Micronutrients in Long-Term Care (LTC): Issues and opportunities for improvement

BACKGROUND: Malnutrition is common among long-term care (LTC) residents, yet there is limited research on micronutrient (vitamin and mineral) malnutrition in the LTC setting. Micronutrient deficiencies may exacerbate symptoms of dementia, depression, infections, osteoporosis, and other prevalent conditions in LTC. PURPOSE: This research accomplishes phase 1 of a multi-phase study, with the overall research objective of investigating the potential and extent of micronutrient malnutrition in LTC and identifying and developing food-first strategies to improve micronutrient intake in LTC residents. This was done through four sub-studies (detailed below): METHODS & FINDINGS: Each method and respective findings/conclusions are described below. Sub-Studies 1 and 2: Scoping Review Observational (SRO) and Intervention (SRI)--Methods: A rigorous scoping review was conducted using selected key terms in four health-related electronic databases. The initial search identified 2248 eligible titles and abstracts for screening with inclusion/exclusion criteria. Results: SRO (n=50 citations): Intake for vitamin D, folate, calcium, vitamin E and B6 were consistently <50% of the Recommended Dietary Allowance (RDA) regardless of divergent food intake assessment methods. More than one study found biomarkers to be low for vitamin D, C, folate, and iron in LTC residents. SRI (n=25 citations): Vitamin D and calcium were the most common micronutrients to be included in both pill supplementation and food fortification interventions. Different formulations (e.g. single vs. multi-nutrient) were trialed, making comparisons difficult. Supplementation and fortification demonstrated efficacy but no studies comparing these strategies were identified. Conclusion: Findings suggest that micronutrient intake and biochemical status are suboptimal for key nutrients in LTC. Single nutrient interventions predominated and more work on efficacy of multi-nutrient physiological doses, whether in supplemental or fortification formulations is needed. Limited fortification studies have been completed and there is a need to determine efficacy for prevention as compared to supplementation. More research on fortification doses and formulations that are acceptable and efficacious is also required. Menu Analysis (MA) and Super-Menus (SM)-- Methods: Regular, non-therapeutic menus (week 1, all meals) from diverse LTC homes (n=5) across Canada were analyzed for micronutrient content using Food Processor with the Canadian Nutrient File. EaTracker was used to determine Canada’s Food Guide servings. Site dietitians provided home recipes/portion sizes, and validated menu analyses. SM were designed to meet micronutrient needs without increasing volume and calories, considering the preferences and portion sizes used in LTC. Results: Despite planning to and generally meeting CFG recommendations, menus’ nutrient content varied significantly across homes. Micronutrients of greatest concern across all menus were vitamins D (8.90 ± 5.29 µg/d) and E (5.13 ± 1.74 mg/d). Folate, magnesium, and potassium were also below recommended values. SM were significantly higher in several nutrients as compared to home menus, but still were unable to meet vitamin D (11.2 ± 2.54 µg, mean 56% RDA), E (12.6 ± 4.08, 84% RDA) and potassium (4018 ± 489 mg, 85%) recommendations. Conclusion: Evidently, current guidelines for menu planning may be inadequate to address micronutrient needs, and more nutrient-dense strategies need to be explored in LTC. Careful menu planning results in most micronutrients recommendations being met. Acceptability Testing (AT)-- Prior to implementation, potential interventions should be assessed for their need, feasibility, and acceptability with knowledge users. Methods: Online LTC Staff webinar focus groups, expert Key Informant interviews and in-person focus groups (residents and family) were conducted to develop and determine the acceptability of a micronutrient fortification strategy. Polling and rating questions provided quantitative data to confirm qualitative data. Results: Focus groups and key informant interviews provided insight into potential food vehicles for fortification (e.g. soups, desserts, condiments), production and regulatory issues, and helped to develop the strategy to minimize anticipated barriers and promote uptake. Development of outsourced/pre-made fortified products was the preferred intervention, with mandatory training and clear protocols for preparers to ensure appropriate use. Conclusion: Knowledge users can envision food fortification as a potential intervention if products are easy to access and incorporate into current production systems. All stakeholders desire efficacy research to support use of this strategy in LTC. OVERALL CONCLUSION: Triangulation of methods (SRI, SRO, MA/SM, and AT) and findings offers a multidimensional understanding of potential micronutrient deficiencies in LTC and food-first strategies that can be used to prevent this form of malnutrition. In general, food-first interventions in LTC to prevent or ameliorate micronutrient deficiency are lacking and quality menu planning using the DRI as a guide and food fortification are plausible strategies. Further work is needed to determine the relationship between micronutrient intake and biomarkers of function; does sufficient micronutrient nutrition support the overall health and quality of life of residents. Greater knowledge and awareness of micronutrient qualities of foods and of best practices in food-preparation methods through better training and education of LTC health providers is needed. As a food fortification strategy is further developed, involvement of multi-level stakeholders is needed to ensure uptake. This work provides foundation for a micronutrient food fortification strategy to address malnutrition in LTC.4 month

Public Databases and Software for the Pathway Analysis of Cancer Genomes

The study of pathway disruption is key to understanding cancer biology. Advances in high throughput technologies have led to the rapid accumulation of genomic data. The explosion in available data has generated opportunities for investigation of concerted changes that disrupt biological functions, this in turns created a need for computational tools for pathway analysis. In this review, we discuss approaches to the analysis of genomic data and describe the publicly available resources for studying biological pathways

An analysis of the need for columbaria facilities in Hong Kong : a policy tools approach to public action

published_or_final_versionPolitics and Public AdministrationMasterMaster of Public Administratio

Ventricular-vascular coupling is predictive of adverse clinical outcome in paediatric pulmonary arterial hypertension

AIMS: Ventricular-vascular coupling, the ratio between the right ventricle's contractile state (Ees) and its afterload (Ea), may be a useful metric in the management of paediatric pulmonary arterial hypertension (PAH). In this study we assess the prognostic capacity of the ventricular-vascular coupling ratio (Ees/Ea) derived using right ventricular (RV) pressure alone in children with PAH. METHODS: One hundred and thirty paediatric patients who were diagnosed with PAH via right heart catheterisation were retrospectively reviewed over a 10-year period. Maximum RV isovolumic pressure and end-systolic pressure were estimated using two single-beat methods from Takeuchi et al (Ees/Ea_(Takeuchi)) and from Kind et al (Ees/Ea_(Kind)) and used with an estimate of end-systolic pressure to compute ventricular-vascular coupling from pressure alone. Patients were identified as either idiopathic/hereditary PAH or associated PAH (IPAH/HPAH and APAH, respectively). Haemodynamic data, clinical functional class and clinical worsening outcomes-separated into soft (mild) and hard (severe) event categories-were assessed. Adverse soft events included functional class worsening, syncopal event, hospitalisation due to a proportional hazard-related event and haemoptysis. Hard events included death, transplantation, initiation of prostanoid therapy and hospitalisation for atrial septostomy and Pott's shunt. Cox proportional hazard modelling was used to assess whether Ees/Ea was predictive of time-to-event. RESULTS: In patients with IPAH/HPAH, Ees/Ea_(Kind) and Ees/Ea_(Takeuchi) were both independently associated with time to hard event (p=0.003 and p=0.001, respectively) and when adjusted for indexed pulmonary vascular resistance (p=0.032 and p=0.013, respectively). Neither Ees/Ea_(Kind) nor Ees/Ea_(Takeuchi) were associated with time to soft event. In patients with APAH, neither Ees/Ea_(Kind) nor Ees/Ea_(Takeuchi) were associated with time to hard event or soft event. CONCLUSIONS: Ees/Ea derived from pressure alone is a strong independent predictor of adverse outcome and could be a potential powerful prognostic tool for paediatric PAH

Differential Emphases on Modernity and Confucian Values in Social Categorization: The Case of Hong Kong Adolescents in Political Transition

This study investigated if modernity and Confucian values were ingroup's positively valued distinctiveness for Hong Kong adolescents with different social identities. Participants (236 Hong Kong adolescents) filled out a questionnaire which tapped social identity and intergroup perception. They also participated in a card-sorting activity in which they decided if any of 20 attributes (e.g., advanced, respecting collective will) could be used to characterize a specific ethnic-social group (e.g., mainland Chinese, Hongkongers, Americans). Multidimensional scaling performed on the card-sorting data resulted in a two-dimensional solution. Emphasis on Dimension I (modernity) correlated with positive perception of Hong Kong and Hong Kong people while emphasis on Dimension 2 (Confucian values) correlated with positive perception of China and Chinese. In addition, compared to adolescents who identified themselves as Chinese or Chinese-Hongkongers, those who identified themselves as Hongkongers or Hongkonger-Chinese placed more emphasis on modernity and less on Confucian values. The results were discussed with reference to Tajfel's theory of social identity. (C) 1999 Elsevier Science Ltd. All rights reserved

Study protocol for "Moving bright, eating smart"- a phase 2 clinical trial on the acceptability and feasibility of a diet and physical activity intervention to prevent recurrence in colorectal cancer survivors

Background: Colorectal cancer is the second most common cancer and cancer-killer in Hong Kong with an&nbsp;alarming increasing incidence in recent years. The latest World Cancer Research Fund report concluded that foods&nbsp;low in fibre, and high in red and processed meat cause colorectal cancer whereas physical activity protects againstcolon cancer. Yet, the influence of these lifestyle factors on cancer outcome is largely unknown even though&nbsp;cancer survivors are eager for lifestyle modifications. Observational studies suggested that low intake of a&nbsp;Western-pattern diet and high physical activity level reduced colorectal cancer mortality. The Theory of PlannedBehaviour and the Health Action Process Approach have guided the design of intervention models targeting a&nbsp;wide range of health-related behaviours.Methods/design: We aim to demonstrate the feasibility of two behavioural interventions intended to improve&nbsp;colorectal cancer outcome and which are designed to increase physical activity level and reduce consumption of a&nbsp;Western-pattern diet. This three year study will be a multicentre, randomised controlled trial in a 2x2 factorialdesign comparing the &ldquo;Moving Bright, Eating Smart&rdquo; (physical activity and diet) programme against usual care.&nbsp;Subjects will be recruited over a 12-month period, undertake intervention for 12 months and followed up for a&nbsp;further 12 months. Baseline, interim and three post-intervention assessments will be conducted.&nbsp;Two hundred and twenty-two colorectal cancer patients who completed curative treatment without evidence of&nbsp;recurrence will be recruited into the study. Primary outcome measure will be whether physical activity and dietary&nbsp;targets are met at the end of the 12-month intervention. Secondary outcome measures include the magnitude andmechanism of behavioural change, the degree and determinants of compliance, and the additional health benefits&nbsp;and side effects of the intervention.Discussion: The results of this study will establish the feasibility of targeting the two behaviours (diet and physical activity) and demonstrate the magnitude of behaviour change. The information will facilitate the design of a further&nbsp;larger phase III randomised controlled trial with colorectal cancer outcome as the study endpoint to determine&nbsp;whether this intervention model would reduce colorectal cancer recurrence and mortality

Perceptions of patient aggression in psychiatric hospitals: a qualitative study using focus groups with nurses, patients, and informal caregivers

BackgroundAggression in psychiatric hospitals has been of interest to researchers. Information on how different stakeholders perceive patient aggression remains equivocal. Even less is known about possible similarities or differences in stakeholders’ perceptions of how aggressive behaviour is understood, managed and prevented in psychiatric hospitals. We aimed to explore multiple viewpoints on patient aggression, its possible causes and outcomes, and development ideas for prevention and management.MethodsA qualitative design was adopted. The data were collected using focus group interviews. A thematic approach was used for interpretation. The data were collected on 15 adult wards in two inpatient psychiatric settings in Hong Kong. Participants were nurses working on the psychiatric inpatient wards, patients admitted to the wards, and informal caregivers visiting inpatient wards (N = 94).ResultsCommonalities between all groups were found on how patient aggression is perceived, and why it occurs. Patients and especially nurses described how patient aggression occurred with no clear reason or forewarning and how patients were physically controlled or restricted after aggressive events. Only nurses and patients expressed experiencing physical burden, while all groups considered psychological burden to be a consequence of aggression. All groups proposed that helpful attitudes among nurses, better communication, structural changes, and better self-management skills would prevent patient aggression. Risk assessment was proposed only by nurses and patients, while safety measures were proposed by nurses and informal caregivers only. The use of restrictive interventions to manage aggressive events was proposed by all groups.ConclusionsDespite the complex diversity of perspectives in different stakeholder groups regarding patient aggression, the findings highlighted that it is possible to achieve some mutual understanding of aggression in psychiatric hospitals and identify areas to be developed. Staffs’ attitudes and skills for engagement and communication with patients and informal caregivers should be improved. There is also still room to develop the therapeutic environment and culture toward meaningful activities during the treatment period.</p

Physical activity for cancer survivors: meta-analysis of randomised controlled trials

Objective To systematically evaluate the effects of physical activity in adult patients after completion of main treatment related to cancer

Physical Restraint Events in Psychiatric Hospitals in Hong Kong: A Cohort Register Study

The need to better monitor coercion practices in psychiatric hospitals has been recognised. We aim to describe how physical restraint events occur in psychiatric hospitals and identify factors associated with physical-restraint use. A cohort register study was used. We analyzed physical restraint documents among 14 wards in two psychiatric hospitals in Hong Kong (1 July and 31 Dec. 2018). In total, 1798 incidents occurred (the rate of physical restraint event 0.43). Typically, physically restrained patients were in early middle-age, of both genders, diagnosed with schizophrenia-spectrum and other psychotic disorders, and admitted voluntarily. Alternate methods for physical restraint were reported, such as an explanation of the situation to the patients, time-out or sedation. A longer period of being physically restrained was associated with being male, aged >= 40 years, having involuntary status, and neurodevelopmental-disorder diagnosis. Our findings support a call for greater action to promote the best practices in managing patient aggression and decreasing the use of physical restraint in psychiatric wards. The reasons for the use of physical restraint, especially for those patients who are admitted to a psychiatric hospital on a voluntary basis and are diagnosed with neurodevelopmental disorders, needs to be better understood and analysed