3-vessel disease). It is not known whether the extent of angiographic CAD or the conventional CAD risk factors of Indo-Guyanese (IG) immigrants differs from that of Caucasians.We reviewed the conventional CAD risk factors and angiographic findings of 198 IG and 191 Caucasians who were consecutively referred for cardiac catheterization with a diagnosis of stable angina pectoris or acute coronary syndrome.Three-vessel CAD was approximately 1.5 times more common among IG than Caucasians (34.8% vs. 24.0%; P = .02). Age (P = .01), male sex (P = .03) and diabetes mellitus (P = .05) were independently associated with an increased likelihood of 3-vessel CAD and there was a trend towards IG ethnicity predicting 3-vessel disease (P = .13). The frequency of diabetes mellitus (51.5% vs. 30.9%; P.001), hypertension (82.3% vs. 67.0%; P.001) and dyslipidemia (75.5% vs. 60.2%; P = .001) were significantly greater among IG, however, that of smoking was not. While IG were significantly leaner than Caucasians (27.7 kg/m2 vs. 30.0 kg/m2 ; P.001), their mean body mass index fell within the ethnic-specific range for obesity.We conclude that IG immigrants presenting for coronary angiography have significantly higher rates of 3-vessel CAD as well as higher rates of diabetes mellitus, hypertension and dyslipidemia than Caucasians. Aggressive screening, prevention and treatment may be warranted in this cohort.

Objectives. To examine the outcome in patients with SSc requiring parenteral nutrition (PN), and to compare their clinical characteristics with those of other SSc patients and of patients requiring PN/home parenteral nutrition (HPN) for other conditions. Methods. Retrospective review of SSc and Intestinal Failure Unit databases at a tertiary referral centre for SSc/national unit for intestinal failure over a 13-yr period. Results. Eight patients with SSc requiring PN during the study period were identified (2 males, 6 females: median age at commencement of PN 51 yrs, range 42–56 yrs). All patients commencing PN had bacterial overgrowth and malabsorption not responding to antibiotic therapy. The median duration of PN therapy in the eight patients was 40 months (range 0.8–192 months). Between them the eight patients had a total of 13851 catheter-use days and only two line infections (0.14/1000 catheter days), a lower rate of line infection than in other HPN-treated patients at Hope Hospital (0.52/1000 catheter days). Three patients died during the 13-yr period, none of causes related to their PN. Six were unable to manage their HPN regime themselves, mainly because of problems with hand function. Conclusions. Although patient numbers were small, our findings suggest that HPN can be safely and successfully used long-term in patients with SSc and should be considered for patients unable to maintain their nutritional status because of severe gastrointestinal involvement. Impaired hand function should not preclude SSc patients from receiving HPN: family members or community nurses may be trained in the care of the HPN line. Background Approximately 90% of patients with the multisystem connective tissue disease SSc develop gastrointestinal involvement of their disease, although many are asymptomatic [1, 2]. Gastrointestinal problems occur in both the lcSSc and dcSSc disease subtypes [3]. Any part of the gastrointestinal tract may become involved and an autopsy study showed that approximately half of the patients have histological involvement of their small bowel [4]. A small minority of patients develop intestinal failure. The usual scenario in this minority is that small intestinal involvement, with impaired peristalsis, results in bowel dilatation and stasis that in turn lead to bacterial overgrowth, malabsorption, and sometimes pseudoobstruction. Gastrointestinal involvement in SSc can therefore be life-threatening: of 264 patients with dcSSc from 29 centres, with an average duration of follow-up of 5.2 yrs, 13 (5%) died of gastrointestinal disease, representing 15% of deaths definitely related to SSc [5]. When a patient is unable to maintain his/her nutritional status, as in SSc-related intestinal failure, parenteral nutrition (PN) may be required to prevent, or correct, malnutrition. Other forms of artificial feeding, including oral supplementation, naso-jejunal feeding and feeding via percutaneous enterogastrostomy (PEG)/ percutaneous jejunostomy tubes may be tried before introducing PN. Complications of PN administration include central venous catheter infections, occlusions and fractures of the central line, hepatic disease and osteoporosis. If the indication for PN suggests that long-term treatment will be required, as in SSc, home parenteral nutrition (HPN) may be considered. PN is a potentially life-saving treatment but training the patient as carer for the central line for HPN may pose particular problems in SSc because of concomitant problems including impaired hand function and cardiorespiratory disease. The aim of this retrospective study was to examine the outcome in patients with SSc requiring PN, and to compare their clinical characteristics with those of other SSc patients and of patients requiring PN/HPN for other conditions.

OBJECTIVE: To quantify the impact of infliximab therapy on health care resource utilization in the UK. METHODS: A retrospective audit was undertaken at seven centres in the UK, which reviewed patient notes for a period of 6 months before and 6 months after an initial infliximab infusion. Details of hospital admissions, outpatient visits, operations, diagnostic procedures, drug usage, and overall efficacy were collected. Results were compared for the two 6 month study periods. RESULTS: A total of 205 patients (62% female, median age 33 years) with moderate/severe Crohn's disease were audited. The majority of patients had chronic active disease (62%) and most received one infusion initially (72%). Clinicians rated 74% of responses as good to excellent and patients 72%. Most patients had concomitant immunosuppression (pre: 75%, post: 75%). Approximately half of the patients (45%) stopped taking steroids, with a further 34% having a dosage reduction. A fall of 1093 inpatient days was seen (1435 vs. 342) in the 6 months following infliximab administration. There were seven fewer operations, 33 fewer examinations under anaesthetic, and 99 fewer diagnostic procedures. Outpatient visits were similar pre- versus post- (555 vs. 534). The total reduction in direct costs amounted to an estimated pounds 591,006. Three hundred and fifty-three infliximab infusions were administered at an estimated cost of pounds 562,719. Thus, there was a net reduction of pounds 28,287 or pounds 137.98 per patient. CONCLUSIONS: Infliximab appears to be a potentially cost effective treatment for selected patients based on the reduced number of inpatient stays, examinations under anaesthetic, and diagnostic procedures over a 6 month period.

Background and aims Mid upper arm anthropometry (MUAA) is often used as a measure of nutritional status to detect changes in body composition. The aim of this study was to investigate the reliability and validity of MUAA including mid arm circumference (MAC) and triceps skin fold thickness (TSFT) to determine the usefulness in clinical practice. Method We measured MUAA in 158 consecutive admissions along with subjective global assessment (SGA) and body mass index (BMI). Inter- and intra-rater reliability was evaluated in an additional 50 patients. Results The sensitivity and specificity of MUAA

Background and aims: In the UK, cerebrovascular accident (CVA) is the third commonest cause of death and the commonest diagnosis in patients receiving home enteral feeding (HETF). This study aimed to use data from the British Artificial Nutrition Survey (BANS) collected between 1996 and 1999 to assess the outcome of patients on HETF, including mortality, return to oral feeding, level of physical activity, and level of dependency, which has resource implications. Results: it is estimated that about 1.7% of all patients suffering a CVA in the UK between 1996 and 1999 received HETF. At one year, 29.6% died while receiving HETF and another 13% returned to oral feeding. Mortality increased with age and was twice as high in those managed in nursing homes compared to those in their own homes. The patients receiving tube feeding spent only 0.6% of their time in hospital. A total of 43.9% of patients were bed-bound at home (1.9% unconscious) and an additional 30.3% were house-bound. Only 21.2% were independent, and the majority were totally dependent on their carers. In CVA patients on HETF the level of dependency was greater than for those with all types of diagnoses (n=12,997). Conclusion: This study has described the outcome of a large number of patients receiving HETF in the UK. Since patients spent less than 1% of their time in hospital, HETF relieves pressure on the expensive hospital environment, but places more demands on the carers, who have to deal with severely disabled patients. Recovery of swallowing function should be assessed intermittently to prevent unnecessary HETF.

300 consecutive admissions over 7 years to a purpose-built intestinal failure unit are reviewed. The commonest underlying condition was Crohn's disease (42%), and the commonest complication precipitating admission was intestinal fistula (42%). Total parenteral nutrition was used in 85% and surgery in 50%. A multidisciplinary approach to management gave a high success rate--90% of patients were discharged from hospital, although nearly 25% needed home parental nutrition. These results suggest that chronic intestinal failure should be managed in specialised units in the same manner as other types of organ failure.

Over the last 10 years, the Nutrition Unit at Hope Hospital has trained and looked after 76 patients on home parenteral nutrition for a total of 100 patient years. Although 40 per cent of patients have required home parenteral nutrition for 6 months or less one patient has been on treatment for 7 years. The quality of life measured on a 4 point scale was good for the majority of patients. Sepsis and superior vena caval thrombosis are the main problems encountered. Overall mortality rate was 18 per cent and the sepsis rate was 0·14 episodes per patient per year. Home parenteral nutrition is an effective and safe treatment of intestinal failure.

Summary A women with β-thalassemia intermedia, and iron overload following many years’ treatment with oral iron, was treated with subcutaneous desferrioxamine. During the course of this treatment she developed tinnitus, which was considered to be a rare complication of the use of this chelating agent. The mechanism of this effect is not understood.

Total body pool and intestinal absorption of ascorbic acid were studied in 12 patients undergoing operation for Crohn's disease (six with fistulae and six without) and in six control patients undergoing operation for reasons other than Crohn's disease. L-[carboxyl-14C]Ascorbic acid, 0.19-0.40 megabecquerels (MBq), was given orally. After a period of equilibration, the labeled ascorbic acid was flushed out of the patient's body tissues using large doses of unlabeled ascorbic acid. Intestinal absorption of ascorbic acid, assessed from the total cumulative urinary 14C recovery, was found to be similar in patients with fistulizing Crohn's disease (73.9 +/- 8.45%), those without fistulas (72.8 +/- 11.53%), and in controls (80.3 +/- 8.11%). Total body pools of ascorbic acid, calculated using the plasma 14C decay curves, were similar in patients with Crohn's disease with fistulas (17.1 +/- 5.91 mg/kg), patients without fistulas (9.6 +/- 3.58 mg/kg), and in controls (13.3 +/- 4.28 mg/kg). The results indicate that ascorbic acid absorption is normal in patients with both fistulizing and nonfistulizing Crohn's disease. The results suggest that routine supplements of vitamin C are not necessary unless oral ascorbic acid intake is low.

The pharmacokinetics of metronidazole were studied after oral and intravenous administration to seven patients with Crohn's disease and five patients with ulcerative colitis. The oral/intravenous availability ratio was 0.97 +/- 0.2 in the Crohn's patients and 0.90 +/- 0.1 in the colitics (mean +/- s.e. mean). Plasma clearance was 3.24 +/- 0.2 l h-1 and 4.1 +/- 0.5 l h-1, respectively. These differences were not statistically significant. Ten of the patients on long term sulphasalazine were studied to observe the effect of 2 weeks metronidazole therapy on plasma sulphapyridine concentration. The sulphapyridine concentration changed from 22.1 +/- 2.0 micrograms ml-1 to 15.95 +/- 4.5 micrograms ml-1 in the Crohn's patients and 26.0 +/- 6.0 micrograms ml-1 to 36.4 +/- 8.5 micrograms ml-1 in the colitis group, pre- and post-metronidazole. These differences were not statistically significant. These results suggest that metronidazole does not interfere with diazo-link splitting of sulphasalazine and that patients with Crohn's disease handle metronidazole in a similar manner to patients with colitis.

We pursued the possibility that Mycobacterium kansasii might be an aetiological agent in Crohn's disease by carrying out a trial of treatment with antimycobacterial drugs. Twenty seven patients with Crohn's disease took part in a two year randomised double blind, crossover, controlled trial of rifampicin plus ethambutol against placebo. Fourteen patients completed the trial; four required an operation; five were withdrawn as poor compliers, and four because of adverse effects. There was no significant difference in response to the active drugs compared with placebo when expressed in terms of a Crohn's disease activity index or any clinical indicator of disease activity. There was no suggestion that any subgroup of patients - for example, different regions of bowel affected or previous operation - were favourably affected by the drugs. There was no consistent pattern of change in prednisolone requirements although eight patients on long term sulphasalazine had a significant reduction in their plasma sulphapyridine concentrations during the active treatment period. A significant reduction in total white blood count and an increase in plasma ALT were seen during active therapy. The results of the study do not suggest that rifampicin and ethambutol have a role to play in the treatment of Crohn's disease.