Philip J.J. Herrod

Knowledge and attitudes of surgical trainees towards nutritional support: Food for thought☆

BACKGROUND & AIMS Up to 40% of patients admitted to UK hospitals are malnourished and appropriate nutritional intervention can improve outcomes. We investigated the knowledge and attitudes of UK surgical trainees towards nutritional support and compared their responses with dieticians. METHODS Trainee surgeons and qualified dieticians were asked to complete a multiple choice question test derived from topics relating to nutritional support, followed by a questionnaire on their attitudes towards nutrition. Participants were unaware that they would be tested. RESULTS The test was administered to 63 doctors and 25 dieticians. There were 19 newly qualified doctors (foundation year 1 [FY(1)]), 21 junior surgeons (speciality-training years 1 and 2 [ST(1-2)]) and 23 senior surgeons (speciality-training years 3 and above [ST(3+)]). Mean [SE] test scores were lower for doctors compared to dieticians (14.0 [0.64] versus 26.4 [0.22], p<0.001). The respective test scores for FY(1), ST(1-2), ST(3+) doctors were 9.8 [0.78], 14.3 [1.10] and 17.3 [0.76]. Only 47% of doctors felt they had adequate knowledge of this subject and 65% stated that they regularly made decisions on nutritional support. Furthermore, only 25% stated they could calculate daily energy and nutritional requirements. CONCLUSION Despite making decisions related to nutritional support regularly, surgical doctors in the UK demonstrated less knowledge of the fundamental principles of nutritional support than dieticians.

The importance of fluid and electrolyte management – A medical student's perspective

Reading the paper by Awad et al.1 made me reflect on my own education on fluid and electrolyte balance. In my two years at medical school to date I have been taught very little about the importance of fluid and electrolyte balance. Indeed, before I began my own research for my BMedSci project on the subject, my only teaching had been two 50 min lectures. The first of these was entitled ‘‘Disorders of fluid & electrolyte balance’’. This lecture failed to emphasize the clinical relevance of the information it described. It instead concentrated on the importance of the kidneys in regulating fluid & electrolyte balance and did not make much comment on the effects of an imbalance on the patient. Also, this lecture went into much more detail on potassium imbalance, glossing over the importance of sodium and water balance. The second was entitled ‘‘Clinical chemistry of disorders of fluid and electrolyte balance’’. This lecture mentioned some of the clinical scenarios in which fluid and electrolyte imbalance occurs, such as dehydration and fluid overload, and included three case histories which encouraged more understanding of the topic rather than just factual recall. However, like the first lecture, it concentrated mostly on the body systems involved in the regulation of fluid and electrolyte balance rather than focusing on the consequences of imbalance. However, I am not even half way through my undergraduate medical studies, and have also not started the clinical phase of the course. Therefore, it would be logical for me to assume that I would be taught more on the topic in later years, enabling me to have adequate knowledge on the subject to manage my patients appropriately. However, according to the published literature, this does not seem to be likely. It would seem then that many junior doctors, having qualified from medical school still do not have a good understanding of the topic2 and many authors have called for this to be remedied.4,5 From doing a small amount of research on the topic, it is now clear to me that good fluid and electrolyte management is vital to patient well being.5,6 ‘‘Salt and water are probably the most common therapeutic agents that we give to patients’’ and it is vital that doctors understand this issue fully, especially as it has been shown that text book coverage of the topic may be lacking. The challenge then is to improve teaching of fluid and electrolyte management at medical school in order to better equip

Random duodenal biopsy to exclude coeliac disease as a cause of anaemia is not cost-efective and should be replaced with universally performed pre-endoscopy serology in patients on a suspected cancer pathway.

AbstractBackgroundRandom duodenal biopsy to exclude coeliac disease during upper gastrointestinal endoscopy for the investigation of iron deficiency anaemia remains a common procedure, but is expensive and time-consuming. Serological investigation for coeliac disease is also recommended, having excellent accuracy with the added benefit of lower cost. This study sought to examine the utility of duodenal biopsy and coeliac serology in the diagnosis of coeliac disease. MethodsA prospectively maintained database was interrogated to identify all patients having upper gastrointestinal endoscopy for the investigation of anaemia between January 01, 2016, and December 31, 2016. ResultsOf the 1131 patients having an endoscopy, coeliac serology was measured in only 412 (36%) and was positive in 9 cases (2%), leading to 6 histological diagnoses of coeliac disease and 3 false positives. Two-hundred and seventy-four patients with negative serology had biopsies taken which were all negative. Only 2/451 (0.4%) patients who had biopsies performed in the absence of a serology test were histologically positive for coeliac disease. The cost per diagnosis of a case of coeliac disease in those with either negative or absent coeliac serology was £18,839 (US

Non-pharmacological strategies to reduce blood pressure in older adults: a systematic review and meta-analysis

25,244, €21,196).ConclusionsRandom duodenal biopsy is not a cost-effective method of diagnosing coeliac disease and should be replaced with pre-endoscopy coeliac serology.

One- and two-year outcomes and predictors of mortality following emergency laparotomy: a consecutive series from a United Kingdom teaching hospital.

Abstract Background The incidence of hypertension increases with advancing age and represents a substantial burden of disease. Lifestyle modification is the first-line intervention in treatment algorithms; however, most evidence for this comes from studies involving young participants using interventions that may not be feasible in older adults. The aim of this review was to assess the effect of non-pharmacological interventions on hypertension in older adults. Methods We did a systematic review of all randomised controlled trials involving participants with a mean age of 65 years or over investigating non-pharmacological strategies to reduce blood pressure. We searched Medline, EMBASE, CINAHL, AMED, and PubMed from inception to March 3, 2017, with no language restriction (appendix). Outcomes were aggregated with a random-effects model, and the I 2 statistic was used to quantify statistical heterogeneity. Risk of bias was judged with the Cochrane Collaborations risk assessment tool. This systematic review is registered with PROSPERO, number CRD42017059443. Findings Initial searches returned 719 citations, which yielded 53 eligible studies with a total of 5139 participants (pooled mean age 69 years, SD 5·3). Most interventions described aerobic exercise (24 studies), dynamic resistance exercise (12), or a combination of these exercises (12). Two studies described isometric exercise and three studies reported different dietary interventions. Interventions lasted between 6 weeks and 1 year and involved two to four sessions per week. All studies included were at high risk of bias. Compared with control (mainly non-intervention), aerobic exercise led to a mean difference in systolic and diastolic blood pressure of −5·09 mm Hg (95% CI −7·22 to −2·97, p Interpretation Exercise-based lifestyle intervention may elicit a modest reduction in blood pressure of 5/3 mm Hg in elderly people. Isometric exercise could potentially yield greater benefit but further research is required for confirmation. Funding PJJH is supported by a research training fellowship jointly awarded by the Royal College of Surgeons of England and the Dunhill Medical Trust.