Pilot study investigating the effect of enteral and parenteral nutrition on the gastrointestinal microbiome post-allogeneic transplantation

Nutrition support is frequently required post-allogeneic haematopoietic progenitor cell transplantation (HPCT); however, the impact of mode of feeding on the gastrointestinal microbiome has not been explored. This study aimed to determine if there is a difference in the microbiome between patients receiving enteral nutrition (EN) and parenteral nutrition (PN) post-allogeneic HPCT. Twenty-three patients received either early EN or PN when required. Stool samples were collected at 30 days post-transplant and analysed with shotgun metagenomic sequencing. There was no difference in microbial diversity between patients who received predominantly EN (n = 13) vs. PN (n = 10) however patients who received predominantly EN had greater abundance of Faecalibacterium (P < 0·001) and ruminococcus E bromii (P = 0·026). Patients who had minimal oral intake for a longer duration during provision of nutrition support had a different overall microbial profile (P = 0·044), lower microbial diversity (P = 0·004) and lower abundance of faecalibacterium prausnitzii_C (P = 0·030) and Blautia (P = 0·007) compared to patients with greater oral intake. Lower microbial diversity was found in patients who received additional beta lactam antibiotics (P = 0·042) or had a longer length of hospital stay (P = 0·019). Post-HPCT oral intake should be encouraged to maintain microbiota diversity and, if nutrition support is required, EN may promote a more optimal microbiota profile.     

A quality improvement nutrition screening and intervention program available to Home and Community Care eligible clients

Objective:  To develop and implement a nutrition screening and dietetic referral system for Home and Community Care (HACC) eligible clients.
Design:  Quality improvement project utilising a prospective, observational design.
Setting:  Sixteen Australian organisations caring for HACC eligible clients.
Subjects:  One thousand one hundred and forty-five HACC eligible clients (mean age 76.5 ± 7.2 years) were screened for nutritional risk during 2003–2005.
Interventions:  Nutrition screening was conducted by trained project officers, allied health staff, community care coordinators and nursing staff using a modified version of the malnutrition screening tool (MST). Dietitians performed a nutrition assessment using the scored Patient Generated-Subjective Global Assessment (PG-SGA) and provided individualised nutrition counselling for those identified to be at risk of malnutrition and agreeing to treatment.
Results:  According to the MST, 170 clients (15%) were identified as being at risk of malnutrition. Of these, 75 (44%) agreed to the dietetic referral and PG-SGA assessment, and 57 were subsequently assessed as malnourished (PG-SGA category B or C), suggesting a malnutrition prevalence between 5% and 11%. Of the 34 malnourished clients receiving multiple dietetic reviews (mean 4.1 ± 2.0 per client), 28 improved, with 17 achieving a well-nourished PG-SGA A rating.
Conclusion:  The development and implementation of a nutrition screening and referral system can identify HACC eligible clients who would benefit from services provided by a dietitian. Further research should identify the reasons why some HACC eligible clients are reluctant to be referred to a dietitian.     

Psychological morbidity in Australian doctors who have and have not experienced a medico-legal matter: cross-sectional survey

OBJECTIVE: To describe the differences in psychological morbidity between Australian general practitioners (GPs) who have experienced a medico-legal matter and those who have not. METHODS: A total of 1,499 GPs were initially invited to participate in the study. Two hundred and sixty requested not to participate, with 1,239 subsequently being sent a survey. There were 566 respondents (45.7% response rate to survey). There were two sources of data. First, a cross-sectional survey sought demographic information, personality traits via the Eysenck Personality Questionnaire (EPQ), history of a medico-legal matter with any medical defence organization, and measures of psychological morbidity, including the General Health Questionnaire (GHQ), Sheehan Disability Scale (SDS), and Alcohol Use Disorders Identification Test. Second, information was extracted from the United Medical Protection database on medico-legal matters. RESULTS: Fifty-nine per cent of respondents to the survey reported ever having a medico-legal matter, with 13% having a current medico-legal matter. Those with a current matter reported increased levels of disability (in work, social or family life) and higher prevalence of psychiatric morbidity (45% vs 27% GHQ 'case identification' rates), compared to those with no current matter. Those respondents with a history of past medico-legal matters reported increased levels of disability (SDS) and depression subscores (GHQ). Male respondents drank significantly more alcohol than female respondents, and male respondents with current or past medico-legal matters had significantly higher levels of alcohol use than male respondents with no experience of medico-legal matters. CONCLUSIONS: Doctors who have current and past medico-legal matters have a higher level of psychological morbidity. The study design was unable to distinguish cause or effect. A longitudinal study is planned to investigate this. The findings have significant implications for medical training, doctor support systems and medical insurance groups.     

Factors associated with health care-acquired urinary tract infection

BACKGROUND: Health care-acquired urinary tract infection is common, and the risk factors should be understood by those who manage hospitalized patients and researchers interested in interventions and programs designed to reduce rates. METHODS: We used multivariable logistic regression to identify factors that demonstrated a statistical association with infection. RESULTS: The incidence rate for infection was 1.66%, and risks increased for patients with prolonged length of stay (odd ratio [OR], 5.28; 95% confidence interval [CI]: 2.46-11.34), urinary catheter (OR, 5.16; 95% CI: 2.84-9.36), unresolved spinal injury (OR, 4.07; 95% CI: 1.04-15.92), transfer to/from another hospital (OR, 2.9; 95% CI: 1.39-6.04), some assistance for daily living prior to admission (OR, 2.58; 95% CI: 1.51-4.41), underlying neurologic disease (OR, 2.59; 95% CI: 1.49-4.49), previous stroke (OR, 1.94; 95% CI: 1.03-3.67), and fracture or dislocation on admission (OR, 3.34; 95% CI: 1.75-6.38). Male sex was protective (OR, 0.44; 95% CI: 0.26-0.77). CONCLUSION: Our data describe a general hospital population and therefore have relevance to many hospital-based health care professionals. The statistical model is a good fit to the data and has good predictive power. We identify high-risk groups and confirm the need for good decision making for managing the risks of health care-acquired urinary tract infection. This requires information on the effectiveness of risk-reducing strategies and the changes to economic costs and health benefits that result and the synthesis of these data in appropriately designed economic models.     

Obesity management in liver clinics: translation of research into clinical practice

BACKGROUND AND AIMS: Despite the benefits of modest weight reduction for overweight patients with chronic liver disease, long-term maintenance of weight loss is difficult to achieve in clinical practice. The aims of this study were to determine if a nutrition research protocol could be translated into clinical practice and meet the demand for dietetic service, to evaluate the effectiveness and resource implications of intensive lifestyle intervention for weight loss, and to assess the effectiveness of standard dietetic therapy as a treatment option for patients unable to attend the program. METHOD: Using a modified research protocol, an intensive weight reduction program was introduced into standard clinical care for overweight patients attending a tertiary hospital liver outpatient clinic. An audit of weight loss and cost outcomes was conducted. RESULTS: Ninety-three patients were referred to the dietetic service for weight management. Of these, 50 enrolled in an intensive lifestyle intervention, 18 received standard dietetic therapy and 25 refused any intervention. After 6 months, 83% of patients in the intensive intervention achieved weight loss with a significant decrease in weight (P < 0.001) and waist circumference (P < 0.001). In contrast, only 24% of patients receiving standard dietetic therapy achieved weight loss with no significant change in mean weight or waist circumference. Cost per kilogram weight loss after intensive intervention was $AU31 and continuation of lifestyle intervention was calculated to be less than $AU100 per patient per year. CONCLUSIONS: A clinically based, intensive lifestyle intervention is a feasible treatment option for outpatient weight management in overweight patients with chronic liver disease. Providing patients who are unable to participate in intensive programs with standard dietetic therapy is not cost-effective.