Food for thought. Malnutrition risk associated with increased risk of healthcare-associated infection.

BACKGROUND: Infection and malnutrition are interconnected. UK and Irish guidelines recommend the Malnutrition Universal Screening Tool (MUST) for nutritional risk screening. Patients with a MUST score of ≥2 are considered at high risk of malnutrition and referral for nutritional assessment is recommended. AIM: To explore the association between healthcare-associated infection (HCAI) and the MUST score categories of patients. METHODS: This was a cross-sectional study in May 2017 on ten representative wards in our institution. Patient demographics, MUST score, presence of medical devices, HCAI and antimicrobial use were collected. FINDINGS: Of 240 patients, the HCAI prevalence was 10.4% (N = 25) and 26% (N = 63) were at high risk of malnutrition (MUST score ≥2). Patients with HCAI were more likely to have had surgery (odds ratio (OR): 5.5; confidence interval (CI): 2.1-14.3; P < 0.001), a central vascular catheter (OR: 10.0; CI: 3.6-27.2; P < 0.001), or a urinary catheter in situ (OR: 7.5; CI: 2.8-20.0; P < 0.001), and to have a high risk of malnutrition (OR: 4.3; CI: 1.7-11.2; P < 0.001). A higher MUST score remained a significant predictor of a patient having HCAI on multivariate regression analysis (CI: 0.2-0.6; P < 0.001). CONCLUSION: Patients at risk of malnutrition when assessed with the MUST were more likely to have HCAI. However, prospective studies are required to investigate the temporal association between MUST and HCAI and which interventions best address malnutrition risk and HCAI reduction in different settings.

Comparative outcomes of total parenteral nutrition use in patients aged greater or less than 80 years of age.

OBJECTIVES: Total-parenteral-nutrition (TPN) can act as a bridge to enteral nutrition. The current study aims to explore the outcomes of TPN use in older adults which are at present poorly defined. DESIGN, SETTING AND PARTICIPANTS: Data on 172 patients who received TPN between January-December 2011 were prospectively recorded and examined. RESULTS: Mean age was 62.7 ± 16.8 years (12.8% ≥ 80 years). Those ≥ 80 years were less often male (31.8% Vs 57.3%, P=0.038) and had no history of hepatic dysfunction (0.0% Vs 16.7%, P=0.025). In those ≥ 80 years the indication was more often suspected ileus (40.9% Vs 13.3%, P=0.004). Patients ≥ 80 years developed hypertriglyceridaemia less frequently (7.7% Vs 36.2%, P=0.031). There was no difference in the duration of TPN administration, the rate of TPN line sepsis, serum electrolyte derangement or glycaemic control. Change in serum albumin over the course of treatment did not differ (≥ 80 Vs <80 years, -0.28 ± 0.62 mg/dL Vs -2.00 ± 1.57 mg/dL, P=0.323). CONCLUSIONS: These data suggest TPN use is safe in patients aged ≥ 80 years and advanced age alone should not preclude TPN use.

Management of parenteral nutrition associated hyperglycaemia: a comparison of subcutaneous and intravenous insulin regimen.

PN is associated with significant hyperglycaemia, which may be detrimental to clinical outcome. There are few data on the management of this phenomenon outside of intensive care units. In our unit, we studied the efficacy of protocol-based intravenous insulin delivery as compared to subcutaneous insulin prescribed individually outside of the critical care setting. In a retrospective review over a two-year period, we compared patients with PN-associated hyperglycaemia who had received both modes of insulin therapy. A total of 122 who developed PN-associated hyperglycaemia were identified. Those on the intravenous insulin regimen were within glycaemic target for more time than those on the subcutaneous regimen (62% Vs 43%, p = 0.008). We therefore conclude that outside of the critical care setting, intravenous insulin delivers better glycaemic control and should therefore be considered optimum therapy for patients with PN-associated hyperglycaemia.

The esophagitis to adenocarcinoma sequence; the role of inflammation.

Esophageal adenocarcinoma (EAC) is the eighth most common cancer worldwide, and approximately 15% of patients survive 5years. Reflux disease (GERD) and Barrett's esophagus (BE) are major risk factors for the development of EAC, and epidemiologic studies highlight a strong association with obesity. The immune, inflammatory and intracellular signaling changes resulting from chronic inflammation of the esophageal squamous epithelium are increasingly well characterized. In GERD and Barrett's, an essential role for T-cells in the initiation of inflammation in the esophagus has been identified, and a balance between T-cell responses and phenotype may play an important role in disease progression. Obesity is a chronic low-grade inflammatory state, fueled by adipose tissue derived- inflammatory mediators such as IL-6, TNF-α and leptin, representing a novel area for targeted research. Additionally, reactive oxygen species (ROS) and receptor tyrosine kinase (RTK) activation may drive progression from esophagitis to EAC, and downstream signaling pathways employed by these molecules may be important. This review will explain the diverse range of mechanisms potentially driving and maintaining inflammation within the esophagus and explore both existing and future therapeutic strategies targeting the process.

An evaluation of the Cortrak Enteral access system in our intensive care.

Appropriate nutrition is considered a cornerstone of Intensive care; however its successful initiation is frequently impeded by decreased gastric emptying secondary to opiates, sepsis, or ileus. The presence of a postpyloric tube will guarantee delivery of calories while reducing the incidence of reflux and aspiration. Enteral nutrition is approximately 100 fold cheaper than parenteral nutrition. A nasojejunal tube may be placed blindly (success 15%), by direct vision with a gastroscope, or under fluoroscopic guidance in the X-ray department. This study examines the use of the Cortrak Enteral access system (CEAS) in placement of nasojejunal tubes, a method facilitated by the use of an electromagnet. A retrospective review was conducted to evaluate the effectiveness of the CEAS for establishing nasojejunal feeding in the Intensive Care Unit (ICU) between January and December 2010. Our results found that the CEAS was successful in positioning a nasojejunal tube in ten out of twelve patients (83% success rate). Successful placement was confirmed by portable abdominal / chest x-ray. Placement took an average of 30 minutes, and prokinetic agents were used to facilitate two placements. The duration of successful enteral nutrition varied from 2 to 15 days post placement. The CEAS is a simple bedside tool for placing postpyloric tubes. While there is a learning curve associated with its use, it may confer significant benefits to individual patients and also to those responsible for ever shrinking budgets.

Primary care anticoagulant management using near patient testing.

BACKGROUND: Indications for anticoagulant treatment are increasing and new approaches to anticoagulant services require a shift from hospital to primary care. AIM: To pragmatically test the validity and effectiveness of primary care anticoagulant management using near patient testing. METHODS: Twelve CoaguCheck monitors were supplied to 16 rural practices that had previously provided supervision of anticoagulant therapy. Practices were required to record data for eligible patients from September 1998 to April 1999 and to forward one blood sample per week to the regional hospital laboratory for parallel testing. RESULTS: Nine practices returned data on 122 patients. Indications for anticoagulation Included atrial fibrillation (n = 56), valve replacement (n = 12) and deep venous thrombosis or pulmonary embolus (n=12). Regression of the mean of 185 paired readings against their difference confirmed the validity of the CoaguCheck monitor (r2 = 0.00 [95% CI -0.38 to 0.38]). There were 692 International Normalised Ratio (INR) tests performed representing an average of 5.7 tests per patient. The desired therapeutic range was provided for 609 (88%) of these tests; 294 (48.3%) were within the desired therapeutic range. Results differed significantly between practices. CONCLUSIONS: This study confirmed the validity of anticoagulant management using the CoaguCheck monitor in primary care.