Attitudes towards and knowledge of nutrition support amongst health care professionals on London intensive care units.

BACKGROUND: Nutrition support on intensive care units (ICUs) has gained a higher profile ever since the development of published guidelines (Clin. Nutr. 2006, 25, 210; J. Parenter. Enteral Nutr. 2009, 33, 277; http://www.nice.org.uk/Guidance/CG32; Clin. Nutr. 2009, 28, 387). However, there are limited data available on knowledge and attitudes towards nutrition support specific to ICU. METHODS: An online survey was sent to all healthcare professionals working on ICUs across London via an e-mail link. The aim of the study was to assess the knowledge base of and attitudes of staff towards nutrition support, within an ICU setting, and to understand their educational needs. The results were analysed using descriptive statistics. RESULTS: Attitudes were in line with the evidence in current nutrition guidelines. The proportion of healthcare professionals who were regarded as demonstrating sufficient understanding of the evidence set out in the nutrition support guidelines were 44% of clinicians, 26% of nurses, 76% of dietitians and 67% of other staff. In total, 59% of staff wanted more education on a number of aspects related to nutrition support on ICU. CONCLUSIONS: The present study highlights the need for more prominent dissemination of the current guidelines and illustrates the preferred mode. Specific gaps in knowledge regarding energy intake and the use of parenteral feeding are highlighted. It is hoped that the present survey will help to guide education in this area.

Clinical trial: Efficacy of a low or modified fat diet for the prevention of gastrointestinal toxicity in patients receiving radiotherapy treatment for pelvic malignancies.

BACKGROUND: Inflammatory responses to pelvic radiotherapy can result in severe changes to normal gastrointestinal function with potentially severe long-term effects. Reduced or modified fat diets may confer benefit. METHODS: This randomised controlled trial recruited patients with gynaecological, urological or lower gastrointestinal malignancy due to receive radical radiotherapy. Patients were randomised to a low fat (20% total energy from long chain triglycerides), modified fat (20% from long chain triglycerides and 20% from medium chain triglycerides) or normal fat diet (40% total energy from long chain triglycerides). The primary outcome was a difference in change in Inflammatory Bowel Disease Questionnaire--Bowel (IBDQ-B) score, from the start to end of radiotherapy. RESULTS: A total of 117 patients with pelvic tumours (48% urological; 32% gastrointestinal; 20% gynaecological), with mean (SD) age: 65 (11.0) years, male:female ratio: 79:38, were randomised. The mean (SE) fall in paired IBDQ-B score was -7.3 (0.9) points, indicating a worsening toxicity. Differences between groups were not significant: P = 0.914 (low versus modified fat), P = 0.793 (low versus normal fat) and P = 0.890 (modified versus normal fat). The difference in fat intake between low and normal fat groups was 29.5 g [1109 kJ (265 kcal)] amounting to 11% (of total energy intake) compared to the planned 20% differential. Full compliance with fat prescription was only 9% in the normal fat group compared to 93% in the low fat group. CONCLUSIONS: A low or modified fat diet during pelvic radiotherapy did not improve gastrointestinal symptom scores compared to a normal fat intake. An inadequate differential in fat intake between the groups may have confounded the results.

Intensity-modulated Radiotherapy and Anal Cancer: Clinical Outcome and Late Toxicity Assessment.

AIMS: To assess the potential impact on long-term consequences of treatment (intensity-modulated radiotherapy with concomitant chemotherapy) in patients diagnosed with anal cancer. MATERIALS AND METHODS: We identified 43 eligible patients treated with concomitant chemoradiotherapy (pelvic intensity-modulated radiotherapy) at the Royal Marsden Hospital between 2010 and 2013. We determined late genitalia and bowel side-effects using specific questionnaires [Pelvic Symptom Questionnaire, Vaizey Incontinence Questionnaire, Inflammatory Bowel Disease Questionnaire (IBDQ) and IBDQ-B]. Using descriptive statistics, we report clinical outcomes in all patients, by time, since the end of treatment (grouped as 1-1.5, 1.5-2.5 and 2.5-3.5 years). RESULTS: Twenty-seven of 43 (63%) patients were identified as available for questionnaire follow-up. Reasons for unavailability were death (n = 3), lost to palliative care service (n = 1), referred to surgery (n = 4), lost to follow-up (n = 8). In the 27 patients studied, bowel toxicity was assessed by IBDQ, IBDQ-B and the Vaizey Incontinence Questionnaire. The median value was 208 for IBDQ, 38 for IBDQ-B and 3.0 for the Vaizey Incontinence Questionnaire, as assessed at 1 year or more post-completion of treatment. Treatment was reported to affect quality of life/sexual function in two of the female patients (n = 21) and three male patients (n = 6). No insufficiency fractures have been reported. Bone marrow function remained stable over the time of the follow-up. CONCLUSIONS: Although there are data supporting a reduction in acute effects using intensity-modulated radiotherapy in anal cancer, there is very little in the literature to establish the late toxicity profile. Our results indicate that there is an effect on bowel and sexual function, but it does not increase over the period observed. These data provide a benchmark against which to compare outcomes with future manipulation in treatment, and provide us with real information to give patients as to the expectation of their functional outcome after treatment.

Systematic review: the efficacy of nutritional interventions to counteract acute gastrointestinal toxicity during therapeutic pelvic radiotherapy.

BACKGROUND: Radiotherapy-induced damage to noncancerous gastrointestinal mucosa has effects on secretory and absorptive functions and can interfere with normal gastrointestinal physiology. Nutrient absorption and digestion may be compromised. Dietary manipulation is an attractive option for the prevention and management of symptoms. AIM: To synthesise the evidence for the use of elemental formula low- or modified-fat diets, fibre, lactose restriction and probiotics, prebiotics and synbiotics to protect the gastrointestinal tract during pelvic radiotherapy. METHODS: Four electronic databases were searched. Randomised controlled trials (RCT), controlled trials (CT) and case series in adult patients receiving radiotherapy for pelvic cancers employing nutritional interventions to reduce gastrointestinal toxicity were included. Methodological quality was assessed using a bespoke tool. RESULTS: Twenty-two original studies (2446 patients) were identified. Study quality was highly variable with only 37% scoring ≥10 points (maximum 17: bespoke scale). Few studies assessed compliance with the intervention. End-points varied and included symptom scales (IBDQ, CTC, Bristol Stool and RTOG). Evidence from RCTs was weak for elemental, low- or modified-fat, fibre and low-lactose interventions with 1/4, 3/4, 1/2, 0/1 trials respectively reporting favourable outcomes. Evidence for probiotics as prophylactic interventions was more promising (4/5 favourable), but dose, strains and methodologies varied. CONCLUSIONS: There is insufficient high-grade evidence to recommend nutritional intervention during pelvic radiotherapy. Total replacement of diet with elemental formula may be appropriate in severe toxicity. Probiotics offer promise, but cannot be introduced into clinical practice without rigorous safety analysis, not least in immunocompromised patients. The methodological quality of nutritional intervention studies needs to be improved.

Systematic review: the prevalence of idiopathic bile acid malabsorption as diagnosed by SeHCAT scanning in patients with diarrhoea-predominant irritable bowel syndrome.

BACKGROUND: Recurrent, watery diarrhoea affects one-third of patients diagnosed with irritable bowel syndrome ('IBS-D'). Idiopathic bile acid malabsorption ('I-BAM') may be the cause. AIM: To determine the prevalence of I-BAM in patients suffering from IBS-D. METHODS: A systematic search was performed of publications reporting patients presenting with IBS-D type symptoms, who were subsequently confirmed as having I-BAM by SeHCAT scanning. RESULTS: Eighteen relevant studies, 15 prospective, comprising 1223 patients were identified. Five studies (429 patients) indicated that 10% (CI: 7-13) patients had severe bile acid malabsorption (SeHCAT 7 day retention <5% of baseline value). 17 studies (1073 patients) indicated that 32% (CI: 29-35) patients had moderate bile acid malabsorption (SeHCAT <10%). 7 studies (618 patients) indicated that 26% (CI: 23-30) patients had mild (SeHCAT <15%) bile acid malabsorption. Pooled data from 15 studies showed a dose-response relationship according to severity of malabsorption to treatment with a bile acid binder: response to colestyramine occurred in 96% of patients with <5% retention, 80% at <10% retention and 70% at <15% retention. CONCLUSIONS: Idiopathic adult-onset bile acid malabsorption is not rare. International guidelines for the management of irritable bowel syndrome need to be revised so that clinicians become more aware of this possibility.

Small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy: An observational study.

INTRODUCTION: Loose stool affects up to 80% of all patients during pelvic radiotherapy and faecal incontinence may occur. Several causes for diarrhoea have been defined, though few oncologists target these causes in affected patients and most treat symptomatically only. It is not known whether small bowel bacterial overgrowth, a frequent cause of gastrointestinal symptoms in other contexts, occurs during radiotherapy. The frequency of new-onset lactose intolerance during pelvic radiotherapy is also not clear. AIMS AND METHODS: To perform an observational pilot study to estimate the incidence of small bowel bacterial overgrowth and lactose intolerance during radical pelvic radiotherapy. Before treatment started and at weeks 4-5 of pelvic radiotherapy, a glucose hydrogen breath test and lactose tolerance test were performed. Gastrointestinal symptoms were assessed using the Vaizey incontinence questionnaire and the Radiation Therapy Oncology Group scoring system. RESULTS: Twenty two men and 17 women (median age 61, range 42-81) were recruited, four were treated for gastrointestinal, 17 were treated for gynaecological and 18 for urological cancers. Thirty-eight patients underwent glucose hydrogen breath tests and 26 patients underwent lactose breath tests at both time points. Ten patients (26%) were positive for the glucose hydrogen breath test: 60% of these developed new or worsening faecal incontinence during treatment and 60% had worsening bowel frequency. Four patients (15%) developed lactose intolerance. Of these 1 developed worsening faecal incontinence during treatment, 2 (50%) developed new-onset increase in bowel frequency or a change in the quality of bowel habit. CONCLUSION: Small bowel bacterial overgrowth and lactose intolerance may occur during radical pelvic radiotherapy and are likely to contribute to gastrointestinal symptoms in some patients.

Can biological markers act as non-invasive, sensitive indicators of radiation-induced effects in the gastrointestinal mucosa?

BACKGROUND: Reliable, non-invasive biological markers of the severity of radiotherapy-induced damage to the gastrointestinal tract are not available. Clinicians continue to use symptom scores as surrogate indicators of toxicity. AIM: To determine whether levels of potential biochemical markers of mucosal toxicity change during pelvic radiotherapy. METHODS: Fifty-nine patients (30:29 males:females) with mixed pelvic malignancies, receiving 45-70 Gy were recruited. At baseline and weeks 4 or 5 of radiotherapy, blood samples for citrulline, C-reactive protein, eosinophil cationic protein and stool samples for faecal calprotectin were obtained. Symptoms were measured using the Inflammatory Bowel Disease Questionnaire - Bowel Subset, Radiation Therapy Oncology Group and Vaizey Incontinence Questionnaires. Paired t-tests of change in marker values were calculated. RESULTS: Citrulline (P = 0.02) and faecal calprotectin (P = 0.01) values changed significantly between baseline and 4/5 weeks. Inflammatory Bowel Disease Questionnaire - Bowel Subset fell significantly (mean fall = 10 points, s.d.: 8.9). Changes in markers did not correlate with symptoms. CONCLUSIONS: Some biochemical markers of mucosal toxicity change significantly during treatment. Further studies must investigate the timing of changes of these biochemical markers, their relationship to gastrointestinal physiological change and the radiotherapy dose delivered to the gastrointestinal tract and whether changes in markers acutely can predict the degree of long-term gastrointestinal dysfunction.

Clinical trial: normal diet vs. partial replacement with oral E028 formula for the prevention of gastrointestinal toxicity in cancer patients undergoing pelvic radiotherapy.

BACKGROUND: Acute gastrointestinal symptoms affect 90% of patients during pelvic radiotherapy. Elemental diet is protective in animal models. A nonrandomized study suggested benefit from a partial elemental diet. A pilot study suggested that radiotherapy patients only tolerate oral elemental diet comprising one-third of total calories for 3 weeks. AIM: To assess the feasibility and efficacy of replacing one-third of normal diet with elemental diet during the first 3 weeks of pelvic radiotherapy in reducing acute gastrointestinal toxicity. METHODS: Patients were randomized to elemental diet or no intervention. Toxicity was assessed using the Inflammatory Bowel Disease Questionnaire, Vaizey Incontinence scale and Radiation Therapy Oncology Group tool. Faecal calprotectin measured intestinal mucosal inflammation. RESULTS: Twenty-nine women and 21 men, median age 61.5 years were randomized. Patients taking elemental diet did not have lower gastrointestinal toxicity ratings or inflammatory markers (P > 0.2). The mean dose taken was 21% (2-36%) of total caloric requirements. CONCLUSIONS: Patients cannot tolerate large volumes of oral elemental diet. The quantities consumed in this study produced no therapeutic benefit. Future studies should aim to replace a higher proportion of nutritional intake for a longer duration of radiotherapy treatment.