Exclusive enteral nutrition: An optimal care pathway for use in children with active luminal Crohn's disease.

AIM: Exclusive enteral nutrition (EEN) is recommended as a first-line therapy for active luminal paediatric Crohn's disease, by many contemporary consensus guidelines. However, EEN protocols vary internationally. A key enabler for the use of EEN therapy has been identified as the standardisation of protocols. The aim of this study was to develop an optimal care pathway for use of EEN in children with active luminal Crohn's disease. METHODS: A working group of 11 paediatric gastroenterology dietitians and one paediatric gastroenterologist from Australia and New Zealand was convened to develop a standard optimal care pathway. Seven key areas were identified; clinical indications, workup assessments, EEN prescription, monitoring, food reintroduction, partial enteral nutrition and maintenance enteral nutrition. Recent literature was reviewed, assessed according to the National Health and Medical Research Council guidelines, and consensus statements were developed and voted on. Consensus opinion was used where literature gaps existed. RESULTS: A total of nineteen consensus statements from the seven key areas were agreed upon. The consensus statements informed the optimal care pathway for children with active luminal undertaking EEN in Australia and New Zealand. CONCLUSION: This study developed an EEN optimal care pathway to facilitate standardisation of clinical care for children with active luminal Crohn's disease, and hopefully improve clinical outcomes and identify areas for future research.

Infant and toddler nutrition.

BACKGROUND: General practitioners (GPs) are often the first point of advice about nutrition and feeding concerns in infants and toddlers. OBJECTIVE: The aim of this article is to discuss the assessment of breastfed infants and address commonly presenting issues such as regurgitation, vomiting and bowel habits. Recommendations for starting solids and management of fussy eating are also outlined in this article. DISCUSSION: Breastfeeding should be supported by all healthcare professionals. Intake is difficult to quantify, but can be assessed using growth and urine output, with support from lactation consultants and/or child and family health nurses. Regurgitation is common, and usually resolves itself. If there are clinical concerns about a child's vomiting, they should be investigated medically. Consti-pation can be caused by insufficient fluid intake and should be managed medically; dietary interventions are not recommended as first-line treatment. Solid foods should be introduced around six months of age, when the infant is developmentally ready. Delaying the introduction of solids or allergenic foods does not prevent allergies. Fussy eating is common in toddlers exerting their independence, and behavioural management is essential.

Access to inclusive and culturally sensitive mental healthcare in Black, Indigenous, and People of Color pharmacy students and residents.

PURPOSE: Disparities in accessing culturally sensitive mental healthcare exist and may be exacerbated in pharmacy trainees. The purpose of this study was to identify barriers to culturally sensitive mental healthcare and how to improve access for racially and ethnically minoritized pharmacy students and residents. METHODS: This institutional review board-exempt study included in-person and virtual focus groups. Eligible participants were first-, second-, third-, and fourth-year doctor of pharmacy (PharmD) students and pharmacy residents completing a postgraduate year 1 or 2 program who identified as Black, Indigenous, and People of Color (BIPOC). Barriers to care, identity's influence on seeking care, and areas in which the training programs are doing well or areas for improvement were assessed. Responses were transcribed and analyzed using an open coding system by 2 reviewers, followed by discussion as a team to reach consensus. RESULTS: This study enrolled 8 first-year, 5 second-year, 7 third-year, and 2 fourth-year PharmD students and 4 residents (N = 26). Barriers to care included time, access to resources, and internal and external stigma. Identity barriers included cultural and family stigma and lack of representation in therapists with regard to race, ethnicity, and gender. Areas going well included supportive faculty and paid time off, while areas for improvement included wellness days, reduced workload, and increased diversity within the workforce. CONCLUSION: This study is the first to identify barriers to culturally sensitive mental healthcare in pharmacy trainees who identify as BIPOC while providing insight on how to increase culturally sensitive mental healthcare resources.

Leptin promotes fibroproliferative acute respiratory distress syndrome by inhibiting peroxisome proliferator-activated receptor-γ.

RATIONALE: Diabetic patients have a lower incidence of acute respiratory distress syndrome (ARDS), and those who develop ARDS are less likely to die. The mechanisms that underlie this protection are unknown. OBJECTIVES: To determine whether leptin resistance, a feature of diabetes, prevents fibroproliferation after lung injury. METHODS: We examined lung injury and fibroproliferation after the intratracheal instillation of bleomycin in wild-type and leptin-resistant (db/db) diabetic mice. We examined the effect of leptin on transforming growth factor (TGF)-ß(1)-mediated transcription in primary normal human lung fibroblasts. Bronchoalveolar lavage fluid (BAL) samples from patients with ARDS and ventilated control subjects were obtained for measurement of leptin and active TGF-ß(1) levels. MEASUREMENTS AND MAIN RESULTS: Diabetic mice (db/db) were resistant to lung fibrosis. The db/db mice had higher levels of peroxisome proliferator-activated receptor-γ (PPARγ), an inhibitor of the transcriptional response to TGF-ß(1), a cytokine critical in the pathogenesis of fibroproliferative ARDS. In normal human lung fibroblasts, leptin augmented the transcription of profibrotic genes in response to TGF-ß(1) through a mechanism that required PPARγ. In patients with ARDS, BAL leptin levels were elevated and correlated with TGF-ß(1) levels. Overall, there was no significant relationship between BAL leptin levels and clinical outcomes; however, in nonobese patients, higher BAL leptin levels were associated with fewer intensive care unit- and ventilator-free days and higher mortality. CONCLUSIONS: Leptin signaling is required for bleomycin-induced lung fibrosis. Leptin augments TGF-ß(1) signaling in lung fibroblasts by inhibiting PPARγ. These findings provide a mechanism for the observed protection against ARDS observed in diabetic patients.