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Frontline Gastroenterology May 2024Nutrition is an essential part of gastroenterology specialist training. There is limited evidence of trainee experience in this area. The shorter training programme...
INTRODUCTION
Nutrition is an essential part of gastroenterology specialist training. There is limited evidence of trainee experience in this area. The shorter training programme introduced in 2022 may lead to reduced exposure to this subspecialty. We aimed to explore and describe current nutrition training experiences, confidence and satisfaction to inform future improvements.
METHODS
Gastroenterology trainees were invited to participate in an online survey from 20 May 2022 to 18 July 2022. The questionnaire consisted of 27 questions with a range of free-text and Likert scale responses.
RESULTS
86 responses were received. 39.5% had undertaken an advanced training programme or core placement in nutrition. 52.9% of these felt 'fairly confident' or 'very confident' in managing intestinal failure vs 5.8% of those who had not completed a nutrition placement. Obesity and eating disorders management received the lowest ratings. Nutrition training was described as 'fairly important' or 'very important' by 98.8% and 47.0% included nutrition as part of their preferred future practice. 53.1% of ST6/7 trainees were 'fairly confident' or 'very confident' their training offered adequate experience in nutrition. Participants reported barriers including a lack of education and training opportunities, and limited early rotations offering nutrition training.
CONCLUSION
Gastroenterology trainees believe nutrition training to be important. Nutrition placements increase trainee confidence, knowledge and experiences overall, but there is variability in this. Improved structuring of placements, increased educational opportunities and exposure to this subspecialty at an earlier stage are required to ensure competency in nutrition is reliably achieved during gastroenterology training.
PubMed: 38665797
DOI: 10.1136/flgastro-2023-102563 -
Revista Da Associacao Medica Brasileira... 2024Endogenous melatonin is produced from tryptophan which is an essential amino acid. Besides its role in the regulation of sleep patterns, melatonin has anti-inflammatory...
OBJECTIVE
Endogenous melatonin is produced from tryptophan which is an essential amino acid. Besides its role in the regulation of sleep patterns, melatonin has anti-inflammatory effects. In this case-control study, we aimed to compare tryptophan and melatonin levels and their relationship with the inflammatory response, specifically serum interleukin-1, interleukin-6, and c-reactive protein levels following major abdominal surgery in patients with food restriction and who receive parenteral nutritional therapy.
METHODS
We enrolled 40 patients between the ages of 18 and 65 years in the study. We collected blood and urine samples 48 h before the operation and on postoperative days 1, 3, and 5.
RESULTS AND CONCLUSION
The tryptophan levels in the experimental group were higher than in the control group but failed to reach any statistical difference. Melatonin levels were increased in both groups following the surgery compared with preoperative levels. The increase in the experimental group was statistically different 3 days after the surgery. The difference in the level of interleukin-1 between the control and the experimental groups was greatest on postoperative day 3. On postoperative day 3, the interleukin-6 level in the treatment group was slightly higher than in the control group. We did not find any difference in the levels of c-reactive protein between the groups. As a result, the levels of tryptophan and melatonin were increased in the parenteral nutrition group, irrespective of the postoperative inflammatory response.
Topics: Humans; Melatonin; Middle Aged; Parenteral Nutrition; Tryptophan; Adult; Male; Female; C-Reactive Protein; Case-Control Studies; Interleukin-6; Young Adult; Aged; Adolescent; Interleukin-1; Inflammation; Time Factors; Dietary Supplements; Postoperative Period
PubMed: 38655993
DOI: 10.1590/1806-9282.20230826 -
PloS One 2024Central catheter bloodstream infections (CRBSI) is a major cause of healthcare-associated infections. However, few factors are generally accepted and some studies have... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Central catheter bloodstream infections (CRBSI) is a major cause of healthcare-associated infections. However, few factors are generally accepted and some studies have conflicting finding about some factors, possibly caused by limitation associated with an individual study. This study was to identify risk factors for CRBSI in intensive care units.
METHODS
We searched the PubMed, Cochrane Library, Web of science and EMBASE databases and the 4 top Chinese-language databases, including WanFang data, China National Knowledge Infrastructure (CNKI), and Chinese Science and Technology Journal Database (VIP), China Biology Medicine disc (CBM) as of July 2023. Case control and cohort studies were included. Two authors independently screened the literature and evaluated the quality of the studies using the Newcastle-Ottawa scale (NOS). The pooled effect size was estimated using the odds ratio (OR), and the corresponding 95% confidence interval (CI) was calculated. The Cochrane Q (χ2) and I2 tests were used to assess heterogeneity among studies, and each risk factor was tested for its robustness using fixed- or random-effects models.
FINDINGS
A total of 32 studies enrolled, among which eleven factors were identified, they were divided into two categories: modifiable and unmodifiable factors. Modifiable factors: duration of catheterization (≥ 5d) (OR: 2.07, 95%CI: 1.41-3.03), duration of catheterization (≥ 7d) (OR: 3.62, 95%CI: 2.65-4.97), duration of catheterization (≥ 14d)(OR: 4.85, 95%CI: 3.35-7.01), total parenteral nutrition (OR: 2.27,95%CI: 1.56-3.29), use of multiple-lumen catheters(OR: 3.41, 95%CI: 2.27-5.11), times of tube indwelling (OR: 3.50, 95%CI: 2.93-4.17), length of ICU stay (OR: 4.05, 95%CI: 2.41-6.80), the position of indwelling(OR: 2.41, 95%CI: 2.03-2.85); Unmodifiable factors: APACHEII scores (OR: 1.84, 95%CI: 1.54-2.20), Age≥ 60 years old (OR: 2.19, 95%CI: 1.76-2.73), the extensive use of antibiotic (OR: 3.54, 95%CI: 1.65-7.61), Diabetes mellitus (OR: 3.06, 95%CI: 2.56-3.66), Immunosuppression (OR: 2.87, 95%CI: 2.08-3.95).
CONCLUSIONS
Effective interventions targeting the above modifiable factors may reduce the risk of developing CRBSI in ICU and improve the clinical outcome of patients. Further prospective studies are needed to confirm these findings.
Topics: Humans; Intensive Care Units; Risk Factors; Catheter-Related Infections; Catheterization, Central Venous; Cross Infection; Bacteremia; Central Venous Catheters
PubMed: 38652718
DOI: 10.1371/journal.pone.0296723 -
Cureus Mar 2024Cerebral palsy (CP) is a neurodevelopmental disorder that affects motor function and is often accompanied by secondary musculoskeletal issues. Severe scoliosis, a...
Cerebral palsy (CP) is a neurodevelopmental disorder that affects motor function and is often accompanied by secondary musculoskeletal issues. Severe scoliosis, a lateral curvature of the spine over 40 degrees, poses a significant challenge for individuals with CP, impacting their mobility and overall well-being. While the association between scoliosis and gastrointestinal complications is acknowledged, the occurrence of colonic volvulus with necrosis in the context of CP and severe scoliosis is rare and complex. This case report emphasizes the importance of clinical awareness in managing gastrointestinal complications in patients with CP and severe scoliosis. An 11-year-old female presented with gastroenteritis and a concurrent viral upper respiratory tract infection. She experienced complications such as greenish vomiting, hematemesis, abdominal distention, and constipation. The patient has a medical history of epilepsy and was diagnosed with quadriplegic CP at four months old due to viral meningitis. She is currently on anti-epileptic medications and receives regular follow-ups with neurology. Severe lumbar scoliosis of more than 50 degrees Cobb angle is also noted. Physical examination revealed dehydration, bilious content in nasogastric tube (NGT) aspiration, tender abdomen, and an empty digital rectal examination. Some laboratory findings showed elevated levels of erythrocyte sedimentation rate (ESR), prothrombin time (PT), blood urea nitrogen (BUN), and sodium, while albumin levels were decreased, and white blood cell (WBC) count was mildly elevated. Abdominal computed tomography (CT) with contrast showed a distended ascending colon with air and swirling of the mesentery. The distal half of the large bowel was not dilated, and fecal matter was present. The small bowel appeared to be collapsed, and there was moderate free fluid in the peritoneal cavity, indicating colonic volvulus involving the proximal large bowel. The patient underwent surgery, which involved deflating and removing the distended colon, resecting the gangrenous colon, and performing an ilio-sigmoid anastomosis to restore gastrointestinal continuity. Postoperatively, the patient received close monitoring in the pediatric intensive care unit (PICU), received total parenteral nutrition (TPN) for five days, gradually progressed feeding, and showed overall improvement in her condition. In conclusion, this case report highlights a rare occurrence of colonic volvulus in a patient with CP and severe scoliosis. It emphasizes the complex relationship between neurological and musculoskeletal disorders in gastrointestinal complications. A multidisciplinary approach is important for optimal management. It shows the importance of musculoskeletal factors in patients with neurological conditions. Overall, it contributes to the medical literature and emphasizes tailored management strategies for gastrointestinal issues in such patients.
PubMed: 38650790
DOI: 10.7759/cureus.56743 -
Biomedica : Revista Del Instituto... Mar 2024Metabolic bone disease of premature infants is a rare complication characterized by a lower mineral content in bone tissue.
INTRODUCTION
Metabolic bone disease of premature infants is a rare complication characterized by a lower mineral content in bone tissue.
OBJECTIVE
To establish the incidence of metabolic bone disease in premature infants and to determine associated risk factors.
MATERIALS AND METHOD
We conducted a descriptive prospective cohort study for one year in all newborns under 32 gestational weeks, or 1,500 g, at the Hospital Universitario de Santander to determine the incidence of metabolic bone disease. We collected demographic data and prenatal histories of the selected patients, and later, we measured serum alkaline phosphatase and serum phosphorus at the third week of birth, having as reference values for diagnosis less than 5.6 mg/dl for the first one and more than 500 UI/L for the second one. We applied statistical tools for data analysis, such as average proportions, dispersion, distribution and association measures, and binomial regression.
RESULTS
From a total of 58 patients, 7 had a diagnosis of metabolic bone disease, with an incidence of 12%. The weight was reported as an independent variable for the development of the disease, being significant in children under 1,160 g, as well as prolonged parenteral nutrition for more than 24 days. When performing the multivariate analysis, low weight and short time of parenteral nutrition appeared as risk factors; in the same way, maternal age below 22 years is associated with a higher relative risk, even more than a newborn weight inferior to 1,160 g.
CONCLUSION
Establishing an early intervention in patients with metabolic bone disease enhancing risk factors, such as low weight and prolonged parenteral nutrition, is critical to prevent severe complications.
Topics: Humans; Colombia; Infant, Newborn; Incidence; Bone Diseases, Metabolic; Prospective Studies; Female; Male; Risk Factors; Gestational Age; Parenteral Nutrition; Infant, Premature; Alkaline Phosphatase; Infant, Premature, Diseases; Hospitals, University; Phosphorus
PubMed: 38648348
DOI: 10.7705/biomedica.6926 -
JAMA Network Open Apr 2024Delayed meconium evacuation and delayed achievement of full enteral feeding among premature infants are associated with poor short- and long-term outcomes. Identifying a... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
Delayed meconium evacuation and delayed achievement of full enteral feeding among premature infants are associated with poor short- and long-term outcomes. Identifying a more effective and safer enema for meconium evacuation is imperative for improving neonatal care.
OBJECTIVE
To examine whether breast milk enemas can shorten the time to complete meconium evacuation and achievement of full enteral feeding for preterm infants.
DESIGN, SETTING, AND PARTICIPANTS
This randomized, open-label, parallel-group, single-center clinical trial was conducted from September 1, 2019, to September 30, 2022, among 286 preterm infants with a gestational age of 23 to 30 weeks in the neonatal ward of the Shengjing Hospital of China Medical University in Shenyang.
INTERVENTIONS
Preterm infants were randomly assigned to receive either breast milk enemas or normal saline enemas 48 hours after birth.
MAIN OUTCOME AND MEASURES
The primary outcomes were time to complete meconium evacuation and time to achieve full enteral feeding. Secondary outcomes were duration of hospitalization, weight at discharge, and duration of total parenteral nutrition. Intention-to-treat and per-protocol analyses were conducted.
RESULTS
In total, 286 preterm infants (mean [SD] gestational age, 198.8 [7.9] days; 166 boys [58.0%]) were eligible and included in this study. A total of 145 infants were randomized to the normal saline group, and 141 were randomized to the breast milk group. The time to achieve complete meconium evacuation was significantly shorter in the breast milk group than in the normal saline group (-2.2 days; 95% CI, -3.2 to -1.2 days). The time to achieve full enteral feeding was also significantly shorter in the breast milk group than in the normal saline group (-4.6 days; 95% CI, -8.0 to -1.2 days). The duration of total parenteral nutrition was significantly shorter in the breast milk group than in the normal saline group (-4.6 days; 95% CI, -8.6 to -1.0 days). There were no clinically notable differences in any other secondary or safety outcomes between the 2 groups.
CONCLUSIONS AND RELEVANCE
In this randomized clinical trial testing the effects of breast milk enema on meconium evacuation, breast milk reduced the time to achieve complete meconium evacuation and achieve full enteral feeding for preterm infants with a gestational age of 23 to 30 weeks. Subgroup analyses highlight the need for tailored interventions based on gestational age considerations.
TRIAL REGISTRATION
isrctn.org Identifier: ISRCTN17847514.
Topics: Humans; Enema; Meconium; Infant, Newborn; Milk, Human; Female; Male; Infant, Premature; China; Enteral Nutrition; Gestational Age
PubMed: 38648060
DOI: 10.1001/jamanetworkopen.2024.7145 -
Cureus Mar 2024Introduction Clinical nutrition for preterm and critically ill neonates remains a challenge. Preterms are often hemodynamically and metabolically compromised, which...
Introduction Clinical nutrition for preterm and critically ill neonates remains a challenge. Preterms are often hemodynamically and metabolically compromised, which limits infusion volumes of nutrients and hinders achieving recommended nutrient intakes. While guidelines provide recommended ranges for parenteral nutrition (PN) intakes, they generally recommend enteral nutrition as soon as possible. Thus, in clinical practice, gradually increasing EN intakes complicates assessments of PN guideline adherence. Via a pragmatic approach, we assessed adherence to PN recommendations for macronutrients and energy as stated in the 2018 guidelines of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Methods In this retrospective study, we assessed the nutrition of preterm and critically ill term neonates from the neonatal intensive care unit of the University Hospital Brussels. We analyzed intakes for the first week of life, in which critically ill neonates at our center usually receive the majority of nutrients via PN. The PN-based provision of macronutrients and energy was analyzed descriptively in relation to the ESPGHAN 2018 recommendations. Results Macronutrients and energy provision gradually increased until they reached recommended or targeted values. Compared to term neonates, energy and lipid provision for preterms increased faster, while amino acid provision exceeded the ESPGHAN 2018 recommendations. Conclusions This study adds clinical practice data to the severely understudied field of the ESPGHAN 2018 PN guideline compliance. Using a pragmatic assessment of our nutrition protocols, we found the need to reduce the amount of amino acids per kg body weight per day to meet guideline recommendations.
PubMed: 38646227
DOI: 10.7759/cureus.56654 -
Journal of Cardiothoracic Surgery Apr 2024The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right... (Review)
Review
BACKGROUND
The malposition of central venous catheters (CVCs) may lead to vascular damage, perforation, and even mediastinal injury. The malposition of CVC from the right subclavian vein into the azygos vein is extremely rare. Here, we report a patient with CVC malposition into the azygos vein via the right subclavian vein. We conduct a comprehensive review of the anatomical structure of the azygos vein and the manifestations associated with azygos vein malposition. Additionally, we explore the resolution of repositioning the catheter into the superior vena cava by carefully withdrawing a specific length of the catheter.
CASE PRESENTATION
A 79-year-old female presented to our department with symptoms of complete intestinal obstruction. A double-lumen CVC was inserted via the right subclavian vein to facilitate total parenteral nutrition. Due to the slow onset of sedative medications during surgery, the anesthetist erroneously believed that the CVC had penetrated the superior vena cava, leading to the premature removal of the CVC. Postoperative contrast-enhanced computed tomography of the chest confirmed that the central venous catheter had not penetrated the superior vena cava but malpositioned into the azygos vein. The patient was discharged 15 days after surgery without any complications.
CONCLUSIONS
CVC malposition into the azygos vein is extremely rare. Clinical practitioners should be vigilant regarding this form of catheter misplacement. Ensuring the accurate positioning of the CVC before each infusion is crucial. Utilizing chest X-rays in both frontal and lateral views, as well as chest computed tomography, can aid in confirming the presence of catheter misplacement.
Topics: Female; Humans; Aged; Azygos Vein; Catheterization, Central Venous; Vena Cava, Superior; Central Venous Catheters; Mediastinum
PubMed: 38643163
DOI: 10.1186/s13019-024-02708-9 -
Cureus Mar 2024Although the use of peripherally inserted central catheters (PICCs) has many advantages, misplacement can lead to serious life-threatening complications such as...
INTRODUCTION
Although the use of peripherally inserted central catheters (PICCs) has many advantages, misplacement can lead to serious life-threatening complications such as pericardial effusion (PCE) and cardiac tamponade (CT). This report aims to describe four cases of CT resulting from misplaced PICC, which were successfully managed.
METHODS
Retrospective analysis of neonates who required PICC insertion and had PCE leading to CT in the Neonatal Intensive Care Unit (NICU) at The Children's Hospital 2, Ho Chi Minh City, Vietnam, during the year 2022.
RESULTS
Four cases involved preterm infants at 28-30 weeks gestational age, weighing between 900-1,500 grams. The PCE/CT developed between 3 and 24 days following PICC insertion. The abrupt onset with clinical manifestations that showed hemodynamic instability included sudden deterioration, lethargy, apnea, bradycardia, pale skin, and cardiovascular collapse. We use cardiac point of care ultrasound (POCUS) to assess the condition of these patients and guide the pericardiocentesis procedure. The analysis of the aspirated fluid used for PCE/CT treatment is consistent with the component of parenteral nutrition. No deaths were encountered.
CONCLUSION
Neonates presenting sudden deterioration following PICC insertion should undergo POCUS to prompt identifying PCE/CT. Timely diagnosis via POCUS, prompt pericardiocentesis, and prevention of misplaced PICC-associated serious complications are crucial. Monitoring of the PICC position twice a week is recommended to avoid life-threatening complications. Additionally, incorporating POCUS for identifying the tip of PICC rather than relying solely on X-ray should be considered in the current protocol.
PubMed: 38638757
DOI: 10.7759/cureus.56403 -
Cureus Mar 2024Malnutrition presents a significant risk to patients undergoing gastrointestinal surgery, with direct consequences on postoperative complication rates, recovery times,... (Review)
Review
Malnutrition presents a significant risk to patients undergoing gastrointestinal surgery, with direct consequences on postoperative complication rates, recovery times, and mortality. Our systematic review, guided by PRISMA protocols, examined the impact of preoperative nutritional support on these surgical outcomes. We scrutinized publications from PubMed, Medline, Embase, and the Cochrane Library up to April 2023, including randomized controlled trials, cohort studies, and systematic reviews. The stringent selection process narrowed to 10 studies demonstrating the efficacy of preoperative nutritional support, from oral supplements to enteral and parenteral nutrition, in reducing postoperative complications and length of hospital stays while enhancing recovery rates. The benefits varied, indicating a pressing need for customized nutritional regimens based on patient demographics and surgical specifics. Our findings advocate incorporating individualized nutritional strategies into preoperative care, enhancing patient outcomes. Future research should aim to refine these strategies, focusing on the optimal timing, duration, and type of nutritional support.
PubMed: 38638718
DOI: 10.7759/cureus.56416