N Thompson

A randomized controlled trial of calcium with vitamin D, alone or in combination with intravenous pamidronate, for the treatment of low bone mineral density associated with Crohn's disease

Background : Osteoporosis is a common complication of Crohns disease.

Influence of IL-6, COL1A1, and VDR gene polymorphisms on bone mineral density in Crohn’s disease

Background: Osteoporosis is an important cause of morbidity in patients with Crohn’s disease. The pathogenesis of reduced bone mineral density (BMD) is multifactorial. A range of genetic factors have been implicated in other populations of patients with osteoporosis. Aim: To investigate the influence of interleukin 6 (IL-6), collagen type 1α1 (COL1A1), and vitamin D receptor gene (VDR) single nucleotide polymorphisms (SNP) on BMD in patients with Crohn’s disease. Patients: A cohort of 245 well characterised patients with Crohn’s disease were recruited from the inflammatory bowel disease register at the Freeman Hospital and Royal Victoria Infirmary, Newcastle upon Tyne, and the Queen Elizabeth Hospital, Gateshead, UK. Methods: Patients were genotyped for IL-6 C-174G SNP, COL1A1 Sp1 binding site G T SNP, VDR Taq1, and Fok1 SNPs, and CARD15 R702W, G908R, and L1007fs SNPs. BMD was measured at the lumbar spine (LSP) and hip using dual energy x ray absorptiometry. Results: A total of 158 female and 87 male patients, aged 24–70 years (mean 44), were recruited. There were no significant differences in the distribution of the tested SNPs when analysed for age, body mass index, pre/post-menopausal status, smoking, or steroid use. Two hundred and thirteen patients were genotyped for the IL-6 SNP. LSP and total hip BMD was significantly lower in patients with the GG genotype (48%) than the CC genotype (15%) (p = 0.041, p = 0.014). One hundred and eighty patients were genotyped for the COL1A1 SNP. There was no significant difference in BMD at LSP. Hip BMD was significantly lower in heterozygous patients compared with homozygous wild-types (p = 0.034). There were no significant differences in BMD between genotypes for the two VDR SNPs or the CARD15 genotypes examined. Conclusion:IL-6 and COL1A1 gene polymorphisms influence BMD in patients with Crohn’s disease but the particular VDR gene polymorphisms studied do not have a major effect.

A practical approach to the management of high-output stoma

The development of a high-output stoma (HOS) is associated with water, electrolyte and nutritional complications. Prompt, careful assessment and management is required to avoid rapid clinical deterioration in this patient population. A multidisciplinary approach to management ensures the best possible outcome and quality of life for patients who experience HOS. This article outlines the important considerations in the identification and pathophysiology of HOS. A systematic approach to the management of the condition is outlined, considering fluid and electrolyte requirements, nutrient deficiencies and manipulation of gastrointestinal absorption, motility and secretions using medical and surgical therapies.

Adult parenteral nutrition in the North of England: a region-wide audit

Objectives Parenteral nutrition (PN) is widely used to provide nutritional support to patients with inaccessible or inadequate length of gut or non-functioning gut. The objective was to compare practice in PN administration to results of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report, ‘A Mixed Bag’, and to establish whether good practice was being followed within this part of the UK. Setting Using the Northern Nutrition Network (NNN), we examined the care of adult patients receiving PN in all 10 secondary care hospitals in our region. Participants All patients receiving PN were included with no exclusions. Data were collected on 192 patients (51% females, median age 65 years (range 18–96)). Outcome measures A data collection tool was designed based on the recommendations of the NCEPOD report. Results PN was used for a median of 7 days with a 30-day mortality rate of 8%. Metabolic complications occurred in 34%, of which only 13% were avoidable. The catheter sepsis rate was 1.5 per 1000 PN days. The audit suggests that nutrition team input improves patient assessment prior to starting PN and review once PN is established. Risk of refeeding syndrome was identified in 75%. Areas for improvement are documentation of treatment goal (39%), review of PN constitution (38%), ensuring patients are weighed regularly (56%) and documentation of line-tip position (52%). Conclusions This region-wide prospective audit suggests improved practice within the UK compared to the NCEPOD audit with lower mortality and line sepsis rates. However, documentation remains suboptimal. This work strengthens the case for introducing nutrition teams in hospitals without this service. These findings are likely to be reproduced across the UK and in other healthcare settings. We provide a template for similar audits of clinical practice.

Managing Malnutrition in Older Persons Residing in Care Homes: Nutritional and Clinical Outcomes Following a Screening and Intervention Program

ABSTRACT This study aimed to establish prevalence of malnutrition in older adult care home residents and investigate whether a nutritional screening and intervention program could improve nutritional and clinical outcomes. A community-based cohort study was conducted in five Newcastle care homes. 205 participants entered; 175 were followed up. Residents already taking oral nutritional supplements (ONS) were excluded from interventions. Those with Malnutrition Universal Screening Tool (MUST) score of 1 received dietetic advice and ≥2 received dietetic advice and were prescribed ONS (220 ml, 1.5 kcal/ml) twice daily for 12 weeks. Body mass index (BMI), MUST, mini nutritional assessment score (MNA)®, mid upper arm muscle circumference (MAMC), and Geriatric Depression Scale (GDS) were recorded at baseline and 12 weeks. Malnutrition prevalence was 36.6% ± 6.6 (95% CI). A higher MUST was associated with greater mortality (p = 0.004). Type of intervention received was significantly associated with change in MUST score (p < 0.001); dietetic advice resulting in the greatest improvement. There were no significant changes in BMI (p = 0.445), MAMC (p = 0.256), or GDS (p = 0.385) following the interventions. Dietitian advice may slow the progression of nutritional decline. In this study oral nutritional supplements over a 3-month period did not significantly improve nutritional status in malnourished care home residents.

Critical intestinal ischaemia in a patient with patent mesenteric vasculature.

We present a case of a 62-year-old man with known coeliac disease who was admitted for investigation of abdominal pain and weight loss. He underwent multiple biochemical, haematological, radiological and endoscopic investigations (which were all normal) and also had a normal laparoscopy. Abdominal computerized tomography angiography, however, suggested significant mesenteric stenosis. Mesenteric angiography confirmed superior mesenteric artery stenosis and reproduced the patients abdominal pain when the catheter crossed the lesion. Balloon angioplasty successfully dilated the stenosis, and since then the patient has gained 19 kg in weight (returning his body mass index from 17 to 23) and has been symptom free. Symptomatic single vessel mesenteric ischaemia (other than coeliac artery stenosis in median arcuate syndrome) is not previously well described. The symptom reproduction on catheterization highlights how useful angiography can be in diagnosis of disease significance. Symptom resolution after angioplasty demonstrated clearly how even single vessel disease can cause significant compromise to the mesenteric circulation.

Do non-targeted gastric biopsies affect the management of patients, and can a simple protocol and education reduce the rate?

Objective To determine whether development of localised protocol could reduce the number of non-targeted gastric biopsies taken at endoscopy, without risking harm from non-detection of malignant conditions. Design Retrospective analysis of patient records over a 3-month period in 2013, repeated in 2015 following intervention. Setting Two UK teaching hospitals Patients Patient record data on indication for endoscopy, endoscopy findings, histopathology results and patient outcome. Interventions Guidance on upper gastrointestinal biopsy in the form of a new trust-wide protocol, as well as lecture-based education. Main outcome measures Rates of non-targeted and targeted biopsies before and after intervention, and differences between grade of endoscopist. Results Between 2013 and 2015, there was a 36% reduction in non-targeted biopsies (10.4% vs 6.7%, p=0.001), predominantly within registrar and nurse endoscopist groups, with reduction in non-targeted biopsies of 9.5% and 64%, respectively. Percentage of targeted biopsies remained relatively static, 7.9% and 8.2%. In 2013, 92% of non-targeted biopsies had no management change based on histology; in 2015 this was 90%. Of patients with alteration to management, only 0.4% and 0.7% were due to malignancy, in known high-risk patients. Reduction in non-targeted biopsies resulted in estimated annual savings in this trust of £36,000. Conclusion Development of local protocol reduces the numbers of non-targeted biopsies taken, without risk of harm from non-detection of malignant conditions, enabling a significant reduction in workload within busy histopathology services, with significant cost savings. Localised protocols are adaptable to local population demographics.

UK practice in the prevention of central venous catheter-associated thrombosis in adults on home parenteral nutrition

Background Maintaining central access is imperative for the delivery of home parenteral nutrition (HPN) in those with intestinal failure. Methods to reduce central venous catheter infection are well recognised; however, the prevention of line thrombosis is less well studied. Methods This paper reviews the current evidence and reports a survey of current practice within the UK. Using an electronic survey, respondents were asked to detail their use of anticoagulation in different patient groups and the type of anticoagulation used. Results 41 replies were received from 31 centres. Only one responder used low-dose warfarin routinely; 80% however anticoagulated those with a previous line thrombosis and 65% anticoagulated those that had any deep vein thrombosis or pulmonary embolus. The most commonly used anticoagulant was dose-adjusted warfarin aiming for an international normalised ratio of 2–3. Conclusions The evidence from the current literature in both HPN and the wider field is that there is no clear evidence that anticoagulation is either beneficial or harmful in the prevention of line thrombosis. This survey suggested that practice is varied across the UK likely reflecting the lack of evidence within the current literature.

Fatal gastrointestinal histoplasmosis 15 years after orthotopic liver transplantation

We report a case of ileo-colonic Histoplasmosis without apparent respiratory involvement in a patient who had previously undergone an orthotopic liver transplant (OLT) for primary biliary cholangitis 15 years earlier. The recipient lived in the United Kingdom, a non-endemic region for Histoplasmosis. However, she had previously lived in rural southern Africa prior to her OLT. The patient presented with iron deficiency anaemia, diarrhoea, abdominal pain and progressive weight loss. She reported no previous foreign travel, however, it later became known that following her OLT she had been on holiday to rural southern Africa. On investigation, a mild granulomatous colitis primarily affecting the right colon was identified, that initially improved with mesalazine. Her symptoms worsened after 18 mo with progressive ulceration of her distal small bowel and right colon. Mycobacterial, Yersinia, cytomegalovirus and human immunodeficiency virus infections were excluded and the patient was treated with prednisolone for a working diagnosis of Crohn’s disease. Despite some early symptom improvement following steroids, there was subsequent deterioration with the patient developing gram-negative sepsis and multi-organ failure, leading to her death. Post-mortem examination revealed that her ileo-colonic inflammation was caused by Histoplasmosis.

18 Can a short training module improve nutritional knowledge of malnutrition by junior doctors

Background Malnutrition is a major cause and consequence of poor health. Hospitalised patients are at increased risk of malnourishment; around 30% of people aged over 65 are at risk of malnutrition on admission. Additionally, malnutrition increases costs hugely to the NHS. Despite the prevalence and cost of this problem, formal teaching to junior doctors about malnutrition is limited. Aim To assess whether an online training module could improve knowledge of nutritional management of hospitalised patients. Methods Using SurveyMonkey, a survey was distributed to Foundation Year FY1 and FY2 doctors working at both Newcastle and Northumbria NHS Foundation Trainee (FT). The doctors were asked five questions, then given information relating to malnutrition. Finally they answered the five questions again. The survey took approximately 15 min to complete. Participants could then download a certificate to show involvement with training. Statistical analysis was performed using a paired t-test to assess the doctors’ improvement in answering the questions. Results 87 doctors participated. The results are outlined in the table below.Abstract 18 Table 1 1st round of questions 2nd round of questions Number of Responses Percentage of correct answers (%) Number of Responses Percentage of correct answers (%) Q1 84 7.1 76 40.8 Q2 86 48.4 76 85.5 Q3 86 36.1 76 89.4 Q4 86 20.9 75 82.7 Q5 71 22.5 63 31.8 A paired t-test was used to measure the difference in correct answers selected between the 1st and 2nd attempts, p-value of 0.013. Conclusions Knowledge of malnutrition can be improved by completing a short training module. Future studies should address the technical issues of using SurveyMonkey within FTs and use larger sample sizes to prove the generalisability of the results. Improved knowledge should lead to earlier recognition and treatment of malnutrition with improved health outcomes and reduced costs.