Comparison of prebiotic candidates in ulcerative colitis using an in vitro fermentation model.

AIMS: This study explored the effect of three different prebiotics, the human milk oligosaccharide 2'-fucosyllactose (2'-FL), an oligofructose-enriched inulin (fructo-oligosaccharide, or FOS), and a galacto-oligosaccaride (GOS) mixture, on the faecal microbiota from patients with ulcerative colitis (UC) using in vitro batch culture fermentation models. Changes in bacterial groups and short-chain fatty acid (SCFA) production were compared. METHODS AND RESULTS: In vitro pH controlled batch culture fermentation was carried out over 48 h on samples from three healthy controls and three patients with active UC. Four vessels were run, one negative control and one for each of the prebiotic substrates. Bacterial enumeration was carried out using fluorescence in situ hybridization with flow cytometry. SCFA quantification was performed using gas chromatography mass spectrometry. All substrates had a positive effect on the gut microbiota and led to significant increases in total SCFA and propionate concentrations at 48 h. 2'-FL was the only substrate to significantly increase acetate and led to the greatest increase in total SCFA concentration at 48 h. 2'-FL best suppressed Desulfovibrio spp., a pathogen associated with UC. CONCLUSIONS: 2'FL, FOS, and GOS all significantly improved the gut microbiota in this in vitro study and also led to increased SCFA.

Obesity: a window of opportunity to intervene? Characteristics and management of morbidly obese adult inpatients in three trusts in Southern England.

Obesity affects 22% of men and 24% of women over the age of 16 years in the general population of the UK and is associated with multiple comorbidities. Little is known about the magnitude of the obesity problem among hospitalised adults and, although significant focus has been given to the identification and treatment of the malnourished inpatient, it is not known to what extent obese inpatients are equally -targeted. National guidelines for consideration of bariatric surgery exist, but it is not known to what extent potentially eligible individuals are referred. This multi-centre study -demonstrates a significant burden of obesity (defined as body mass index [BMI] ≥30 kg/m(2)) among those in hospital, affecting 22% of patients. This was more marked among orthopaedic patients and all-comers to intensive care units than on medical or surgical wards. Of those with BMI ≥35 kg/m(2), only 21% had been reviewed by dietetics and only 10% of patients who were potentially eligible for bariatric surgery had been referred to bariatric services. This study shows that there is an opportunity to recognise obesity and intervene in its management during hospital admission.

A review on the use of prebiotics in ulcerative colitis.

The gut microbiome in the inflammatory bowel disease, ulcerative colitis (UC), is different to that of healthy controls. Patients with UC have relative reductions in abundance of Firmicutes and Bifidobacterium in the colon, and an increase in sulfate-reducing bacteria. Prebiotics are dietary substrates which are selectively metabolised by the human colonic microbiota to confer health benefits to the host. This review explores our current understanding of the potential benefits of prebiotics on various clinical, biochemical, and microbiological endpoints in UC, including new perspectives gained from recent studies in the field. This review looks to the future and highlights the need for appropriately designed trials to explore this potentially exciting new avenue for the treatment of UC.

Refeeding risks in patients requiring intravenous nutrition support: Results of a two-centre, prospective, double-blind, randomised controlled trial.

BACKGROUND/AIMS: Refeeding syndrome can result following excessive feeding of malnourished patients. The syndrome remains poorly defined but encompasses a range of adverse effects including electrolyte shifts, hyperglycaemia and other less well-defined phenomena. There are additional risks of underfeeding malnourished individuals. Studies of refeeding syndrome have generally focussed on critical care environments or patients with anorexia nervosa. Here we have conducted a two-centre, prospective, double-blind, randomised controlled trial amongst all patients referred to hospital nutrition support teams for intravenous nutrition support. We sought to determine whether electrolyte and other abnormalities suggestive of refeeding syndrome risk varied depending on initial rate of intravenous feeding. METHODS: Patients at moderate or high risk of refeeding syndrome, as defined by United Kingdom National Institute of Health and Care Excellence guidelines, were screened for inclusion. Patients were randomised to receive either high (30 kcal/kg/day, 0.25 gN/kg/day) or low (15 kcal/day, 0.125 gN/kg/day) rate feeding for the first 48 h prior to escalation to standard parenteral nutrition regimens. The primary outcome was rates of potential refeeding risks within the first 7 days as defined by electrolyte imbalance or hyperglycaemia requiring insulin. Secondary outcomes included effects on QTc interval, infections and length of hospital stay. Statistical analysis was performed with χ2 or Wilcoxon rank sum tests and all analysis was intention-to-treat. Problems with study recruitment led to premature termination of the trial. Registered on the EU Clinical Trials Register (EudraCT number 2007-005547-17). RESULTS: 534 patients were screened and 104 randomised to either high or low rate feeding based on risk of refeeding syndrome. Seven patients were withdrawn prior to collection of baseline demographics and were excluded from analysis. 48 patients were analysed for the primary outcome with potential refeeding risks identified in 46%. No differences in risks were seen between high and low rate feeding (p > 0.99) or high and moderate risk feeding (p = 0.68). There were no differences in QTc abnormalities, infection rates, or hospital length of stay between groups. CONCLUSIONS: In this randomised trial of rates of refeeding risk, in patients pre-stratified as being at high or moderate risk, we found no evidence of increased refeeding related disturbances in those commenced on high rate feeding compared to low rate. No differences were seen in secondary endpoints including cardiac rhythm analysis, infections or length of stay. Our study reflects real world experience of patients referred for nutrition support and highlights challenges encountered when conducting clinical nutrition research.

Supporting people who have eating and drinking difficulties.

Eating and drinking are essential for maintenance of nutrition and hydration, but are also important for pleasure and social interactions. The ability to eat and drink hinges on a complex and coordinated system, resulting in significant potential for things to go wrong.The Royal College of Physicians (RCP) has published updated guidance on how to support people who have eating and drinking difficulties, particularly towards the end of life.Decisions about nutrition and hydration and when to start, continue or stop treatment are some of the most challenging to make in medical practice. The newly updated guidance aims to support healthcare professionals to work together with patients, their families and carers to make decisions around nutrition and hydration that are in the best interests of the patient. It covers the factors affecting our ability to eat and drink, strategies to support oral nutrition and hydration, techniques of clinically-assisted nutrition and hydration, and the legal and ethical framework to guide decisions about giving and withholding treatment, emphasising the two key concepts of capacity and best interests.This article aims to provide an executive summary of the guidance.

Refeeding syndrome : physiological background and practical management.

Refeeding problems have been recognised since the the liberation of starved communities under siege. The main clinical problems may relate to hypophosphataemia, hypomagnesaemia and hypokalaemia with a risk of sudden death; thiamine deficiency with the risk of Wernike's encephalopathy/Korsakoff psychosis and sodium/water retention. The problems are greatest with oral/enteral feeding and especially with carbohydrate due to it increasing plasma insulin and thus glucose entry into cells. It is difficult to predict patients at risk of refeeding problems so there must be a high clinical suspicion on refeeding any malnourished patient (including any who have had no or very little nutrition for over 5 days). Generous vitamin and electrolyte supplementation may be given while monitoring closely and increasing the calorie intake reasonably rapidly from 10 to 20 kcal/kg/24 hours. Often patients in this category are not hungry, but over the course of a few days, the restoration of their appetite is an indication that the risks of refeeding have been managed and it is now safe to increase the feed aiming for repletion. If problems do occur, the feed should be slowed to the previous day's amount, reduced further or rarely stopped while fluid and electrolyte issues are corrected.

Metabolic acidosis in short bowel syndrome: think D-lactic acid acidosis.

Short bowel syndrome (SBS) is a condition when a person's gastrointestinal function is insufficient to supply the body with essential nutrients and hydration. Patients with SBS suffer from diarrhoea and symptoms of malabsorption such as weight loss, electrolyte disturbances and vitamin deficiencies. Long-term management of this condition can be complicated by the underlying disease, the abnormal bowel function and issues related to treatment like administration of parenteral nutrition and the use of a central venous catheter. Here, we describe a case of D-lactic acid acidosis, a rarer complication of SBS, presenting with generalised weakness and severe metabolic acidosis.

Pyoderma gangrenosum as a first presentation of inflammatory bowel disease.

Up to 40% of patients with inflammatory bowel disease (IBD) develop an extraintestinal manifestation of the disease with the skin being the most commonly involved organ. Pyoderma gangrenosum (PG), an autoinflammatory non-infectious neutrophilic dermatosis, occurs in 1-2% of patients with IBD. PG can follow a course independent to that of the bowel disease, however, most reported cases describe PG occurring in patients with an established diagnosis of IBD. We present a case of a young patient who presented with axillary skin ulceration, which was subsequently diagnosed as PG. On further investigation for a possible underlying cause, she was found to have Crohn's disease. She had not developed any preceding change in her bowels and did not have abdominal pain; the IBD was diagnosed on endoscopic findings. This case is also unusual for the distribution of the PG lesions that typically occur in the lower limbs.

Mesenteric vein thrombosis; not going with the flow.

A 71-year-old woman presented with a 2-week history of epigastric pain, nausea and vomiting; on examination she demonstrated signs of peritonism. CT imaging was performed and this demonstrated extensive thrombosis of the superior mesenteric, omental and portal veins with infarction of the distal small bowel. A non-operative approach was initiated and anticoagulation rapidly started. Within 48 h the patient demonstrated significant clinical improvement and she subsequently made a full recovery.

Chronic radiation enteritis and malnutrition.

Radiation enteritis is defined as the loss of absorptive capacity of the intestine following irradiation, which is most commonly seen after radiotherapy for pelvic and abdominal malignancies. It is divided into acute and chronic forms and usually presents with diarrhea and malabsorption. Malnutrition is a common complication of chronic radiation enteritis (CRE). We reviewed the etiology, prevalence, symptoms, diagnosis and management of CRE and CRE with malnutrition in this article. Functional short bowel syndrome as a cause of malnutrition in CRE is also considered. The diagnostic work-up includes serum markers, endoscopy, cross-sectional imaging and the exclusion of alternative diagnoses such as recurrent malignancy. Management options of CRE include dietary manipulation, anti-motility agents, electrolyte correction, probiotics, parenteral nutrition, surgical resection and small bowel transplantation. Treatment may also be required for coexisting conditions including vitamin B12 deficiency, bile acid malabsorption and depression.

Efficacy of nasal bridles in avoiding percutaneous endoscopic gastrostomy placement.

OBJECTIVE: The aim of the study was to report the use of nasogastric tube bridles to avoid dislodging of percutaneous endoscopic gastrostomy tubes. Specifically it was intended to see if they reduced feeding time, medical input and costs. DESIGN: and setting This was a cohort study in a district hospital setting. PATIENTS: 164 patients admitted with conditions causing acutely impaired swallowing. INTERVENTIONS: 140 of 164 patients referred received a NGT bridle. RESULTS: Of these, 49 (35%) died by 28 days and 68 (48.6%) at 1 year; 73 (52.1%) had regained adequate oral intake at 28 days and 27 (19.2%) had proceeded to PEG. Of those not bridled, nine (37.5%) died by 28 days and 10 (41.7%) at 1 year with the remainder eating. There was no significant difference in mortality between groups. There were no complications attributed to bridles. CONCLUSION: We conclude that nasogastric bridles are safe and represent an appropriate method to maintain nutrition while seeing if the underlying disease process will stabilise in these critically ill patients. They have the benefits of avoiding unnecessary PEG and the associated complications and cost.

MARSIPAN and the deadly triad: management of malnourished patients.

A 44-year-old gentleman was admitted with a deliberate overdose of olanzapine, paracetamol and bisoprolol. On admission, he was hypothermic, bradycardic and hypotensive and his body mass index was 12 kg/m(2). Problems identified on admission included polypharmacy overdose, risk of refeeding syndrome and sepsis. Despite careful reintroduction of feeding and generous electrolyte replacement, he developed persistent hypophosphataemia, hypokalaemia and a marked transaminitis. Several days later, he was noted to be hypothermic and hypoglycaemic. No increase in white cell count or C reactive protein was noted and his clinical appearance was otherwise unremarkable. Nevertheless, given these signs he was started on broad spectrum antibiotics for possible sepsis, which was subsequently confirmed on chest radiograph in addition to a further finding of likely aspergilloma on a later chest CT. His metabolic function stabilised after 3 weeks of carefully titrated nutrition and the sepsis responded to antibiotics and antifungal therapy.

Tight glucose control in intensive care units: an update with an emphasis on nutritional issues.

PURPOSE OF REVIEW: Tight glucose control in ICU patients is now regarded as a goal of successful care. Some challenge this on the basis that it produces no benefit and may cause harm. We review the recent literature with an emphasis on nutritional aspects. RECENT FINDINGS: Since 2001, several randomized controlled trials have examined the effect of tight glucose control in ICU patients, but only one showed an overall survival benefit. Glucose potassium insulin infusions have also produced variable results, and sometimes cause falls in plasma phosphate with potential consequences. Several studies have shown tight glucose control is labour-intensive and increases the incidence of hypoglycaemia, which could have profound effects, especially if cerebral perfusion is poor. Nutritional intake during tight glucose control has generally been poorly defined. Unintentional cessation of nutrition has been identified as a risk factor for hypoglycaemia. No difference in glucose control has been found between parenteral and enteral feeding. SUMMARY: Without knowledge of nutrition provision in terms of carbohydrate, total energy intake and route of administration, some studies are difficult to interpret. It is currently difficult to recommend routine use of tight glucose control in the ICU. Many clinicians have adopted regimes to control glucose between 5.0-9.0 mmol/l.

Unexpectedly high incidence of indigenous acute hepatitis E within South Hampshire: time for routine testing?

Hepatitis E indigenous to developed countries (hepatitis EIDC) is a form of hepatitis E in persons with no travel history to highly endemic areas. It has been recognized recently as an emerging clinical entity in a significant number of economically developed countries including UK. However, it is still perceived as a rare disease and routine laboratory testing for hepatitis E is not performed. A series of 13 cases of hepatitis EIDC, diagnosed in a 13-month period from June 2005 within a single center in South Hampshire, UK, is presented. These patients were identified after implementing a novel-screening algorithm that introduced routine hepatitis E serological investigations. Patients were middle aged or elderly and males were affected more commonly. Four patients (31%) required hospital admission. All reverse transcriptase-polymerase chain reaction (RT-PCR) confirmed cases carried hepatitis E virus (HEV) genotype-3, which bore close sequence homology to HEV circulating in UK pigs. None of these patients recalled eating undercooked pork products or close contact with pigs during the 2 months preceding the onset of acute hepatitis. In comparison, during the same period, only two cases of hepatitis A and five cases of acute hepatitis B were diagnosed. These data illustrate the importance of introducing routine hepatitis E testing in all patients with unexplained acute liver disease and absence of relevant travel history. Routine testing can clarify hepatitis E epidemiology whilst improving the clinical management of patients with acute liver disease.