A Systematic Review of Dementia Research Priorities.

INTRODUCTION: Patient involvement is a critical component of dementia research priority-setting exercises to ensure that research benefits are relevant and acceptable to those who need the most. This systematic review synthesises research priorities and preferences identified by people living with dementia and their caregivers. METHODS: Guided by Joanna Briggs Institute methodology, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework, we conducted a systematic search in five electronic databases: CINAHL, Medline, PsycINFO, Web of Science and Scopus. The reference lists of the included studies were also manually searched. We combined quantitative and qualitative data for synthesis and descriptive thematic analysis. RESULTS: Eleven studies were included in this review. Findings are grouped into four main categories: Increase in knowledge, education, and awareness; Determining the cause; Sustainability of care; and Cure of dementia and related conditions. CONCLUSION: There is a need to respond to the stigma associated with dementia, which limits access to care and the quality of life for both people living with dementia and their caregivers. We need to work on changing public, private and workplace attitudes about dementia and encourage supporting and participating in dementia research. Future research should involve people living with dementia and their primary caregivers from culturally and linguistically diverse communities in priority-setting exercises.

A scoping review of parenteral requirements (macronutrients, fluid, electrolytes and micronutrients) in adults with chronic intestinal failure receiving home parenteral nutrition.

INTRODUCTION: Home parenteral nutrition (HPN) prescriptions should be individualised in adults with chronic intestinal failure (IF). The aims of the review were to explore HPN requirements and available guidelines and to determine whether adults (≥ 18 years) receive recommended parenteral nutrient doses. METHODS: Online databases searches identified empirical evidence (excluding case-reports), reviews and guidelines (Published 2006-2024 in English language). Additional reference lists were hand-searched. Older studies, cited in national guidelines were highlighted to map evidence source. Two reviewers screened 1660 articles independently, with 98 full articles assessed and 78 articles included (of which 35 were clinical studies). Citation tracking identified 12 older studies. RESULTS: A lack of evidence was found assessing parenteral macronutrient (amounts and ratios to meet energy needs), fluid and electrolyte requirements. For micronutrients, 20 case series reported serum levels as biomarkers of adequacy (36 individual micronutrient levels reported). Studies reported levels below (27 out of 33) and above (24 out of 26) reference ranges for single micronutrients, with associated factors explored in 11 studies. Guidelines stated recommended parenteral dosages. Twenty-four studies reported variable proportions of participants receiving HPN dosages outside of guideline recommendations. When associated factors were assessed, two studies showed nutrient variation with type of HPN administered (multichamber or individually compounded bags). Five studies considered pathophysiological IF classification, with patients with short bowel more likely to require individualised HPN and more fluid and sodium. CONCLUSIONS: This review highlights substantial evidence gaps in our understanding of the parenteral nutritional requirements of adult receiving HPN. The conclusions drawn were limited by temporal bias, small samples sizes, and poor reporting of confounders and dose. Optimal HPN nutrient dose still need to be determined to aid clinical decision-making and further research should explore characteristics influencing HPN prescribing to refine dosing recommendations.

Clinical deterioration as a nurse sensitive indicator in the out-of-hospital context: A scoping review.

AIMS: To explore and summarise the literature on the concept of 'clinical deterioration' as a nurse-sensitive indicator of quality of care in the out-of-hospital context. DESIGN: The scoping review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review and the JBI best practice guidelines for scoping reviews. METHODS: Studies focusing on clinical deterioration, errors of omission, nurse sensitive indicators and the quality of nursing and midwifery care for all categories of registered, enrolled, or licensed practice nurses and midwives in the out-of-hospital context were included regardless of methodology. Text and opinion papers were also considered. Study protocols were excluded. DATA SOURCES: Data bases were searched from inception to June 2022 and included CINAHL, PsychINFO, MEDLINE, The Allied and Complementary Medicine Database, EmCare, Maternity and Infant Care Database, Australian Indigenous HealthInfoNet, Informit Health and Society Database, JSTOR, Nursing and Allied Health Database, RURAL, Cochrane Library and Joanna Briggs Institute. RESULTS: Thirty-four studies were included. Workloads, education and training opportunities, access to technology, home visits, clinical assessments and use of screening tools or guidelines impacted the ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting. CONCLUSIONS: Little is known about the work of nurses or midwives in out-of-hospital settings and their recognition, reaction to and relay of information about patient deterioration. The complex and subtle nature of non-acute deterioration creates challenges in defining and subsequently evaluating the role and impact of nurses in these settings. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: Further research is needed to clarify outcome measures and nurse contribution to the care of the deteriorating patient in the out-of-hospital setting to reduce the rate of avoidable hospitalisation and articulate the contribution of nurses and midwives to patient care. IMPACT: What Problem Did the Study Address? Factors that impact a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting are not examined to date. What Were the Main Findings? A range of factors were identified that impacted a nurse's ability to recognise, relay information and respond to clinical deterioration in the out-of-hospital setting including workloads, education and training opportunities, access to technology, home visits, clinical assessments, use of screening tools or guidelines, and avoidable hospitalisation. Where and on whom will the research have an impact? Nurses and nursing management will benefit from understanding the factors that act as barriers and facilitators for effective recognition of, and responding to, a deteriorating patient in the out-of-hospital setting. This in turn will impact patient survival and satisfaction. REPORTING METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Review guidelines guided this review. The PRISMA-Scr Checklist (Tricco et al., 2018) is included as (supplementary file 1).Data sharing is not applicable to this article as no new data were created or analysed in this study." NO PATIENT OR PUBLIC CONTRIBUTION: Not required as the Scoping Review used publicly available information.

Periconceptional 1,3-butanediol supplementation suppresses the superimposed preeclampsia-like phenotype in the Dahl salt-sensitive rat.

Preeclampsia is a hypertensive pregnancy disorder with no treatment beyond management of symptoms and delivery of the fetus and placenta. Chronic hypertension increases the risk of developing superimposed preeclampsia. Previous reports showed that 1,3-butanediol attenuates hypertension in rodents; however, the therapeutic potential of 1,3-butanediol for the prevention of preeclampsia has not been investigated. This study tested the hypothesis that attenuating hypertension before pregnancy and through the placentation period via 1,3-butanediol prevents the onset of preeclampsia in female Dahl salt-sensitive (SS/Jr) rats. Female Dahl SS/Jr rats were divided into two groups: 1,3-butanediol treated (20% via drinking water) and control (ad libitum water). Both groups were maintained on low-salt rodent chow (Teklad 7034, 0.3% NaCl; n = 8/group). Animals were treated with 1,3-butanediol for 7 wk (baseline), mated, and treated through day 12 of pregnancy. 1,3-Butanediol treatment increased plasma ß-hydroxybutyrate (metabolite of 1,3-butanediol) that negatively correlated with maternal body weight in late pregnancy. Mean arterial pressure was lower in the treated group at baseline, early, and mid pregnancy, but no difference was observed in late pregnancy after treatment ended. Uterine artery resistance index (UARI) was reduced in the treated dams. No adverse fetal effects were observed, and there were no differences in pup weight or length. Placentas from treated dams had decreased vascular endothelial growth factor levels as well as decreased placental basal zone thickness and increased labyrinth zone thickness. These findings support the therapeutic role of physiological ketosis via 1,3-butanediol as a potential therapeutic approach for managing chronic hypertension, thereby preventing and mitigating adverse pregnancy outcomes associated with preeclampsia.NEW & NOTEWORTHY A ketogenic diet or increased ß-hydroxybutyrate levels can reduce hypertension, but the potential of 1,3-butanediol, a ß-hydroxybutyrate precursor, for treatment of preeclampsia is unknown. We hypothesized that attenuating hypertension before and during pregnancy via 1,3-butanediol prevents preeclampsia in Dahl Salt-sensitive rats. 1,3-Butanediol significantly lowered blood pressure and improved uterine artery resistance with no observable adverse fetal effects. Physiological ketosis via 1,3-butanediol may be a potential therapeutic approach for managing hypertension and mitigating adverse pregnancy outcomes.

Outcomes of multidisciplinary treatment planning in US cancer care settings.

Multidisciplinary treatment planning (MTP) is a process of engaging multiple disciplines to develop or refine the disease management plan. It is widely implemented in US cancer treatment settings and is considered to have favorable effects on both care quality and other outcomes. However, evidence reviews to date regarding MTP effectiveness have based their conclusions on studies conducted predominantly outside the United States. The authors conducted a systematic review of US-based studies to synthesize and critically appraise evidence of the effects of MTP on cancer care quality, health services outcomes, and survival. Database searches identified studies of MTP outcomes conducted in US cancer care settings from 2000 to 2017. Forty-five studies met criteria for inclusion. MTP was associated with favorable effects on several indicators of cancer care quality, including delivery of guideline-concordant treatment and improvements in diagnostic accuracy, staging completeness, surgical technique, and timeliness. Effects on survival and clinical trials enrollment were mixed. Delivery formats for MTP were generally not well described, and study designs were nonrandomized, limiting the ability to identify mediators of intervention effects. Continued study is warranted to clarify effective components of MTP interventions, and to understand the mechanism(s) through which MTP produces favorable effects on outcomes.

Treatment and Survival Disparities in the National Cancer Institute's Patterns of Care Study (1987-2017).

BACKGROUND: Cancer health services research is a primary tool for analyzing the association between various factors, cancer health care delivery, and the resultant outcomes. To address disparities strategies must be developed to target factors that are related to differences in care; however, to date, most disparities studies have been descriptive. The primary objective was to describe cancer treatment and survival disparities in community oncology practice patterns found in the National Cancer Institute's population-based Patterns of Care (POC) Study (1987-2017). Secondarily, we compared POC findings to peer-reviewed literature. In POC data, older age was consistently associated with decreased odds of treatment and increased mortality. Interestingly, in contrast to current literature, few POC studies found race/ethnicity significantly predicted disparities. Cancer health disparities are complex; they are multifactorial, differ by cancer site and may wax and wane. The complexity supports the need for deeper understanding and targeted interventions to ensure equitable cancer care and outcomes.

Consumer experience and outcomes of insertion, removal, and management practices of short and midline peripheral intravenous catheters in acute health care: a mixed methods systematic review protocol.

OBJECTIVE: This review will synthesize and integrate current research on the practices relating to the insertion, removal, and management of short and midline peripheral intravenous catheters on consumer experiences and outcomes in acute health care. The aim is to provide consolidated evidence to support policy decision-makers and health care workers in overcoming peripheral intravenous catheter device management challenges. Implementing the evidence provided by this review could increase positive consumer outcomes and reduce the gap between research evidence and clinical practice. INTRODUCTION: Peripheral intravenous catheterization is a process in which a device is inserted into a patient's peripheral vein to administer medication, blood products, and therapeutic fluids. Recent studies have demonstrated the positive and negative impacts of peripheral intravenous catheter site placement, pain relief for insertion, complications, consumer engagement, and routine versus clinically indicated removal of these devices on consumers and the health care system. Managing these impacts in relation to research-practice gaps and conflicting evidence remains challenging. Moreover, consumer experiences and outcomes concerning these challenges are unclear. INCLUSION CRITERIA: This review will consider quantitative, qualitative, and mixed methods studies on consumer experiences and outcomes in acute health care. The quantitative component will consider outcomes of patients' pain, satisfaction, anxiety, distress, preferences, fear, and comfort. The qualitative component will consider consumer experiences, including perceptions, preferences, perspectives, attitudes, expectations, and satisfaction. METHODS: This study will follow JBI's convergent segregated approach for mixed method systematic reviews. A search of 11 databases will be conducted for peer-reviewed published articles, theses, and dissertations. There will be no age, date, or language limitations. REVIEW REGISTRATION: PROSPERO CRD42023410214.

The lived experience of midwives' transitioning from a clinical role into teaching in higher education in one jurisdiction of Australia: A pilot study.

AIM: The aim of this pilot study was to explore clinician's experience of transitioning from midwifery clinical practice into university in an academic teaching role within one jurisdiction in Australia. BACKGROUND: There is a dire shortage of midwifery academics globally. In Australia the shortage is symbiotic with the persistent deficit in the midwifery clinical workforce, which is the predominant recruitment pool for universities. The midwifery workforce cannot be replenished without sufficient academics to provide education. DESIGN: Phenomenology was selected as the most appropriate research approach for the study seeking to illuminate the lived experiences of clinicians as they transition into their new role as academics. METHODS: Seven participants were recruited purposively from one jurisdiction in Australia between November 2022 and March 2023. Qualitative conversational interviews were performed facilitating each participant to share their narrative. Participants were then able to direct the conversation to share their lived experience of the transition from a midwifery clinician in practice to a midwifery academic in a university. Demographic details were collected for context. RESULTS: Thematic analysis was used following Giorgi's four stage phenomenological process. Four themes were identified from commonalities between the participants, 'Being a drifter", 'Keeping a foot in both camps to maintain clinical credibility', 'In at the deep end: Not prepared for the reality of academia' and 'Best of both worlds'. CONCLUSIONS: The lived experiences of the participants in this study, as they transitioned from clinical midwifery practice to academia can be related to the Theory of Transition where participants navigate: Preparation, Encounter, Adjustment and Stabilisation. A new role in higher education requires adjustment to the reality of working in academia. Midwives who had experiences of being a casual staff member felt they had the best of both worlds, as they gained an insight into the role of an academic whilst remaining in clinical practice. However, many reported that mentorship would have been beneficial to facilitate stabilisation.

What do we know about midwives' transition from clinical practice to higher education teaching roles? A scoping review.

OBJECTIVE: The aim of this review was to examine the literature to identify what is known about midwives' experiences as academics and their perspectives of transition from clinical practice to university. INTRODUCTION: Literature on health care practitioners, particularly nurses' transition from clinical experts to novice teachers suggests the transition to academia is challenging.Challenges reported by research studies have identified stress, uncertainty, and lack of a supportive and structured transition. There was a dearth of primary research evidence of midwives' perspectives. METHODS: A scoping review using the Johanna Briggs Institute three step approach was employed. First, an initial limited search of Google Scholar and CINAHL was undertaken to identify articles on the topic. Second, the text words contained in the titles and abstracts of relevant articles and the index terms used to describe the articles were used to develop a complete search strategy in databases: EMBASE, MIDIRS, Scopus and PubMed. Finally, a manual search of the reference lists of all included sources of evidence was manually searched for additional studies. RESULTS: Ten papers that included midwives as the participants were located from Australia, The United Kingdom (UK) and the United States of America (USA) between 2006 and 2022. Analysis of the findings led to three themes: Theme 1: Challenges associated with the transition; Theme 2: Dichotomy of identity; and Theme 3: Fear of losing clinical credibility. CONCLUSION: In most studies midwives formed a subset of the sample meaning that the voices of midwifery academics are minimised by the experiences of other health practitioners. However, in depth details were located from four personal reflections which identified that transition from clinical practice to academia can result in a duality of roles while individuals come to terms with their new reality and overcome their fear of losing credibility as clinicians. New academics from health tend to hold onto their identity as clinicians rather than adopting their new persona as academics. Fear of losing credibility stems from the need to maintain competence for continued professional registration as clinicians. Further research is needed which focuses on midwives as the target sample to validate the research evidence from this scoping review.

An innovative behavioral health care curriculum: The integrated advanced practice addictions nursing subspecialty.

INTRODUCTION: There is a significant shortage of behavioral health providers trained in caring for patients with problematic substance use, particularly within integrated care settings. METHOD: An innovative addictions nursing subspecialty curriculum was designed by interdisciplinary faculty from psychiatric nursing, family nursing, counseling, and social work and informed by integrated care, addictions, and telehealth competencies. The subspecialty included prevention, treatment, and recovery approaches to care and encouraged enrollment of students from various health-related disciplines to enhance the students' experiences of integrated care for substance use treatment prior to completion of the program. RESULTS: Subspecialty courses increased the number of advanced practice nurses in the behavioral health care workforce with enhanced knowledge of integrated telehealth substance use treatment. DISCUSSION: Implementation of similar innovative curricula across health disciplines may significantly improve the care delivered to patients with problematic substance use in traditional medical settings. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Intestinal Failure: Epidemiology, Catheter-Related Sepsis and Challenges.

Background The Leicestershire intestinal failure team (LIFT) service provides specialist intestinal failure care to patients in Leicestershire and surrounding counties. Aims To study the epidemiology of intestinal failure (IF) cases referred to the service and review outcomes particularly the indications and delivery of parenteral nutrition (PN). To review catheter-related sepsis (CRS) rates and identify areas for improvement. Methods Service data from January 2016 to November 2017 was analysed retrospectively. Descriptive and inferential statistical analysis was carried out. Chi-square/Fisher Exact tests were used to identify significance on categorical data and non-parametric settling was used for qualitative data analysis. Results A total of 365 patients were referred to the service from January 2016 to November 2017. 58% patients had grade I intestinal failure. 34% and 24% referrals were made by the colorectal and hepato-pancreato-biliary (HPB) units, respectively. Gut rest (27%) and small bowel obstruction (25%) were the most common indications for nutritional support. Duration of PN requirements varied greatly, but most patients (39%) required it for up to seven days. Single lumen PICC line (64%) and cephalic vein (54%) were the most commonly used catheter and site of vascular access, respectively. Chronicity of IF and number of vascular catheters required to provide PN were significantly associated with rates of CRS. Conclusion CRS was found to be statistically significantly associated with chronic IF and number of vascular access catheters required to provide PN. Cost implication and morbidity of CRS could be analysed further to identify other ways to provide safer and cost-efficient parental nutrition for patients with intestinal failure.

Opportunities for Cancer Health Care Disparities and Care Delivery Research: An Analysis of the NCI Health Care Delivery Research Program Portfolio.

Cancer health care disparities are complex, involve patient, clinician and health care system factors, and are defined as adverse differences in cancer outcomes. This analysis describes NCI's Healthcare Delivery Research Program's (HDRP) portfolio of disparities-focused research and identifies future research opportunities. Grants through HDRP (fiscal years 2012 to 2016) focused on detecting, understanding, and/or intervening on disparities in or among health disparity populations were reviewed by co-authors. Forty-eight funded grants were identified, coded, and characterized. Descriptive analyses are reported. Most studies focused on racial/ethnic minorities and socioeconomically disadvantaged groups. Colorectal, breast, and cervical cancers were most frequently examined. Almost 40% of studies addressed the intervening phase of the disparities research continuum. Few studies focused on clinician-level factors or involved the community in the research design. A sustained disparities research emphasis is essential to addressing the determinants of and cancer burden among health disparity populations across the cancer care continuum.

DUSP9-mediated reduction of pERK1/2 supports cancer stem cell-like traits and promotes triple negative breast cancer.

Breast cancer remains a complex disease resulting in high mortality in women. A subset of cancer stem cell (CSC)-like cells expressing aldehyde dehydrogenase 1 (ALDH1) and SOX2/OCT4 are implicated in aggressive biology of specific subtypes of breast cancer. Targeting these populations in breast tumors remain challenging. We examined xenografts from three poorly studied triple negative (TN) breast cancer cells (MDA-MB-468, HCC70 and HCC1806) as well as HMLEHRASV12 for stem cell (SC)-specific proteins, proliferation pathways and dual-specific phosphatases (DUSPs) by quantitative real-time PCR (qRT-PCR), immunoblot analysis and immunohistochemistry. We found that pERK1/2 remained suppressed in TN xenografts examined at various stages of growth, while the levels of pp38 MAPK and pAKT was upregulated. We found that DUSP was involved in the suppression of pERK1/2, which was MEK1/2 independent. Our in vitro assays, using HMLEHRASV12 xenografts as a positive control, confirmed increased phosphatase activity that specifically influenced pERK1/2 but not pp38MAPK or pJNK levels. Family members of DUSPs examined, showed increase in DUSP9 expression in TN xenografts. Increased DUSP9 expression in xenografts was consistently associated with upregulation of SC-specific proteins, ALDH1 and SOX2/OCT4. HRAS driven HMLEHRASV12 xenografts as well as mammospheres from TN breast cancer cells showed inverse relationship between pERK1/2 and increased expression of DUSP9 and CSC traits. In addition, treatment in vitro, with MEK1/2 inhibitor, PD 98059, reduced pERK1/2 levels and increased DUSP9 and SC-specific proteins. Depletion of subsets of SOX2/OCT4 by fluorescence-activated cell sorting (FACS), as well as pharmacological and genetic reduction of DUSP9 levels influenced ALDH1 and SOX2/OCT4 expression and reduced mammosphere growth in vitro as well as tumor growth in vivo. Collectively our data support the possibility that DUSP9 contributed to stem cell-like cells that could influence TN breast tumor growth. Conclusion: Our study shows that subsets of TN breast cancers with MEK1/2 independent reduced pERK1/2 levels will respond less to MEK1/2 inhibitors, thereby questioning their therapeutic efficacy. Our study also demonstrates context-dependent DUSP9-mediated reduced pERK1/2 levels could influence stem cell-like traits in TN breast tumors. Therefore, targeting DUSP9 could be an attractive target for improved clinical outcome in a subset of basal-like breast cancers.

Referrals to the Glasgow sheriff court liaison scheme since the introduction of referral criteria.

This study is an audit of a court liaison scheme operating in Glasgow sheriff court. It represents a follow-on of previous work after the introduction of referral criteria to delineate more closely the appropriate population to be seen. Results were compared with the previous audit. The total number of referrals decreased by 66%, however, the proportion with a psychotic illness increased to 33%. A high referral rate of prisoners with addictions continued, although the service was not primarily designed for them. Fewer patients with no psychiatric diagnosis were referred to the scheme. Outcomes were, however, similar with approximately the same admission rate to hospital. The introduction of criteria appears to have reduced the numbers of inappropriate referrals without excluding the population with serious mental disorder. The introduction of referral criteria seems to have been beneficial to the scheme. The scheme has since changed again and so there may be benefit for a further audit to monitor the continuing appropriateness of referrals. The provision of specific interventions targeting prisoners with addictions is also supported by this audit.

Is faculty practice valuable? The experience of Western Australian nursing and midwifery academics undertaking faculty clinical practice - A discussion paper.

The faculty clinical practice model provides dedicated time for nursing lecturers and educators in a university school of nursing to work with supervision in the clinical environments for an agreed amount of time each year. Allowing academics to partake in faculty clinical practice this way has been shown to update skills and retain clinical competency. Some nursing and midwifery academics believe it is essential to remain clinically current and up-to-date with professional issues in the clinical environments, whereas other academics believe reading current research maintains clinical competency. This discussion paper will explore the authors' own experiences of faculty clinical practice as an opportunity to enhance their learning. Narrative accounts of time spent in the clinical areas being expressed as invaluable as it allowed the authors to become part of the health professional team, refine clinical skills, gain clinical confidence, and share knowledge. This, in turn, impacted upon the academic's teaching style as well as redefined it by introducing incidents and stories from their experience. It has been concluded by the authors that faculty clinical practice allows academics to increase confidence, encourage leadership skills, and improve their teaching abilities in their clinical area of expertise.

Patient and Family Caregivers' Experiences of Living With a Jejunostomy Feeding Tube After Surgery for Esophagogastric Cancer.

BACKGROUND: Jejunostomy feeding tubes (JFTs) can be used to provide nutrition support to patients who have had surgery for esophagogastric cancer. Although previous research reports how patients cope with a gastrostomy tube, little is known about the impact of having a JFT. The aim of this qualitative study was to explore how patients and their informal caregivers experience living with a JFT in the first months following surgery. METHODS: Participants were purposively sampled from a cohort of patients recruited to a trial investigating home enteral nutrition vs standard care after esophagogastric surgery for cancer. The sampling framework considered age, sex, and marital status. Informal caregivers were also invited to participate. Interviews were audio recorded, transcribed verbatim, and anonymized. Inductive thematic analysis was used to identify key themes related to living with a JFT. RESULTS: Fifteen patient interviews were conducted; 8 also included a family caregiver. Analysis of the data resulted in 2 main themes: "challenges" and "facilitators" when living with a JFT. While "physical effects," "worries" and "impact on routine" were the main challenges, "support," "adaptation" and "perceived benefit" were what motivated continuation of the intervention. CONCLUSION: Findings suggest that participants coped well with a JFT, describing high levels of compliance with stoma care and the feeding regimen. Nonetheless, disturbed sleep patterns and stoma-related problems proved troublesome. A better understanding of these practical challenges, from the patient and family caregiver perspective, should guide healthcare teams in providing proactive support to avoid preventable problems.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection.

BACKGROUND: Feeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. METHODS: Consecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009-2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. RESULTS: The study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6-8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. CONCLUSIONS: Small bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

Elimination of Cancer Health Disparities through the Acceleration of HPV Vaccines and Vaccinations: A Simplified Version of the President's Cancer Panel Report on HPV Vaccinations.

The human papillomavirus (HPV) is a major public health concern affecting both females and males. HPV is associated with cervical, anal, head and neck cancers. About 99% of all cervical cancers are related to HPV. HPV vaccines, Gardasil, Cervarix, and Gardasil 9 are used in the primary prevention of HPV related cancers. Gardasil and Gardasil 9 are available for use in both females and males ages 9 to 26, while Cervarix is available for females ages 9 to 25. Gardasil 9 was approved by the FDA for prevention against additional HPV types. Despite the availability of this preventative measure against cervical cancer, the rate of HPV vaccination in the United States remains lower than that of other industrialized nations. The purpose of this study is to elucidate mechanisms to help increase the HPV vaccination rate by using education as a tool; by simplifying the president report so that lay person can understand the information presented in the report. Through the quantitative examination of the data from the states with the lowest and highest vaccination rates, using SPSS statistical analysis; we analyzed several factors involved with the low uptake of the vaccines. The results collected show that socioeconomic status, misconceptions about HPV, and misconceptions about the safety of the vaccines were identified as possible obstacles to the effective uptake of HPV vaccinations. The proposals made by the President's Cancer Panel to accelerate the uptake of vaccines include, increasing coverage of the vaccines through government-sponsored programs, and the Affordable Care Act; increasing accessibility to vaccines through pharmacies, schools, and clinics; and disseminating more information on HPV to healthcare providers, parents, caregivers, and patients. Allowing greater accessibility to the vaccines for all populations regardless of income, education, and eliminating misconceptions of the vaccines would play a significant role in eliminating cancer.

A systematic review of the nutritional consequences of esophagectomy.

BACKGROUND & AIMS: As improved outcomes after esophagectomy have been observed over the last two decades, the focus on care has shifted to survivorship and quality of life. The aim of this review was to determine changes in nutrition after esophagectomy and to assess the evidence for extended nutrition support. METHODS: A search strategy was developed to identify primary research reporting change in nutritional status a minimum of one month after esophagectomy. RESULTS: Changes in nutritional parameters reported by 18 studies indicated a weight loss of 5-12% at six months postoperatively. More than half of patients lost >10% of body weight at 12 months. One study reported a persistent weight loss of 14% from baseline three years after surgery. Three studies reporting on longer term follow up noted that 27%-95% of patients failed to regain their baseline weight. Changes in dietary intake (three studies) indicated inadequate energy and protein intake up to three years after surgery. Global quality of life scores reported in one study correlated with better weight preservation. There were a high frequency of gastrointestinal symptoms reported in six studies, most notably in the first year after surgery, but persisting up to 19 years. Extended enteral nutrition on a selective basis has been reported in several studies. CONCLUSIONS: Nutritional status is compromised in the months/years following oesophagectomy and may never return to baseline levels. The causes/consequences of weight loss/impaired nutritional intake require further investigation. The role of extended nutritional support in this population remains unclear.

High-output stoma after small-bowel resections for Crohn's disease.

BACKGROUND: A 56-year-old Caucasian woman with a history of Crohn's disease and multiple bowel resections resulting in a loop jejunostomy was referred to our Nutritional Unit from a neighboring district general hospital for further management. She was first seen in October 2001, and initial assessment indicated that she was malnourished with fluid depletion, evidenced by the high volume of stomal fluid produced. There had been no sudden change in her medication, her Crohn's disease was quiescent and there was no evidence of any intra-abdominal sepsis. Despite a high calorific intake through her diet, she continued to lose weight. INVESTIGATIONS: Serum urea and electrolytes; magnesium; C-reactive protein; full blood count; urinary spot sodium; anthropometric measurements. DIAGNOSIS: High-output stoma with malabsorption as a consequence of repeated small-bowel surgery. MANAGEMENT: The patient was treated with oral hypotonic fluid restriction (0.5 l/day), 2 l of oral glucose-saline solution per day, high-dose oral antimotility agents (loperamide and codeine phosphate), a proton-pump inhibitor (omeprazole) and oral magnesium replacement. A year later, the patient's loop jejunostomy was closed and an end ileostomy fashioned, bringing an additional 35 cm of small bowel into continuity; macronutrient absorption improved but her problem of dehydration was only slightly reduced. She was stabilized on a twice-weekly subcutaneous magnesium and saline infusion and daily oral 1alpha-hydroxycholecalciferol.