Elevated Whole-Blood Manganese Levels in Adult Patients Prescribed "Manganese-Free" Home Parenteral Nutrition.

BACKGROUND: Manganese toxicity can occur as a complication of home parenteral nutrition (HPN). Patients can present with Parkinson disease-like symptoms. Preparations of trace elements (TEs) in parenteral nutrition (PN) generally provide amounts in excess of requirements. Our previous review observed 60% of adult HPN patients had high whole-blood manganese levels. Multi-TE (MTE) solutions were subsequently removed from all HPN formulations in January 2015. The aim of this evaluation was to determine whole-blood concentrations of manganese in adult patients receiving HPN to establish whether levels are now maintained within the normal reference range. METHODS: A retrospective review of whole-blood manganese levels in all patients receiving HPN between January 2018 and January 2019 from 1 hospital site was carried out. RESULTS: 100 patients were included in the review (59 female and 41 male). Normal whole-blood manganese levels (73-219 nmol/L) were observed in 70% of patients and elevated levels (>219 nmol/L) in 30% of patients. In the patients with elevated levels, 57% had not received manganese supplementation for at least 1 year prior to manganese being measured. Markers of cholestasis were similar between the 2 groups. CONCLUSIONS: Incidence of elevated whole-blood manganese concentrations in patients receiving HPN decreased from 60% to 30% upon discontinued use of an MTE solution. Elevated levels remain a concern despite patients being prescribed "manganese-free" PN. Patients receive this TE in amounts adequate to meet requirements through contamination and dietary intake alone, suggesting additional parenteral supplementation of manganese is not required.

Do non-targeted gastric biopsies affect the management of patients, and can a simple protocol and education reduce the rate?

OBJECTIVE: To determine whether development of localised protocol could reduce the number of non-targeted gastric biopsies taken at endoscopy, without risking harm from non-detection of malignant conditions. DESIGN: Retrospective analysis of patient records over a 3-month period in 2013, repeated in 2015 following intervention. SETTING: Two UK teaching hospitals. PATIENTS: Patient record data on indication for endoscopy, endoscopy findings, histopathology results and patient outcome. INTERVENTIONS: Guidance on upper gastrointestinal biopsy in the form of a new trust-wide protocol, as well as lecture-based education. MAIN OUTCOME MEASURES: Rates of non-targeted and targeted biopsies before and after intervention, and differences between grade of endoscopist. RESULTS: Between 2013 and 2015, there was a 36% reduction in non-targeted biopsies (10.4% vs 6.7%, p=0.001), predominantly within registrar and nurse endoscopist groups, with reduction in non-targeted biopsies of 9.5% and 64%, respectively. Percentage of targeted biopsies remained relatively static, 7.9% and 8.2%. In 2013, 92% of non-targeted biopsies had no management change based on histology; in 2015 this was 90%. Of patients with alteration to management, only 0.4% and 0.7% were due to malignancy, in known high-risk patients. Reduction in non-targeted biopsies resulted in estimated annual savings in this trust of £36,000. CONCLUSION: Development of local protocol reduces the numbers of non-targeted biopsies taken, without risk of harm from non-detection of malignant conditions, enabling a significant reduction in workload within busy histopathology services, with significant cost savings. Localised protocols are adaptable to local population demographics.

Fatal gastrointestinal histoplasmosis 15 years after orthotopic liver transplantation.

We report a case of ileo-colonic Histoplasmosis without apparent respiratory involvement in a patient who had previously undergone an orthotopic liver transplant (OLT) for primary biliary cholangitis 15 years earlier. The recipient lived in the United Kingdom, a non-endemic region for Histoplasmosis. However, she had previously lived in rural southern Africa prior to her OLT. The patient presented with iron deficiency anaemia, diarrhoea, abdominal pain and progressive weight loss. She reported no previous foreign travel, however, it later became known that following her OLT she had been on holiday to rural southern Africa. On investigation, a mild granulomatous colitis primarily affecting the right colon was identified, that initially improved with mesalazine. Her symptoms worsened after 18 mo with progressive ulceration of her distal small bowel and right colon. Mycobacterial, Yersinia, cytomegalovirus and human immunodeficiency virus infections were excluded and the patient was treated with prednisolone for a working diagnosis of Crohn's disease. Despite some early symptom improvement following steroids, there was subsequent deterioration with the patient developing gram-negative sepsis and multi-organ failure, leading to her death. Post-mortem examination revealed that her ileo-colonic inflammation was caused by Histoplasmosis.

Managing Malnutrition in Older Persons Residing in Care Homes: Nutritional and Clinical Outcomes Following a Screening and Intervention Program.

This study aimed to establish prevalence of malnutrition in older adult care home residents and investigate whether a nutritional screening and intervention program could improve nutritional and clinical outcomes. A community-based cohort study was conducted in five Newcastle care homes. 205 participants entered; 175 were followed up. Residents already taking oral nutritional supplements (ONS) were excluded from interventions. Those with Malnutrition Universal Screening Tool (MUST) score of 1 received dietetic advice and ≥2 received dietetic advice and were prescribed ONS (220 ml, 1.5 kcal/ml) twice daily for 12 weeks. Body mass index (BMI), MUST, mini nutritional assessment score (MNA)®, mid upper arm muscle circumference (MAMC), and Geriatric Depression Scale (GDS) were recorded at baseline and 12 weeks. Malnutrition prevalence was 36.6% ± 6.6 (95% CI). A higher MUST was associated with greater mortality (p = 0.004). Type of intervention received was significantly associated with change in MUST score (p < 0.001); dietetic advice resulting in the greatest improvement. There were no significant changes in BMI (p = 0.445), MAMC (p = 0.256), or GDS (p = 0.385) following the interventions. Dietitian advice may slow the progression of nutritional decline. In this study oral nutritional supplements over a 3-month period did not significantly improve nutritional status in malnourished care home residents.

Mutifactorial analysis of risk factors for reduced bone mineral density in patients with Crohn's disease.

AIM: To determine the prevalence of osteoporosis in a cohort of patients with Crohn's disease (CD) and to identify the relative significance of risk factors for osteoporosis. METHODS: Two hundred and fifty-eight unselected patients (92 M, 166 F) with CD were studied. Bone mineral density (BMD) was measured at the lumbar spine and hip by dual X-ray absorptiometry. Bone formation was assessed by measuring bone specific alkaline phosphatase (BSAP) and bone resorption by measuring urinary excretion of deoxypyridinoline (DPD) and N-telopeptide (NTX). RESULTS: Between 11.6%-13.6% patients were osteoporotic (T score < -2.5) at the lumbar spine and/or hip. NTX levels were significantly higher in the patients with osteoporosis (P < 0.05) but BSAP and DPD levels were not significantly different. Independent risk factors for osteoporosis at either the lumbar spine or hip were a low body mass index (P < 0.001), increasing corticosteroid use (P < 0.005), and male sex (P < 0.01). These factors combined accounted for 23% and 37% of the reduction in BMD at the lumbar spine and hip respectively. CONCLUSION: Our results confirm that osteoporosis is common in patients with CD and suggest that increased bone resorption is the mechanism responsible for the bone loss. However, less than half of the reduction in BMD can be attributed to risk factors such as corticosteroid use and low BMI and therefore remains unexplained.

Critical intestinal ischaemia in a patient with patent mesenteric vasculature.

We present a case of a 62-year-old man with known coeliac disease who was admitted for investigation of abdominal pain and weight loss. He underwent multiple biochemical, haematological, radiological and endoscopic investigations (which were all normal) and also had a normal laparoscopy. Abdominal computerized tomography angiography, however, suggested significant mesenteric stenosis. Mesenteric angiography confirmed superior mesenteric artery stenosis and reproduced the patient's abdominal pain when the catheter crossed the lesion. Balloon angioplasty successfully dilated the stenosis, and since then the patient has gained 19 kg in weight (returning his body mass index from 17 to 23) and has been symptom free. Symptomatic single vessel mesenteric ischaemia (other than coeliac artery stenosis in median arcuate syndrome) is not previously well described. The symptom reproduction on catheterization highlights how useful angiography can be in diagnosis of disease significance. Symptom resolution after angioplasty demonstrated clearly how even single vessel disease can cause significant compromise to the mesenteric circulation.