Prevalence of vitamin D deficiency and modifiable risk factors in patients with Crohn's disease: A prospective observational study.

AIMS: To determine the prevalence of vitamin D deficiency in adults with Crohn's Disease (CD) in Birmingham, UK (latitude 52.4°N, -1.9°E) and identify modifiable risk factors. DESIGN/METHOD: A nurse-led, single-centre, prospective study was conducted over 5 months in 2019 and 2020 in outpatients with CD, at a tertiary referral hospital in Birmingham UK. Vitamin D (25OHD) levels were measured at a single timepoint by a dried blood spot sample. Modifiable risk factor data were collected including intake of vitamin D-containing foods, use of vitamin D supplements, sun exposure and current smoking. RESULTS: Total 150 participants (53.3% male, 79.3% white British). Vitamin D deficiency (25OHD <50 nmol/L) was found in 53.3%. 32.7% of participants took over-the-counter vitamin D supplements and 20.7% used prescribed supplements. We found that diets were generally poor in relation to vitamin D-rich foods. In terms of sun exposure, few (18%) had visited a sunny country recently, and few (6%) covered their whole body with clothing. Most used High Sun Protection Factor (80%) with a median grade of SPF 45. CONCLUSION: Patients with CD are at high risk of vitamin D deficiency as defined by 25OHD < 50 nmol/L, with the prevalence of deficiency being highest during the winter months. Patients with CD in the UK are unlikely to maintain vitamin D levels from sunlight exposure, dietary sources or over-the-counter supplements. IMPACT: Patients with Crohn's Disease are at high risk of developing vitamin D deficiency but there is little data from the UK at this latitude. We demonstrate the prevalence and severity of vitamin D deficiency in people with Crohn's Disease in the UK. The prevalence of vitamin D deficiency in this group is high and warrants monitoring by nurses and clinical teams. Nurses and clinical teams should consider strategies for vitamin D supplementation in patients with Crohn's Disease.

Frequency dependence of the ultrasonic power reflected from the water-tissue interface of human cancellous bone in vitro.

Numerous studies have performed in vitro ultrasonic measurements of cancellous bone in water to develop techniques for ultrasonic bone assessment. Because cancellous bone is a highly porous medium, ultrasonic reflections at the water-bone interface may be frequency dependent. The goal of this study was to investigate the effect of porosity on the frequency dependence of the reflected power. Ultrasonic measurements were performed in a water tank at room temperature on 15 specimens of cancellous bone prepared from the proximal end of 9 human femurs using single element, broadband transducers with center frequencies of 3.5, 5, 7.5, and 10 MHz. Power spectra of pulses reflected from the water-specimen interface were corrected for the frequency response of the measurement system to obtain the reflected power in decibels RdB(f). To suppress random phase cancellation effects, RdB(f) was averaged over multiple sites on multiple specimens. A frequency dependence of RdB(f) was observed in the 2.6-10 MHz range. The frequency dependence was moderate, with a maximum change of less than 6 dB over the entire frequency range. RdB(f) was greatest for low porosity specimens. The frequency averaged intensity reflection coefficient ranged from 7.4 × 10-4 to 7.8 × 10-3 for high and low porosity specimen groups, respectively.

Vitamin A deficiency: experience from a tertiary referral UK hospital; not just a low- and middle-income country issue.

OBJECTIVE: Vitamin A (VA) deficiency, more common in low- and middle-income countries (LMIC) secondary to malnutrition, is associated with increased morbidity and mortality. The prevalence and impact of VA deficiency in high-income countries (HIC) where chronic conditions may predispose is less well understood. DESIGN: Interpretation of serum retinol may be affected by inflammation, so C-reactive protein (CRP) levels were sought. Binary logistic regression and generalised estimating equations were performed to review the relationship between CRP and VA. SETTING: We examined the scale of low and deficient VA status in our tertiary University Teaching Hospital (HIC). PARTICIPANTS: Patients undergoing serum retinol concentrations 2012-2016 were identified from laboratory records, and records examined. RESULTS: Totally, 628 assays were requested, with eighty-two patients VA low (0·7-0·99 Umol/l) or deficient (<0·7 Umol/l). Sixteen patients were symptomatic (fifteen deficient), predominantly visual. Only one symptomatic patient's VA deficiency was secondary to poor intake. Other symptomatic patients had chronic illnesses resulting in malabsorption. The incidence of a low VA level increases significantly with a raised CRP. CONCLUSION: The majority of patients tested either were replete or likely to have abnormal VA levels due to concomitant inflammation. A minority of patients had signs and symptoms of VA deficiency and was a cause of significant morbidity, but aetiology differs from LMIC, overwhelmingly malabsorption, most commonly secondary to surgery or hepatobiliary disease. A correlation between inflammation and low VA levels exists, which raises the possibility that requesting a VA level in an asymptomatic patient with active inflammation may be of questionable benefit.

Intravenous supplementation type and volume are associated with 1-year outcome and major complications in patients with chronic intestinal failure.

BACKGROUND AND AIM: No marker to categorise the severity of chronic intestinal failure (CIF) has been developed. A 1-year international survey was carried out to investigate whether the European Society for Clinical Nutrition and Metabolism clinical classification of CIF, based on the type and volume of the intravenous supplementation (IVS), could be an indicator of CIF severity. METHODS: At baseline, participating home parenteral nutrition (HPN) centres enrolled all adults with ongoing CIF due to non-malignant disease; demographic data, body mass index, CIF mechanism, underlying disease, HPN duration and IVS category were recorded for each patient. The type of IVS was classified as fluid and electrolyte alone (FE) or parenteral nutrition admixture (PN). The mean daily IVS volume, calculated on a weekly basis, was categorised as <1, 1-2, 2-3 and >3 L/day. The severity of CIF was determined by patient outcome (still on HPN, weaned from HPN, deceased) and the occurrence of major HPN/CIF-related complications: intestinal failure-associated liver disease (IFALD), catheter-related venous thrombosis and catheter-related bloodstream infection (CRBSI). RESULTS: Fifty-one HPN centres included 2194 patients. The analysis showed that both IVS type and volume were independently associated with the odds of weaning from HPN (significantly higher for PN <1 L/day than for FE and all PN >1 L/day), patients' death (lower for FE, p=0.079), presence of IFALD cholestasis/liver failure and occurrence of CRBSI (significantly higher for PN 2-3 and PN >3 L/day). CONCLUSIONS: The type and volume of IVS required by patients with CIF could be indicators to categorise the severity of CIF in both clinical practice and research protocols.

Pseudotumor cerebri syndrome with different types of hormonal contraceptives in women of child-bearing age.

BACKGROUND AND PURPOSE: There is a lack of comparative safety data on the risk of pseudotumor cerebri syndrome (PTCS) associated with different hormonal contraceptives. We sought to quantify the risk of PTCS associated with eight different types of hormonal contraceptives compared with oral levonorgestrel. METHODS: We conducted a retrospective cohort study, with a case-control analysis of 4 871 504 women aged 15-45 years in the period 2008-2015, using IQVIA Ambulatory Electronic Medical Records data in the USA. Patients who used nine different contraceptive agents including intrauterine levonorgestrel, medroxyprogesterone injection, etonogestrel/ethinyl estradiol vaginal ring and combination oral contraceptives (COCs) that contained ethinyl estradiol and the progestins levonorgestrel, norgestimate, desogestrel, norethindrone and drospirenone, were included. Diagnosis of PTCS was defined using the first International Classification of Diseases, 9th or 10th revision, code for intracranial hypertension in patients who had also received an imaging code in the 30 days prior to the index date. RESULTS: A total of 3323 PTCS cases and 13 292 matched controls were identified. No increase in risk was found when analysing intrauterine levonorgestrel or COCs containing desogestrel, norethindrone, drospirenone, norgestimate or norgestrel versus COC levonorgestrel. The adjusted incidence rate ratio for etonogestrel/etonogestrel/ethinyl estradiol vaginal ring and medroxyprogesterone suspension compared with levonorgestrel COC was 4.45 [95% confidence interval (CI) 1.98-9.96] and 2.20 (95% CI 1.33-3.64), respectively. CONCLUSIONS: This study found an elevated risk for PTCS among users of etonogestrel vaginal ring and medroxyprogesterone suspension when compared with oral levonorgestrel. Future studies are needed to confirm these findings.

Residual Function Effectively Controls Plasma Concentrations of Secreted Solutes in Patients on Twice Weekly Hemodialysis.

Background Most patients on hemodialysis are treated thrice weekly even if they have residual kidney function, in part because uncertainty remains as to how residual function should be valued and incorporated into the dialysis prescription. Recent guidelines, however, have increased the weight assigned to residual function and thus reduced the treatment time required when it is present. Increasing the weight assigned to residual function may be justified by knowledge that the native kidney performs functions not replicated by dialysis, including solute removal by secretion. This study tested whether plasma concentrations of secreted solutes are as well controlled in patients with residual function on twice weekly hemodialysis as in anuric patients on thrice weekly hemodialysis.Methods We measured the plasma concentration and residual clearance, dialytic clearance, and removal rates for urea and the secreted solutes hippurate, phenylacetylglutamine, indoxyl sulfate, and p-cresol sulfate in nine patients on twice weekly hemodialysis and nine patients on thrice weekly hemodialysis.Results Compared with anuric patients on thrice weekly dialysis with the same standard Kt/Vurea, patients on twice weekly hemodialysis had lower hippurate and phenylacetylglutamine concentrations and similar indoxyl sulfate and p-cresol sulfate concentrations. Mathematical modeling revealed that residual secretory function accounted for the observed pattern of solute concentrations.Conclusions Plasma concentrations of secreted solutes can be well controlled by twice weekly hemodialysis in patients with residual kidney function. This result supports further study of residual kidney function value and the inclusion of this function in dialysis adequacy measures.

Ultrasonic backscatter difference measurements of cancellous bone from the human femur: Relation to bone mineral density and microstructure.

Ultrasonic backscatter techniques are being developed to detect changes in cancellous bone caused by osteoporosis. One technique, called the backscatter difference technique, measures the power difference between two portions of a backscatter signal. The goal of the present study is to investigate how bone mineral density (BMD) and the microstructure of human cancellous bone influence four backscatter difference parameters: the normalized mean of the backscatter difference (nMBD) spectrum, the normalized slope of the backscatter difference spectrum, the normalized intercept of the backscatter difference spectrum, and the normalized backscatter amplitude ratio (nBAR). Ultrasonic measurements were performed with a 3.5 MHz broadband transducer on 54 specimens of human cancellous bone from the proximal femur. Volumetric BMD and the microstructural characteristics of the specimens were measured using x-ray micro-computed tomography. Of the four ultrasonic parameters studied, nMBD and nBAR demonstrated the strongest univariate correlations with density and microstructure. Multivariate analyses indicated that nMBD and nBAR depended on trabecular separation and possibly other microstructural characteristics of the specimens independently of BMD. These findings suggest that nMBD and nBAR may be sensitive to changes in the density and microstructure of bone caused by osteoporosis.

Disinhibited eating mediates differences in attachment insecurity between bariatric surgery candidates/recipients and lean controls.

Previous research has shown that attachment anxiety is a good predictor of body mass index. This relationship is significantly mediated by disinhibited (over-) eating and is likely to reflect a specific form of affect regulation. This study explored whether obese bariatric surgery candidates (BSC; N=34) and bariatric surgery recipients (BSR; N=15) would show higher levels of attachment insecurity (higher attachment anxiety and/or higher attachment avoidance) than a group of age and gender-matched lean controls (N=54). Mediation analyses showed that compared to lean controls (M=2.96, SE=0.1), both BSC (M=3.5, SE=0.2) and BSR (M=3.4, SE=0.2) groups had a more insecure attachment orientation. These relationships were significantly mediated by disinhibited eating (BSC: lower limit confidence interval (LLCI)=0.06 and upper limit confidence interval (ULCI)=0.62; BSR: LLCI=0.02 and ULCI=0.76). There was no such relationship when the BSC and BSR groups were compared (LLCI=-0.15 & ULCI=0.3). These observations suggest that attachment insecurity may be a risk factor for obesity and bariatric surgery because of associated disinhibited eating. Moreover, these factors may be important to consider when bariatric surgery results in poor outcomes.

Gastrointestinal manifestations of neuroendocrine tumours: their investigation and management.

The incidence of neuroendocrine tumours (NETs) is on the rise in the UK. Patients with NETs need to be managed by a team of clinical specialties. There are a number of challenging gastrointestinal (GI) manifestations related to NETs that can occur in these patients, but a limited literature base exists to guide clinicians.Whilst life expectancy can be several years for patients with NETs, the GI symptoms can have a significant impact on their quality of life. It is therefore imperative to be familiar with the common GI manifestations associated with NETs, so symptoms can be appropriately managed with an overall aim of restoring the patient's quality of life.

Effect of gate choice on backscatter difference measurements of cancellous bone.

A variety of ultrasonic techniques have been developed to detect changes in bone caused by osteoporosis. One approach, called the backscatter difference technique, analyzes the power difference between two different portions of a backscatter signal. Analysis gates with a certain delay τd, width τw, and separation τs are used to define portions of the backscatter signal for analysis. The goal of the present study was to investigate how different choices of τd, τw, and τs affect four backscatter difference parameters: the normalized mean of the backscatter difference (nMBD), the normalized slope of the backscatter difference (nSBD), the normalized intercept of the backscatter difference (nIBD), and the normalized backscatter amplitude ratio (nBAR). Backscatter measurements were performed on 54 cube shaped specimens of human cancellous bone. nMBD, nSBD, nIBD, and nBAR were determined for 34 different combinations of τd, τw, and τs for each specimen. nMBD and nBAR demonstrated the strongest correlations with apparent bone density (0.48 ≤ Rs ≤ 0.90). Generally, the correlations were found to improve as τw + τs was increased and as τd was decreased. Among the four backscatter difference parameters, the measured values of nMBD were least sensitive to gate choice (<16%).

The effect of osteopathic manipulative treatment on quality of life in patients with cardiac implantable electronic devices.

CONTEXT: Osteopathic manipulative treatment (OMT) has been demonstrated to have an effect on the autonomic nervous system, which may have antiarrhythmic effects. The effects of OMT in patients with cardiac implantable electronic devices (CIEDs) have not previously been reported. This study investigated the impact of OMT on quality of life (QOL) in this patient population. OBJECTIVES: The purpose of this study is to investigate the effects of OMT on QOL in CIED patients. METHODS: Subjects with CIEDs were recruited into a double-blind randomized controlled institutional review board (IRB)-approved clinical trial (ClinicalTrials.gov ID: NCT04004741) and randomized to OMT or light touch (control) groups. Subjects received a one-time intervention, performed by board-certified neuromusculoskeletal medicine (NMM) and osteopathic manipulative medicine (OMM) physicians. The OMT protocol utilized techniques including myofascial release, rib raising, facilitated positional release (FPR), and osteopathic cranial manipulative medicine. Subjects' QOL was assessed immediately preceding intervention and one-month postintervention utilizing the Research ANd Development (RAND) 36-Item Short Form Health Survey (SF-36, eight parameters). Groups were compared utilizing unpaired t tests; α=0.05. RESULTS: Forty-two subjects were enrolled, with four lost to follow-up, which resulted in 19 OMT and 19 control subjects for analysis. Of the eight QOL parameters, two showed significant improvement with OMT: role limitations due to physical health (p=0.001) and pain (p=0.003). CONCLUSIONS: This study demonstrates the potential for QOL improvement in CIED patients. Specifically, subjects in the OMT group reported an improvement in activities of daily living as well as a decrease in overall pain, including pain interfering with work. Additional research is necessary to further understand the physiologic effects of OMT, including its effects on arrhythmias, in CIED patients.

Potential therapeutic effects of adjunct osteopathic manipulative treatments in SARS-CoV-2 patients.

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) affects various human organ systems, including the lymphatic, pulmonary, gastrointestinal, and neurologic systems. The utilization of osteopathic manipulative treatment (OMT) techniques has been clinically effective in the alleviation of various upper respiratory infection symptoms. Consequently, the use of osteopathic manipulative medicine (OMM) in SARS-CoV-2 patients as adjunct treatment can be beneficial in promoting overall recovery. This paper attempts to address the pathophysiology of SARS-CoV-2 infection at the cellular level and its downstream effects. Subsequently, osteopathic principles were investigated to evaluate potential therapeutic effects, providing a holistic approach in the SARS-CoV-2 treatment. Although the association between the benefits of OMT on clinical improvement during the 1918 Spanish influenza pandemic can be seen, further investigation is required to establish a direct correlation between OMT and symptom management in SARS-CoV-2.

Feasibility of Home Parenteral Nutrition in Patients with Intestinal Failure Due to Neuroendocrine Tumours: A Systematic Review.

INTRODUCTION: Maintaining adequate nutritional status can be a challenge for patients with small bowel neuroendocrine tumours (NETs). Surgical resection could result in short bowel syndrome (SBS), whilst without surgical resection there is a considerable risk of ischemia or developing an inoperable malignant bowel obstruction (IMBO). SBS or IMBO are forms of intestinal failure (IF) which might require treatment with home parenteral nutrition (HPN). Limited data exist regarding the use of HPN in patients with small bowel neuroendocrine tumours, and it is not frequently considered as a possible treatment. METHODS: A systematic review was performed regarding patients with small bowel NETs and IF to report on overall survival and HPN-related complications and create awareness for this treatment. RESULTS: Five articles regarding patients with small bowel NETs or a subgroup of patients with NETs could be identified, mainly case series with major concerns regarding bias. The studies included 60 patients (range 1-41). The overall survival time varied between 0.5 and 154 months on HPN. However, 58% of patients were alive 1 year after commencing HPN. The reported catheter-related bloodstream infection rate was 0.64-2 per 1000 catheter days. CONCLUSION: This systematic review demonstrates the feasibility of the use of HPN in patients with NETs and IF in expert centres with a reasonable 1-year survival rate and low complication rate. Further research is necessary to compare patients with NETs and IF with and without HPN and the effect of HPN on their quality of life.

Investigating the Relationship between Home Parenteral Support and Needs-Based Quality of Life in Patients with Chronic Intestinal Failure: A National Multi-Centre Longitudinal Cohort Study.

Home parenteral support (HPS) is an essential but potentially burdensome treatment that can affect quality of life (QoL). The aims of this longitudinal study were to understand whether any changes in HPS over time were associated with QoL. The Parenteral Nutrition Impact Questionnaire (PNIQ) was used, and data were collected on HPS prescribed at three time points. Data were analysed using multi-level mixed regression models presented as effect size and were adjusted for confounders. Study recruited 572 participants from 15 sites. Of these, 201 and 145 completed surveys at second and third time-points, respectively. PNIQ score was out of 20 with a higher score indicating poorer QoL. Any reduction in HPS infusions per week was associated with an improved PNIQ score of -1.10 (95% CI -2.17, -0.02) unadjusted and -1.34 (95% CI -2.45, -0.24) adjusted. Per day change to the number of infusions per week was associated with a change in the PNIQ score of 0.32 (95% CI -0.15, 0.80) unadjusted and 0.34 (95% CI -0.17, 0.85) adjusted. This is the largest national study to demonstrate improvements in QoL associated with HPS reduction over time using an HPS-specific and patient-centric tool, adding unique data for use of therapies in intestinal failure.

Experiences of the COVID-19 pandemic: A survey of patients on home parenteral nutrition.

Patients on home parenteral nutrition (HPN) have had to endure sweeping changes to their personal lives and medical care during the COVID-19 pandemic. We evaluated the patients' perspectives of these changes at our Intestinal Failure/Rehabilitation centre in order to initiate a debate on improving HPN care. The findings point to high levels of anxiety and depression amongst the 35 patients surveyed with many reporting frustration at conflicting information from different sources. Telephone consultations were well received and most were keen for these to continue. In light of these results, we outline recommendations to enhance our patients' experiences in the coming phases of the pandemic.

The Effect of Pedal Pump Lymphatic Technique Versus Passive Recovery Following Maximal Exercise: A Randomized Cross-Over Trial.

CONTEXT: Muscle damage and delayed onset muscle soreness (DOMS) can occur following intense exercise. Various modalities have been studied to improve blood lactate accumulation, which is a primary reason for DOMS. It has been well established that active recovery facilitates blood lactate removal more rapidly that passive recovery due to the pumping action of the muscle. The pedal pump is a manual lymphatic technique used in osteopathic manipulative medicine to increase lymphatic drainage throughout the body. Pedal pump has been shown to increase lymphatic flow and improve immunity. This may improve circulation and improve clearance of metabolites post-exercise. OBJECTIVE: This study compared the use of pedal pump lymphatic technique to passive supine recovery following maximal exercise. METHODS: 17 subjects (male n = 10, age 23 ± 3.01; female n = 7, age 24 ± 1.8), performed a maximal volume O2 test (VO2 max) using a Bruce protocol, followed by a recovery protocol using either pedal pump technique or supine passive rest for 10 min, followed by sitting for 10 min. Outcome measures included blood lactate concentration (BL), heart rate (HR), systolic blood pressure (SBP) and VO2. Subjects returned on another day to repeat the VO2 max test to perform the other recovery protocol. All outcomes were measured at rest, within 1- minute post-peak exercise, and at minutes 4, 7, 10 and 20 of the recovery protocols. A 2 × 6 repeated measures ANOVA was used to compare outcome measures (p ≤ 0.05). RESULTS: No significant differences were found in VO2, HR, or SBP between any of the recovery protocols. There was no significant difference in BL concentrations for recovery at minutes 4, 7, or 10 (p > 0.05). However, the pedal pump recovery displayed significantly lower BL concentrations at minute 20 of recovery (p = 0.04). CONCLUSION: The pedal pump significantly decreased blood lactate concentrations following intense exercise at recovery minute 20. The use of manual lymphatic techniques in exercise recovery should be investigated further.

Autoimmune disease and interconnections with vitamin D.

Vitamin D has well-documented effects on calcium homeostasis and bone metabolism but recent studies suggest a much broader role for this secosteroid in human health. Key components of the vitamin D system, notably the vitamin D receptor (VDR) and the vitamin D-activating enzyme (1α-hydroxylase), are present in a wide array of tissues, notably macrophages, dendritic cells and T lymphocytes (T cells) from the immune system. Thus, serum 25-hydroxyvitamin D (25D) can be converted to hormonal 1,25-dihydroxyvitamin D (1,25D) within immune cells, and then interact with VDR and promote transcriptional and epigenomic responses in the same or neighbouring cells. These intracrine and paracrine effects of 1,25D have been shown to drive antibacterial or antiviral innate responses, as well as to attenuate inflammatory T cell adaptive immunity. Beyond these mechanistic observations, association studies have reported the correlation between low serum 25D levels and the risk and severity of human immune disorders including autoimmune diseases such as inflammatory bowel disease, multiple sclerosis, type 1 diabetes and rheumatoid arthritis. The proposed explanation for this is that decreased availability of 25D compromises immune cell synthesis of 1,25D leading to impaired innate immunity and over-exuberant inflammatory adaptive immunity. The aim of the current review is to explore the mechanistic basis for immunomodulatory effects of 25D and 1,25D in greater detail with specific emphasis on how vitamin D-deficiency (low serum levels of 25D) may lead to dysregulation of macrophage, dendritic cell and T cell function and increase the risk of inflammatory autoimmune disease.

Impact of home parenteral nutrition on family members: A national multi-centre cross-sectional study.

BACKGROUND & AIMS: Home parenteral nutrition (HPN) is a necessary treatment for patients with chronic, type 3, intestinal failure (IF). HPN often requires lifestyle adaptations, which are likely to affect quality of life (QoL) in both patients and family members. The aim of this study was to identify the level of burden on family members who are involved with HPN care and to understand specific factors that contribute to any burden. METHODS: Patients over the age of 18 and receiving HPN were identified in IF clinics from multiple centres across the U.K. Eligible patients were asked to complete the parenteral nutrition impact questionnaire (PNIQ) to assess their QoL, while family members were asked to complete the burden scale for family caregivers (BSFC). Logistical regression was undertaken giving adjusted odds ratios (aOR). RESULTS: 678 participants completed the survey representing 339 patients with their appointed family member. Mean PNIQ score was 11.53 (S.D. 5.5), representing a moderate impact of HPN on patients' QoL. On the BSFC scale, 23% of family members reported a moderate to very severe subjective burden indicating an increased risk of psychosomatic symptoms. After adjusting for age and gender, predictors of BSFC included: family members self-reported health status using the EuroQol visual analogue scale (aOR 19.91, 95% CI 1.69, 233.99, p = 0.017) and support received by health services (aOR = 5.83, 95% CI = 1.93, 17.56, p = 0.002). Employment status, disease type, number of nights on HPN and length of time on HPN were not associated with BSFC. CONCLUSIONS: Family members with a poor health status or lack of support by health service were more likely to have a moderate to very severe subjective burden. Tailored support from the multi-professional IF team may reduce the burden experienced by family members of people dependent on HPN.

Chronic Intestinal Failure in Children: An International Multicenter Cross-Sectional Survey.

Background: The European Society for Clinical Nutrition and Metabolism database for chronic intestinal failure (CIF) was analyzed to investigate factors associated with nutritional status and the intravenous supplementation (IVS) dependency in children. Methods: Data collected: demographics, CIF mechanism, home parenteral nutrition program, z-scores of weight-for-age (WFA), length or height-for-age (LFA/HFA), and body mass index-for-age (BMI-FA). IVS dependency was calculated as the ratio of daily total IVS energy over estimated resting energy expenditure (%IVSE/REE). Results: Five hundred and fifty-eight patients were included, 57.2% of whom were male. CIF mechanisms at age 1−4 and 14−18 years, respectively: SBS 63.3%, 37.9%; dysmotility or mucosal disease: 36.7%, 62.1%. One-third had WFA and/or LFA/HFA z-scores < −2. One-third had %IVSE/REE > 125%. Multivariate analysis showed that mechanism of CIF was associated with WFA and/or LFA/HFA z-scores (negatively with mucosal disease) and %IVSE/REE (higher for dysmotility and lower in SBS with colon in continuity), while z-scores were negatively associated with %IVSE/REE. Conclusions: The main mechanism of CIF at young age was short bowel syndrome (SBS), whereas most patients facing adulthood had intestinal dysmotility or mucosal disease. One-third were underweight or stunted and had high IVS dependency. Considering that IVS dependency was associated with both CIF mechanisms and nutritional status, IVS dependency is suggested as a potential marker for CIF severity in children.

Venting issues.

Introduction: A 65-year-old woman with type 3 intestinal failure secondary to scleroderma of the gut (limited cutaneous sclerosis (centromere positive) and rheumatoid arthritis (anti-cyclic citrullinated peptide (CCP) and rheumatoid factor positive)) on home parenteral nutrition since 2011 underwent a venting PEG replacement in 2015 for intractable vomiting due to gut dysmotility and small bowel bacterial overgrowth, poorly responding to cyclical antibiotics. An endoscopy was undertaken for planned PEG review for consideration of elective replacement (figure 1).Figure 1Initial endoscopy.Based on this endoscopy, her case was discussed at a multidisciplinary team meeting and the anaesthetic risk of laparotomy to remove the PEG was deemed too high (previous endoscopic PEG exchange under sedation had been poorly tolerated due to tube removal through the oesophagus (possibly affected by scleroderma), and necessitated anaesthesia). Therefore, it was decided to insert a new venting PEG endoscopically alongside the previous buried PEG (cut short and clamped) with the plan to remove the old one at a later date. QUESTIONS: What is shown during the initial endoscopy?What is shown during follow-up endoscopy?