Trevor R. Smith

Background: There is little information about the effectiveness of oral nutritional supplements (ONS) in combatting nutrient inadequacies in primary care, where most malnutrition exists. Aim: To examine the extent to which readymade ONS add or displace the nutrients consumed in the diet and their impact on combatting dietary inadequacies. Methods: 308 free-living people >50 years with medium + high risk of malnutrition (Malnutrition Universal Screening Tool) were randomised to receive readymade low volume (2.4 kcal/mL), liquid ONS plus dietary advice (ONS + DA) or dietary advice alone (DA). Intake was assessed at baseline (24 h recall) and 4-weekly for 12 weeks (3-day diet record). Total nutrient intake was benchmarked against UK and European dietary reference values (DRVs). The proportion of energy and nutrients from the ONS that added or displaced those from the diet (net addition/displacement) was calculated. Results: ONS + DA led to significantly greater total energy and nutritional intakes, with 25/29 nutrient intakes significantly higher than with DA alone. There were no significant differences in dietary energy and nutrient intakes from food between the groups. There was little or no displacement of nutrients from the diet, with over 90% of the energy and nutrients consumed in the ONS additive to the diet. ONS + DA more than halved the number of people with nutrient intakes that failed to meet DRVs and the number of nutrients per person that did not meet DRVs compared to DA alone. Conclusions: Supplementation with readymade, low volume (2.4 kcal/mL) liquid ONS overcomes most nutrient intake inadequacies in malnourished older people in primary care without significantly reducing intake from the diet. This makes ONS an effective way to improve nutritional intakes above dietary advice alone to improve the outcomes for the management of older people at risk of malnutrition.

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.

Introduction Nasojejunal tube (NJT) insertion using the Cortrak® enteral access system (CEAS) has been reported to be a simple technique for placing postpyloric feeding tubes. CEAS uses an electromagnetic sensing device that tracks and displays the path of the feeding tube during placement at the bedside and avoids the need for endoscopic or radiological techniques. We evaluated the effectiveness of Cortrak® NJT insertion 1 year after introduction into practice at our institution. Methods A prospectively collected database including information on indications, timelines, duration and complications of Cortrak® NJ tube insertion was analysed. Insertion attempts over a 12 month period, between January 2021 and December 2021, were included. Insertions were performed by specialist nurses (1 Gastroenterology specialist nurse and 2 nutrition nurse specialists) who had undergone the necessary training. Results 77 attempts at Cortrak® NJT insertion in 62 patients were evaluated. 36 attempts (46.8%) were performed as daycase procedures with the remainder performed in patients admitted to hospital for other reasons. 12 attempts were unsuccessful (15.6%) and 7 of these went on to have endoscopically placed NJTs. Median time for insertion was 7 minutes (2 – 21 mins) and median number of days between request and insertion was 1 day (0-5 days). No patients required intravenous sedation or analgesia. There were no immediate procedural complications. During the same period, 52 endoscopic NJTs were performed. The average number of endoscopic NJTs performed annually in the preceding 3 years was 86 suggesting a trend in reduced endoscopy suite use for insertion since the introduction of Cortrak® NJTs. 15 of the patients with successful Cortrak® NJT insertions were previously reliant on the endoscopic route, including 1 patient who required multiple gastroscopies with anaesthetic support. Conclusions Cortrak® NJT insertion has been an effective, timely and safe method of post-pyloric tube insertion since introduction at our institution. This technique has the potential of reducing workload on endoscopy units and should be offered first line as the method of NJT placement in appropriate candidates.

Introduction Patients with suspected inflammatory bowel disease (IBD) referred from primary care often face diagnostic and treatment delays. This study aimed to compare a novel direct-access IBD endoscopy pathway with the traditional care model. Method Single centre real-world study analysing primary care referrals with suspected IBD. Group A: patients triaged to direct-access IBD endoscopy. Group B: patients undergoing traditional outpatient appointments before the availability of direct-access IBD endoscopy. Demographics, fecal calprotectin (FCP), C-reactive protein (CRP), disease activity score, endoscopy findings, treatment and follow-up were collected and statistically analysed. Ranked semantic analysis of IBD symptoms contained within referral letters was performed. Results Referral letters did not differ significantly in Groups A and B. Demographic data, FCP and CRP values were similar. Referral to treatment time (RTT) at the time of IBD endoscopy was reduced from 177 days (Group B) to 24 days (Group A) (pConclusion Our novel pathway resulted in an 86% reduction in RTT with associated increased diagnostic yield while saving 100% of initial IBD consultant outpatient appointments. Replication in other trusts may improve patient experience and accelerate time to diagnosis/treatment while optimising the use of healthcare resources.

Patients unable to continue decreasing PN volume for 6 months were evaluated (with colonoscopy and laboratory investigations) to start sGLP-2. Seventeen patients were started on sGLP-2. The most common underlying aetiology (42.8%) was intestinal ischaemia. Some patients could not start treatment due to active malignancies, preneoplasm, inflammatory bowel disease or lack of insurance.

COVID-19 negatively impacts nutritional status and as such identification of nutritional risk and consideration of the need for nutrition support should be fundamental in this patient group. In recent months, clinical nutrition professional organisations across the world have published nutrition support recommendations for health care professionals. This review summarises key themes of those publications linked to nutrition support of adults with or recovering from COVID-19 outside of hospital. Using our search criteria, 15 publications were identified from electronic databases and websites of clinical nutrition professional organisations, worldwide up to 19th June 2020. The key themes across these publications included the importance in the community setting of: (i) screening for malnutrition, which can be achieved by remote consultation; (ii) care plans with appropriate nutrition support, which may include food based strategies, oral nutritional supplements and referral to a dietitian; (iii) continuity of nutritional care between settings including rapid communication at discharge of malnutrition risk and requirements for ongoing nutrition support. These themes, and indeed the importance of nutritional care, are fundamental and should be integrated into pathways for the rehabilitation of patients recovering from COVID-19.

Objective: It has been assumed that a significant proportion of COVID-19 patients show evidence of hyperinflammation of which secondary haemophagocytic lymphohistiocytosis (sHLH) is the most severe manifestation. To facilitate diagnosis of sHLH the HScore has been developed and validated. We set out to examine the prevalence of sHLH-like hyperinflammation in COVID-19. Methods: We retrospectively examined HScore parameters in 626 COVID-19 cases admitted to our institute of which 567 were suitable for analysis and compared these to a cohort of confirmed infection associated sHLH cases. To account for missing data, we calculated the maximum possible HScore of the recorded parameters (%HScore). Results: Early measurement of HScore parameters (day -1 to 4 from diagnosis) strongly predicted the %HScore over the course of the admission (p <0.0001). The retrospective cohort of sHLH showed significantly higher %HScores as compared to COVID-19 (median 73.47 vs 18.13 respectively, p <0.0001). The overall prevalence of individuals with an 80% probability of sHLH in our COVID-19 cohort was 1.59% on admission and only rose to 4.05% during the whole disease course. In the small cohort with scores suggestive of sHLH, there was no excess mortality compared with the whole cohort. %HScores were higher in younger patients (p<0.0001) and did not reliably predict outcome at any cut-off value (AUROC 0.533, p=0.211; OR 0.99). Conclusion: Surprisingly, these findings show that sHLH-type hyperinflammation is not prevalent in COVID-19, and %HScores do not predict outcome. Therefore, new algorithms are required to optimise case selection for clinical trials of targeted anti-inflammatory interventions.

Large trials assessing oral nutritional supplements (ONS) and dietary advice (DA) in primary care are lacking. This study examined effects of ONS + DA versus DA on intake, weight, QoL, healthcare use and satisfaction in malnourished free-living older people. Three hundred and eight people (71.5 ± 10.7y) were randomised to receive ONS + DA (n154) or DA (n154) for 12 weeks. At baseline, 4, 8, 12 weeks, intake, weight, QoL, healthcare use and satisfaction were measured. ONS + DA group (mean daily intake ONS 480 kcal; 21 g protein; 80% compliance) had significantly greater total energy and protein intakes (+401 kcal/d, p < 0.001; +15 g/d, p < 0.001) and weight gain (+0.8 kg; p < 0.001) compared to DA. QoL improved in both groups over time with a significant improvement in index with ONS + DA (p = 0.009). Significantly more participants found ONS + DA made a difference for them (p = 0.011), but no differences were found between groups using Euroqol. Compared to DA, healthcare use reduced with ONS + DA, (HCP visits by 34%, emergency admissions 50%, LOS 62%). Acceptability of both interventions was high (ONS 96%, DA 95%), with significantly more participants satisfied with ONS (89%) than DA (73%) (p = 0.009). This trial in primary care indicates that ONS are acceptable, make a difference to patients, significantly improve intake and weight, and reduce health care use with potential savings.