American Society for Parenteral and Enteral Nutrition and American Dietetic Association: Standards of Practice and Standards of Professional Performance for Registered Dietitians (Generalist, Specialty, and Advanced) in Nutrition Support

The Standards of Practice for Registered Dietitians in Nutrition Support and the Standards of Professional Performance for the Registered Dietitian in Nutrition Support are key resources for RDs at all knowledge and performance levels. These standards can and should be used by RDs in daily practice to consistently improve and appropriately demonstrate competency and value as providers of safe and effective nutrition support therapy. The standards development and evaluation process is dynamic—these standards will be reviewed at least every 5 years for applicability to practice. Current and future initiatives of A.S.P.E.N. and ADA will provide information that will be used in these updates and in further clarifying and documenting the specific roles and responsibilities of practitioners at each level. As a quality initiative of A.S.P.E.N., its Dietetics Practice Section, ADA, and their DNS DPG, the standards themselves are an application of continuous quality improvement concepts and represent another very important collaborative endeavor.     

Exploring Disease Management Programs for Diabetes Mellitus

Diabetes mellitus is a chronic illness that affects the world on an epidemic scale. It requires complex healthcare and considerable economic resources. Diabetes disease management programs use a variety of strategies to improve clinical outcome measures and reduce costs. Studies have demonstrated the effectiveness of these programs on reducing glycosylated hemoglobin levels, improving cardiovascular risks, and reducing utilization of services. However, the most effective components of disease management strategies or combination of strategies remain unknown. This narrative review explores the components, impact, benefits, and barriers of current diabetes disease management models and also presents a novel hybrid model incorporating elements of both on-site and off-site programs.On-site disease management programs include strategies characterized by unique patient identification and evaluation, implementation of intervention methods, on-site health provider team members, and specific environmental resources. Advantages of this model include the face-to-face encounter between patients and providers, the proximity of the healthcare team members to facilitate ease of communication and build independence and trust between patients and providers, and technology resources, such as the electronic medical record. A number of clinical trials have demonstrated the effectiveness and cost effectiveness of on-site diabetes disease management programs. However, because of the methodological limitations of many studies, further studies are needed to confirm such findings. Barriers to the implementation of on-site programs may include patient population characteristics such as complexity of co-morbid illness and social Stressors, including low health literacy, that require adaptation of the disease management model. In comparison, off-site disease management programs utilize administrative resources to identify patients with chronic illnesses. Other key elements include the evaluation of clinical care practices using established guidelines with auditing and feedback to providers based on their performance, and the use of reminders for both patients and providers to influence better processes of care. This process is often independent of the traditional on-site care delivered directly by providers.A hybrid disease management model that incorporates both on-site and off-site disease management components could be the ideal model for optimizing care of patients with chronic illness. The suggested hybrid model incorporates many features of previous models of disease management but gives a new construct that can be customized to different clinic settings, provider practices, and patient populations, including patients with other complex chronic illness. This hybrid model could be applied to a variety of individual or multiple chronic illnesses. This model would engage both on-site healthcare providers and support staff along with off-site administrative staff and electronic medical data to provide patients optimal care while potentially reducing overall costs.     

Distance to food stores & adolescent male fruit and vegetable consumption: mediation effects

Background  

The physical environments in which adolescents reside and their access to food stores may influence their consumption of fruit and vegetables. This association could either be direct or mediated via psychosocial variables or home availability of fruit and vegetables. A greater understanding of these associations would aide the design of new interventions. The purpose of this study was to examine associations between distance to food stores and restaurants and fruit and vegetable consumption and the possible mediating role of psychosocial variables and home availability.     

Effects of ambient air pollution on functional status in patients with chronic congestive heart failure: a repeated-measures study

Background  

Studies using administrative data report a positive association between ambient air pollution and the risk of hospitalization for congestive heart failure (HF). Circulating levels of B-type natriuretic peptide (BNP) are directly associated with cardiac hemodynamics and symptom severity in patients with HF and, therefore, serves as a marker of functional status. We tested the hypothesis that BNP levels would be positively associated with short-term changes in ambient pollution levels among 28 patients with chronic stable HF and impaired systolic function.     

Progression of Epididymal Maldevelopment Into Hamartoma-like Neoplasia in VHL Disease

Inactivation of the von Hippel-Lindau (VHL) gene and activation of the hypoxia-inducible factor (HIF) in susceptible cells precedes formation of tumorlets and frank tumor in the epididymis of male VHL patients. We performed detailed histologic and molecular pathologic analysis of tumor-free epididymal tissues from VHL patients to obtain further insight into early epididymal tumorigenesis. Four epididymides from two VHL patients were serially sectioned to allow for three-dimensional visualization of morphologic changes. Areas of interest were genetically analyzed by tissue microdissection, immunohistochemistry for HIF and markers for mesonephric differentiation, and in situ hybridization for HIF downstream target vascular endothelial growth factor. Structural analysis of the epididymides revealed marked deviations from the regular anatomic structure resulting from impaired organogenesis. Selected efferent ductules were represented by disorganized mesonephric cells, and the maldeveloped mesonephric material was VHL-deficient by allelic deletion analysis. Furthermore, we observed maldeveloped mesonephric material near cystic structures, which were also VHL-deficient and were apparent derivatives of maldeveloped material. Finally, a subset of VHL-deficient cells was structurally integrated in regular efferent ductules; proliferation of intraductular VHL-deficient cells manifests itself as papillary growth into the ductular lumen. Furthermore, we clarify that that there is a pathogenetic continuum between microscopic tumorlets and formation of tumor. In multiple locations, three-dimensional reconstruction revealed papillary growth to extend deeply into ductular lumina, indicative of progression into early hamartoma-like neoplasia. We conclude epididymal tumorigenesis in VHL disease to occur in two distinct sequential steps: maldevelopment of VHL-deficient mesonephric cells, followed by neoplastic papillary proliferation.     

The prevalence, aetiology and clinical significance of pseudo-sinusoidal fetal heart rate patterns in labour.

OBJECTIVE--To investigate the prevalence of sinusoidal and pseudo-sinusoidal fetal heart rate (FHR) patterns in labour and the relation between the characteristics of the FHR pattern and fetal outcome. DESIGN--A prospective observational study over a 6-month period in which all women who had continuous FHR monitoring in labour had their intrapartum cardiotocographs (CTGs) scrutinized for the presence of sinusoidal or pseudo-sinusoidal FHR patterns. SETTING--John Radcliffe Hospital, Oxford. SUBJECTS--1520 women who had fetal monitoring during labour for various reasons. MAIN OUTCOME MEASURES--Both internal (electrocardiographic) and external (ultrasound) recordings of the FHR were analysed. Abnormal FHR patterns were related to obstetric characteristics and fetal outcome in terms of Apgar scores, umbilical artery pH and admission to the special care unit. RESULTS--No true sinusoidal FHR patterns were observed, but pseudo-sinusoidal FHR patterns were found in 230 of the 1520 CTGs examined (15%). Of these, 219 were classified as minor (amplitude 5-15 beats/min) and 11 as intermediate (amplitude 16-24 beats/min). Major pseudo-sinusoidal FHR patterns (amplitude greater than 24 beats/min) were not observed. Minor pseudo-sinusoidal FHR patterns had a mean duration of 21 (SD 13) min and typically occurred once or twice early in labour. Using logistic regression analysis a significant, independent relation was demonstrated between the presence of minor pseudo-sinusoidal FHR patterns and the use of pethidine (RR 1.84, 95% CI 1.3 to 2.59, P less than 0.0001) and epidural analgesia (RR 1.85, 95% CI 1.24 to 2.76, P less than 0.001). Intermediate pseudo-sinusoidal FHR patterns were found in association with both in utero fetal sucking and transient episodes of fetal hypoxia such as that caused by periodic umbilical cord compression. CONCLUSION--Pseudo-sinusoidal FHR patterns in labour will usually be associated with a normal fetal outcome but a careful fetal assessment is mandatory.