Nutritional care pathways in cancer patients with malignant bowel obstruction: A retrospective multi-centre study.

INTRODUCTION: Variation in access to parenteral nutrition (PN) in patients with intestinal failure secondary to malignant bowel obstruction (MBO) exists due to differing practice, beliefs and resource access. We aimed to examine differences in nutritional care pathways and outcomes, by referral to nutrition team for PN in patients with MBO. METHODS: This is a retrospective cohort study of MBO adults admitted to eight UK hospitals within a year and 1 year follow-up. Demographic, nutritional and medical data were analysed by comparing patients referred (R) or not referred (NR) for PN. Differences between groups were tested by Kruskal-Wallis, Chi-Squared tests and multi-level regression and survival using Cox regression. RESULTS: 232 patients with 347 MBO admissions [median 66yr, (IQR: 55-74yrs), 67 % female], 79/232 patients were referred for PN (R group). Underlying primary malignancies of gynaecological and gastrointestinal origin predominated (71 %) and 78 % with metastases. Those in the NR group were found to be older, weigh more on admission, and more likely to be treated conservatively compared to those in the R group. For 123 (35 %) admissions, patients were referred to a nutrition team, and for 204 (59 %) admissions, patients were reviewed by a dietician. Multi-disciplinary team discussion and dietetic contact were more likely to occur in the R group-123/347 admissions (R vs NR group: 27 % vs. 7 %, P = 0.001; 95 % vs 39 %, P < 0.0001). Median admission weight loss was 8 % (IQR: 0 to 14). 43/123 R group admissions received inpatient PN only, with 32 patients discharged or already established on home parenteral nutrition. Overall survival was 150 days (126-232) with no difference between R/NR groups. CONCLUSION: In this multi-centre study evaluating nutritional care management of patients with malignant bowel obstruction, only 1 in 3 admissions resulted in a referral to the nutrition team for PN, and just over half were reviewed by a dietician. Further prospective research is required to evaluate possible consequences of these differential care pathways on clinical outcomes and quality of life.

Investigating the Relationship between Home Parenteral Support and Needs-Based Quality of Life in Patients with Chronic Intestinal Failure: A National Multi-Centre Longitudinal Cohort Study.

Home parenteral support (HPS) is an essential but potentially burdensome treatment that can affect quality of life (QoL). The aims of this longitudinal study were to understand whether any changes in HPS over time were associated with QoL. The Parenteral Nutrition Impact Questionnaire (PNIQ) was used, and data were collected on HPS prescribed at three time points. Data were analysed using multi-level mixed regression models presented as effect size and were adjusted for confounders. Study recruited 572 participants from 15 sites. Of these, 201 and 145 completed surveys at second and third time-points, respectively. PNIQ score was out of 20 with a higher score indicating poorer QoL. Any reduction in HPS infusions per week was associated with an improved PNIQ score of -1.10 (95% CI -2.17, -0.02) unadjusted and -1.34 (95% CI -2.45, -0.24) adjusted. Per day change to the number of infusions per week was associated with a change in the PNIQ score of 0.32 (95% CI -0.15, 0.80) unadjusted and 0.34 (95% CI -0.17, 0.85) adjusted. This is the largest national study to demonstrate improvements in QoL associated with HPS reduction over time using an HPS-specific and patient-centric tool, adding unique data for use of therapies in intestinal failure.

Impact of home parenteral nutrition on family members: A national multi-centre cross-sectional study.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) is a necessary treatment for patients with chronic, type 3, intestinal failure (IF). HPN often requires lifestyle adaptations, which are likely to affect quality of life (QoL) in both patients and family members. The aim of this study was to identify the level of burden on family members who are involved with HPN care and to understand specific factors that contribute to any burden. METHODS: Patients over the age of 18 and receiving HPN were identified in IF clinics from multiple centres across the U.K. Eligible patients were asked to complete the parenteral nutrition impact questionnaire (PNIQ) to assess their QoL, while family members were asked to complete the burden scale for family caregivers (BSFC). Logistical regression was undertaken giving adjusted odds ratios (aOR). RESULTS: 678 participants completed the survey representing 339 patients with their appointed family member. Mean PNIQ score was 11.53 (S.D. 5.5), representing a moderate impact of HPN on patients' QoL. On the BSFC scale, 23% of family members reported a moderate to very severe subjective burden indicating an increased risk of psychosomatic symptoms. After adjusting for age and gender, predictors of BSFC included: family members self-reported health status using the EuroQol visual analogue scale (aOR 19.91, 95% CI 1.69, 233.99, p = 0.017) and support received by health services (aOR = 5.83, 95% CI = 1.93, 17.56, p = 0.002). Employment status, disease type, number of nights on HPN and length of time on HPN were not associated with BSFC. CONCLUSIONS: Family members with a poor health status or lack of support by health service were more likely to have a moderate to very severe subjective burden. Tailored support from the multi-professional IF team may reduce the burden experienced by family members of people dependent on HPN.

Nutrition support in intensive care units in England: a snapshot of present practice.

Nutrition support is an important part of care management in critically ill patients, not only to prevent and treat malnutrition but also it has a significant impact on recovery from illness and overall outcome. There is little information available about present nutritional support practice for patients in intensive care units (ICU) in the UK. This survey was designed to evaluate the present nutrition support practice in ICU and high dependency units (HDU) in England. Data were gathered by a 72 h phone survey from 245 ICU and HDU in 196 hospitals in England. A questionnaire was completed over the telephone, including general information, nutrition support and teams involved in the nutrition management in the ICU. Of 1286 total patients in the ICU, 703 (54·6 %) were receiving nasogastric feeding, two (1·5 %) were receiving feeding via a percutaneous endoscopically placed gastrostomy tube and two (1·5 %) were receiving nasojejunal feeding. One hundred and forty-seven (11·4 %) patients were on parenteral feeding during the study period. A nutrition support team was not available in 158 (83·1 %) ICU and there was no dietitian or specialist nutrition nurse to cover ICU in nine (4·7 %) hospitals. In conclusion, the present survey reported an increased trend in usage of enteral feeding in ICU in England, and a reduction in the use of parenteral nutrition compared with previous surveys. However, we are still far from integrating nutrition into care management in the ICU.

Gender differences in leadership, workforce and scholarly presentation within a national society: a gastroenterology perspective.

In the UK, gastroenterology has been a male predominant medical speciality. Data regarding gender within workforce, academia and leadership at a national level are lacking. Data regarding scholarly presentation at the following annual conferences were collected and analysed; British Society of Gastroenterology (BSG) 2013, 2014, and Digestive Diseases Federation (DDF) in 2015. Data from the 2013-2015 BSG annual workforce reports were examined. In 2015, female higher specialty trainees (STs) made up 39% (328/848) of the trainee workforce, versus 37% and 35% in 2014 and 2013. From 2013 to 2015, less than a fifth of all consultant gastroenterologists were women. Female consultant (18%), ST (39%), associate (86%) and student attendance (47%) at DDF 2015 did not change significantly from 2013 to 2014. Female speakers (trainees and consultants) were significantly lower at DDF 2015 compared with BSG 2014; 43/331 (13%) versus 56/212 (26.4%) (p=0.0001) and BSG 2013 63/231 (27%) (p=0.0001). The number of female chairs, delivery of the named lectures and prizes awarded to women did not differ across the 3-year period. Female leadership via representation at Council and Executive at BSG was 4/30 (13%) in 2015 and did not differ in 2013/2014, with no elected council members since 2008 and one female president in 1973. The proportion of female gastroenterology trainees and consultants is increasing, but remains lower than across all medical specialties and is reflected in attendance and scholarly contributions. Action within the BSG is underway to address female under-representation in leadership roles.

Results of the British Society of Gastroenterology supporting women in gastroenterology mentoring scheme pilot.

INTRODUCTION: Mentorship has long been recognised as beneficial in the business world and has more recently been endorsed by medical and academic professional bodies. Recruitment of women into gastroenterology and leadership roles has traditionally been difficult. The Supporting Women in Gastroenterology network developed this pilot scheme for female gastroenterologists 5 years either side of the Completion Certificate of Specialist Training (CCST) to examine the role that mentorship could play in improving this discrepancy. METHOD: Female gastroenterology trainees and consultant gastroenterologists within 5 years either side of CCST were invited to participate as mentees. Consultant gastroenterologists of both genders were invited to become mentors. 35 pairs of mentor:mentees were matched and completed the scheme over 1 year. Training was provided. RESULTS: The majority of the mentees found the sessions useful (82%) and enjoyable (77%), with the benefit of having time and space to discuss professional or personal challenges with a gastroenterologist who is not a colleague. In the longitudinal study of job satisfaction, work engagement, burnout, resilience, self-efficacy, self-compassion and work-life balance, burnout scale showed a small but non significant improvement over the year (probably an effect of small sample size). Personal accomplishment improved significantly. The main challenges were geography, available time to meet and pair matching. The majority of mentors surveyed found the scheme effective, satisfying, mutually beneficial (70%) and enjoyable (78%). CONCLUSION: Mentorship is shown to be beneficial despite the challenges and is likely to improve the recruitment and retention of women into gastroenterology and leadership roles, but is likely to benefit gastroenterologists of both genders.

Factors associated with vitamin D deficiency in a multicultural inflammatory bowel disease cohort.

OBJECTIVE: The aim of this study was to determine the prevalence of vitamin D deficiency in a multicultural inflammatory bowel disease (IBD) cohort and determine predictors of deficiency including ethnicity. DESIGN: Patients with IBD were recruited into a dedicated database over a 6-month period and evaluated retrospectively. SETTING: Department of Gastroenterology, St George's University Hospital, London, UK. OUTCOMES MEASURED: Clinical data including demographics, ethnic group, disease phenotype by the Montreal classification, vitamin D level and season tested were recorded from clinical and electronic medical records. Vitamin D levels were classified as normal (≥50 nmol/l) and deficient (<50 nmol/l). RESULTS: 168 patients had a vitamin D level measured subsequent to diagnosis. There was no significant difference in the median vitamin D level between patients with Crohn's disease (CD) and ulcerative colitis (UC) (39 nmol/l (IQR 23-56) vs 28 nmol/l (IQR 17-51), p=0.35). Overall the median vitamin D level was significantly lower in non-Caucasians (Asian and Black) versus Caucasians (28 nmol/l (IQR 17-41) vs 41 nmol/l (IQR 25-63), p<0.0001). Multiple regression analysis revealed IBD related surgery (OR 2.9) and ethnicity (OR 6.0 non-Caucasian vs Caucasian) in CD and ethnicity (OR 5.0 non-Caucasian vs Caucasian) in UC were independently associated with vitamin D deficiency. CONCLUSIONS: Vitamin D deficiency is common in IBD patients; therefore, we suggest monitoring of vitamin D levels and correction with supplements especially in non-Caucasians and those with a history of IBD related surgery.

Attitudes and expectations of gastroenterology outpatients about the importance of diet and possible relationship to their symptoms.

OBJECTIVES: To evaluate gastroenterology outpatients' attitudes to the importance of diet and its relationship to their symptoms, as well as their expectations of dietary advice from health professionals. DESIGN: Prospective clinical audit. SETTING: Gastroenterology outpatient department of St George's Healthcare NHS Trust. PATIENTS: Two hundred and twenty-five patients, aged between 18 and 70 years met the inclusion criteria. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participants' responses to a structured questionnaire. RESULTS: Sixty-nine per cent of participants felt their diet played an important role in their condition. Factors significantly associated with a positive dietary attitude included younger age (40.6 years vs 46.0 years, p<0.01), regularity of dietary pattern (108 vs 35, p<0.01), number of symptoms (4.6 vs 2.5, p<0.01), severity of gastrointestinal symptoms (2.3 vs 1.5, p<0.01), history of weight loss (34% vs 20.3%, p<0.05) and history of dietary advice (71.1% vs 33.3%, p<0.01). Sixty-eight per cent (68%) of participants were interested in receiving dietary advice, though only 36% expected to receive it. No differences were found for any comparisons based on average body mass index. CONCLUSION: The majority of gastroenterology outpatients view diet as playing an important role in their condition, particularly those who have more severe symptoms and those who have received dietary advice. Although a large proportion of patients are interested in receiving dietary advice, few expect to receive it in clinics. Further research is required to explore the reasons why, and to assess the confidence of health professionals in providing nutritional advice.

Nutritional training in gastroenterology.

Despite the clear importance of nutritional knowledge for health professionals, such education has long been notoriously patchy at both undergraduate and postgraduate levels. Gastroenterologists in particular have a special responsibility to provide advice and expertise, not only in general nutrition but also in artificial nutrition support in the setting of extreme risk of malnutrition and intestinal failure. Recently, with the restructuring of undergraduate medical teaching and the advent of modernising medical careers, curricula have been examined in detail and training programmes have become competency based. These changes, together with increasing public expectations regarding both the importance of nutrition and ability of doctors to provide advice and guidance, have provided an opportunity to reassess nutritional training at all levels of medical education. In this review, the authors consider the factors which may have hindered the progression of nutritional education for doctors, and gastroenterologists in particular, as well as the steps which have been taken in recent years to address these issues and move such training forward. There is now a real opportunity to improve the quality of nutrition training in gastroenterology. If this can be achieved, all gastroenterologists of the future, instead of shrinking from difficult nutritional issues, should be able to manage them with confidence and enthusiasm no matter what their subspecialty; indeed, an increasing proportion may become nutrition subspecialists in their own right.

Detection and verification of Mycobacterium avium subsp. paratuberculosis in fresh ileocolonic mucosal biopsy specimens from individuals with and without Crohn's disease.

Mycobacterium avium subsp. paratuberculosis is a robust and phenotypically versatile pathogen which causes chronic inflammation of the intestine in many species, including primates. M. avium subsp. paratuberculosis infection is widespread in domestic livestock and is present in retail pasteurized cows' milk in the United Kingdom and, potentially, elsewhere. Water supplies are also at risk. The involvement of M. avium subsp. paratuberculosis in Crohn's disease (CD) in humans has been uncertain because of the substantial difficulties in detecting this pathogen. In its Ziehl-Neelsen staining-negative form, M. avium subsp. paratuberculosis is highly resistant to chemical and enzymatic lysis. The present study describes the development of optimized sample processing and DNA extraction procedures with fresh human intestinal mucosal biopsy specimens which ensure access to M. avium subsp. paratuberculosis DNA and maximize detection of these low-abundance pathogens. Also described are two nested PCR methodologies targeted at IS900, designated IS900[L/AV] and IS900[TJ1-4], which are uniquely specific for IS900. Detection of M. avium subsp. paratuberculosis in mucosal biopsy specimens was also evaluated by using mycobacterial growth indicator tube (MGIT) cultures (Becton Dickinson). IS900[L/AV] PCR detected M. avium subsp. paratuberculosis in 34 of 37 (92%) patients with CD and in 9 of 34 (26%) controls without CD (noninflammatory bowel disease [nIBD] controls) (P = 0.0002; odds ratio = 3.47). M. avium subsp. paratuberculosis was detected by IS900[L/AV] PCR in MGIT cultures after 14 to 88 weeks of incubation in 14 of 33 (42%) CD patients and 3 of 33 (9%) nIBD controls (P = 0.0019; odds ratio = 4.66). Nine of 15 (60%) MGIT cultures of specimens from CD patients incubated for more than 38 weeks were positive for M. avium subsp. paratuberculosis. In each case the identity of IS900 from M. avium subsp. paratuberculosis was verified by amplicon sequencing. The rate of detection of M. avium subsp. paratuberculosis in individuals with CD is highly significant and implicates this chronic enteric pathogen in disease causation.