The Nutritional Intake of Patients with Organic Acidaemias on Enteral Tube Feeding: Can We Do Better?

BACKGROUND

Detailed nutritional intake data on children with organic acidaemias (OA) (propionic acidaemia (PA), vitamin B12 nonresponsive methylmalonic acidaemia (MMA) and isovaleric acidaemia (IVA)) remains unreported. Aim and subjects: A review of the longitudinal nutritional intake of 14 children with organic acidaemias (PA n = 8; MMA n = 5; IVA n = 1) dependent on enteral tube feeding (≥90% of energy requirements) from a single treatment centre.

METHODS

Nutritional intake (energy, protein, precursor-free L-amino acids, vitamins and minerals), anthropometry and nutritional biochemistry data were collated from diagnosis to current age.

RESULTS

The median energy intake was only 72% (63-137) of the estimated average DH (1991) requirement (EAR), decreasing significantly by 40% between 6 months and 5 years (p < 0.05). Total protein intake met WHO/FAO/UNU (2007) safe intake levels with median (range) precursor-free L-amino acids providing 21% (14-28) of total protein intake. Median mineral intake for sodium was 57% (20-97%), potassium 64% (27-125%) and magnesium 72% (22-116%) and was consistently < RNI for all age points. Fibre median intake was 4 g/day (0-11 g), and fluid intake provided 80% (60-100%) of the requirements for age. Linear growth was poor, and children were overweight for their height (1-10 years: z score median weight +0.6, height -1.2). Nutritional markers consistently indicated that plasma valine concentrations were < target reference ranges in PA and MMA. Iron deficiency anaemia was common in MMA/PA, and in PA, 50% of plasma zinc concentrations were < reference range.

CONCLUSION

In MMA/PA, energy intake decreases over time, weight gain accelerates, but linear height is poor. There are many nutrient deficiencies which may affect short- and long-term outcome of patients with organic acidaemias. The quality of long-term diet in these conditions deserves more attention.

Bevacizumab and Combination Chemotherapy in rectal cancer Until Surgery (BACCHUS): a phase II, multicentre, open-label, randomised study of neoadjuvant chemotherapy alone in patients with high-risk cancer of the rectum

BACKGROUND

In locally advanced rectal cancer (LARC) preoperative chemoradiation (CRT) is the standard of care, but the risk of local recurrence is low with good quality total mesorectal excision (TME), although many still develop metastatic disease. Current challenges in treating rectal cancer include the development of effective organ-preserving approaches and the prevention of subsequent metastatic disease. Neoadjuvant systemic chemotherapy (NACT) alone may reduce local and systemic recurrences, and may be more effective than postoperative treatments which often have poor compliance. Investigation of intensified NACT is warranted to improve outcomes for patients with LARC. The objective is to evaluate feasibility and efficacy of a four-drug regimen containing bevacizumab prior to surgical resection.

METHODS/DESIGN

This is a multi-centre, randomized phase II trial. Eligible patients must have histologically confirmed LARC with distal part of the tumour 4-12 cm from anal verge, no metastases, and poor prognostic features on pelvic MRI. Sixty patients will be randomly assigned in a 1:1 ratio to receive folinic acid + flurourcil + oxaliplatin (FOLFOX) + bevacizumab (BVZ) or FOLFOX + irinotecan (FOLFOXIRI) + BVZ, given in 2 weekly cycles for up to 6 cycles prior to TME. Patients stop treatment if they fail to respond after 3 cycles (defined as ≥ 30 % decrease in Standardised Uptake Value (SUV) compared to baseline PET/CT). The primary endpoint is pathological complete response rate. Secondary endpoints include objective response rate, MRI tumour regression grade, involved circumferential resection margin rate, T and N stage downstaging, progression-free survival, disease-free survival, overall survival, local control, 1-year colostomy rate, acute toxicity, compliance to chemotherapy.

DISCUSSION

In LARC, a neoadjuvant chemotherapy regimen - if feasible, effective and tolerable would be suitable for testing as the novel arm against the current standards of short course preoperative radiotherapy (SCPRT) and/or fluorouracil (5FU)-based CRT in a future randomised phase III trial.

TRIAL REGISTRATION

Clinical trial identifier BACCHUS: NCT01650428.

The lactose and galactose content of milk fats and suitability for galactosaemia

Introduction

Butter oil, ghee and butter are theoretically low in lactose. All three products are high in milk fat; butter oil and ghee contain approximately 99.3% fat and butter around 80% fat. We report the lactose and galactose content of butter, ghee, and butter oil and assess their suitability in a low galactose diet.

Methods

A total of 12 samples (butter oil n = 5, ghee n = 5, butter n = 2) were analysed by High-Performance Anion Exchange Chromatography with Pulsed Amperometric Detection (HPAEC-PAD) technology used to perform lactose and galactose analyses.

Results

Butter oil and ghee were consistently low in lactose and galactose. Butter oil analysis: lactose, 0.47 to 3.08 mg/100 g; galactose, < 0.05 to 2.28 mg/100 g. Ghee analysis: lactose, < 0.05 to 2.9 mg/100 g; galactose, < 0.05 mg to < 1.0 mg/100 g. Butter analysis: lactose 685 to 688 mg/100 g; galactose, 1.3 mg to 1.6 mg/100 g.

Conclusions

Butter oil (commonly used in food industry) and ghee contain minimal lactose and galactose and so are permitted in a UK galactosaemia diet. Butter is considered too high in lactose and is unsuitable in a low galactose diet.

How strict is galactose restriction in adults with galactosaemia? International practice

Dietary management of 418 adult patients with galactosaemia (from 39 centres/12 countries) was compared. All centres advised lactose restriction, 6 restricted galactose from galactosides ± fruits and vegetables and 12 offal. 38% (n=15) relaxed diet by: 1) allowing traces of lactose in manufactured foods (n=13) or 2) giving fruits, vegetables and galactosides (n=2). Only 15% (n=6) calculated dietary galactose. 32% of patients were lost to dietetic follow-up. In adult galactosaemia, there is limited diet relaxation.

Practices in prescribing protein substitutes for PKU in Europe: No uniformity of approach

BACKGROUND

There appears little consensus concerning protein requirements in phenylketonuria (PKU).

METHODS

A questionnaire completed by 63 European and Turkish IMD centres from 18 countries collected data on prescribed total protein intake (natural/intact protein and phenylalanine-free protein substitute [PS]) by age, administration frequency and method, monitoring, and type of protein substitute. Data were analysed by European region using descriptive statistics.

RESULTS

The amount of total protein (from PS and natural/intact protein) varied according to the European region. Higher median amounts of total protein were prescribed in infants and children in Northern Europe (n=24 centres) (infants <1 year, >2-3g/kg/day; 1-3 years of age, >2-3 g/kg/day; 4-10 years of age, >1.5-2.5 g/kg/day) and Southern Europe (n=10 centres) (infants <1 year, 2.5 g/kg/day, 1-3 years of age, 2 g/kg/day; 4-10 years of age, 1.5-2 g/kg/day), than by Eastern Europe (n=4 centres) (infants <1 year, 2.5 g/kg/day, 1-3 years of age, >2-2.5 g/kg/day; 4-10 years of age, >1.5-2 g/kg/day) and with Western Europe (n=25 centres) giving the least (infants <1 year, >2-2.5 g/kg/day, 1-3 years of age, 1.5-2 g/kg/day; 4-10 years of age, 1-1.5 g/kg/day). Total protein prescription was similar in patients aged >10 years (1-1.5 g/kg/day) and maternal patients (1-1.5 g/kg/day).

CONCLUSIONS

The amounts of total protein prescribed varied between European countries and appeared to be influenced by geographical region. In PKU, all gave higher than the recommended 2007 WHO/FAO/UNU safe levels of protein intake for the general population.

The development of practice standards for radiation oncology in Australia: a tripartite approach

In many areas of health care, practice standards have become an accepted method for professions to assess and improve the quality of care delivery. The aim of this work is to present the development of practice standards for radiation oncology in Australia, highlighting critical points and lessons learned. Following a review of radiotherapy services in Australia, a multidisciplinary group with support from the Australian Government developed practice standards for radiation oncology in Australia. The standards were produced in a multistep process including a nationwide survey of radiotherapy centres and piloting of the standards in a representative subset of all Australian radiotherapy centres. The standards are grouped into three sections: Facility management (covering staffing, data management, equipment and processes); Treatment planning and delivery (providing more detailed guidance on prescription, planning and delivery); Safety and quality management (including radiation safety, incident monitoring and clinical trials participation). Each of the 16 standards contains specific criteria, a commentary and suggestions for the evidence required to demonstrate compliance. The development of the standards was challenging and time consuming, but the collaborative efforts of the professions resulted in standards applicable throughout Australia and possibly further afield.

Overweight and obesity in PKU: The results from 8 centres in Europe and Turkey

Introduction

In PKU there is little data comparing the prevalence of overweight and obesity in different countries. The aim of this cross sectional study was to evaluate prevalence data from different PKU treatment centres in Europe and Turkey.

Subjects and methods

In children, body mass index (BMI) and z scores and in adults BMI were calculated in 947 patients (783 children aged < 19 years; 164 adults aged ≥ 19 years) with PKU from centres in Europe and Turkey (Ankara, Birmingham, Brussels, Copenhagen, Groningen, Madrid, Munich and Porto).

Results

In adults with PKU, 83% of centres (n = 5/6) had less overweight than the general populations but 83% (n = 5/6) had a higher rate of female obesity. In childhood, all centres reported obesity rates within or similar to local population ranges in boys but in 57% (n = 4/7) of centres a higher rate of obesity in girls. The percentage of overweight and obesity increased with age.

Discussion

In PKU, it is clear from a number of treatment centres that women and girls with PKU appear particularly vulnerable to excess weight gain and it is important that female weight gain is closely monitored and individual strategies introduced to prevent excess weight gain. Overall, in PKU there is a need to understand better the food patterns and activity levels of patients.

•

This is the first multicentre study in PKU across Europe/Turkey reporting prevalence of overweight and obesity in 947 patients.

•

In adult centres, 83% had less overweight/obesity then the general populations.

•

In adult centres, 83% had a higher rate of female obesity.

•

In children, all centres reported obesity rates within or similar to local population ranges in boys

•

In children, 57% of centres reported a higher rate of obesity in girls.

Pasteurella multocida infected total knee arthroplasty: a case report and review of the literature

Pasteurella multocida is a rare cause of prosthetic joint infection. This infection generally follows significant animal contact, usually licks and scratches. We report a case of P multocida infection that was treated with linezolid with salvage of the implant. Linezolid is generally active against Gram-positive organisms only with the exception of Pasteurella, which is Gram-negative. We extensively review the previous reported cases of implant infection with P multocida.

Dietary practices in pyridoxine non-responsive homocystinuria: a European survey

BACKGROUND

Within Europe, the management of pyridoxine (B6) non-responsive homocystinuria (HCU) may vary but there is limited knowledge about treatment practice.

AIM

A comparison of dietetic management practices of patients with B6 non-responsive HCU in European centres.

METHODS

A cross-sectional audit by questionnaire was completed by 29 inherited metabolic disorder (IMD) centres: (14 UK, 5 Germany, 3 Netherlands, 2 Switzerland, 2 Portugal, 1 France, 1 Norway, 1 Belgium).

RESULTS

181 patients (73% >16 years of age) with HCU were identified. The majority (66%; n=119) were on dietary treatment (1-10 years, 90%; 11-16 years, 82%; and >16 years, 58%) with or without betaine and 34% (n=62) were on betaine alone. The median natural protein intake (g/day) on diet only was, by age: 1-10 years, 12 g; 11-16 years, 11 g; and >16 years, 45 g. With diet and betaine, median natural protein intake (g/day) by age was: 1-10 years, 13 g; 11-16 years, 20 g; and >16 years, 38 g. Fifty-two percent (n=15) of centres allocated natural protein by calculating methionine rather than a protein exchange system. A methionine-free l-amino acid supplement was prescribed for 86% of diet treated patients. Fifty-two percent of centres recommended cystine supplements for low plasma concentrations. Target treatment concentrations for homocystine/homocysteine (free/total) and frequency of biochemical monitoring varied.

CONCLUSION

In B6 non-responsive HCU the prescription of dietary restriction by IMD centres declined with age, potentially associated with poor adherence in older patients. Inconsistencies in biochemical monitoring and treatment indicate the need for international consensus guidelines.

Possible Kondo physics near a metal-insulator crossover in the a-site ordered perovskite CaCu3Ir4O12

The A-site ordered perovskite (AA(3)')B(4)O(12) can accommodate transition metals on both A' and B sites in the crystal structure. Because of this structural feature, it is possible to have narrow-band electrons interacting with broadband electrons from different sublattices. Here we report a new A-site ordered perovskite (CaCu(3))Ir(4)O(12) synthesized under high pressure. The coupling between localized spins on Cu(2+) and itinerant electrons from the Ir-O sublattice makes Kondo-like physics take place at a temperature as high as 80 K. Results from the local density approximation calculation have confirmed the relevant band structure. The magnetization anomaly found at 80 K can be well rationalized by the two-fluid model.

Body mass index in adult patients with diet-treated phenylketonuria

BACKGROUND

There is an increasing number of adults with phenylketonuria (PKU) on a low phenylalanine diet. In the general population, an increasing body mass index (BMI) in the UK is a major problem with associated co-morbidities. The present study aimed to identify whether patients with diet-treated PKU have obesity rates comparable to those in the general population.

METHODS

Two hundred and thirty-six PKU subjects (49% male, 51% female), aged >16 years, who were diagnosed by newborn screening and were receiving a low phenylalanine diet, were identified from seven metabolic centres in the UK. Retrospective data were collated on age, sex, BMI and mean phenylalanine concentration over the previous 12 months.

RESULTS

Mean (SD) phenylalanine concentration for all 236 subjects was 789 (311) μm; mean (SD) BMI was 26 (5.4) kg m(-2) [males 25 (4.3) kg m(-2) , females 27 (6.2) kg m(-2) ]; mean (SD) age was 26 (7) years; and 55% had a BMI > 25 kg m(-2) . The percentage of subjects with a BMI >25 kg m(-2) and >30 kg m(-2) , as well as increasing obesity with age, was similar to the UK population. A correlation was observed between increasing BMI and a higher phenylalanine concentration (r = 0.243, P = 0.001).

CONCLUSIONS

The number of overweight and obese patients with diet-treated PKU in the UK is a concern. This could lead to other obesity-related complications increasing the complexity of diet and the cost of their care. There is a need to educate patients with respect to adopting a healthy, low phenylalanine diet and lifestyle to prevent further rises in BMI.

Use of sapropterin in the management of phenylketonuria: seven case reports

Sapropterin treatment, with or without dietary treatment, improves blood phenylalanine control, increases phenylalanine tolerance, and may reduce the day-to-day dietary treatment burden in a subset of patients with phenylketonuria (PKU). Balancing the need for maintained control of blood phenylalanine with diet relaxation is complex when administering sapropterin. We present a series of seven patient cases with PKU that illustrate important aspects of using sapropterin with diet in the management of the disorder.

Main issues in micronutrient supplementation in phenylketonuria

For almost all patients with PKU, a low phenylalanine diet is the basis of the treatment despite a widely varying natural protein tolerance. A vitamin and mineral supplement is essential and it is commonly added to a phenylalanine-free (phe-free) source of L-amino acids. In PKU, many phe-free L-amino acid supplements have age-specific vitamin and mineral profiles to meet individual requirements. The main micronutrient sources are chemically derived and their delivery dosage is usually advised in three or more doses throughout the day. Within the EU, the composition of VM (vitamin and mineral) phe-free L-amino acid supplements is governed by the Foods for Special Medical Purposes (FSMP) directive (European Commission Directive number 1999/21/EC and amended by Directive 2006/141/EC). However the micronutrient composition of the majority fails to remain within FSMP micronutrient maximum limits per 100 kcal due to their low energy content and so compositional exceptions to the FSMP directive have to be granted for each supplement. All patients with PKU require an annual nutritional follow-up, until it has been proven that they are not at risk of any vitamin and mineral imbalances. When non-dietary treatments are used to either replace or act as an adjunct to diet therapy, the quality of micronutrient intake should still be considered important and monitored systematically. European guidelines are required about which micronutrients should be measured and the conditions (fasting status) for monitoring.

Micronutrient status in phenylketonuria

Patients with phenylketonuria (PKU) encompass an 'at risk' group for micronutrient imbalances. Optimal nutrient status is challenging particularly when a substantial proportion of nutrient intake is from non-natural sources. In PKU patients following dietary treatment, supplementation with micronutrients is a necessity and vitamins and minerals should either be added to supplement phenylalanine-free l-amino acids or given separately. In this literature review of papers published since 1990, the prevalence of vitamin and mineral deficiency is described, with reference to age of treatment commencement, type of treatment, dietary compliance, and dietary practices. Biological micronutrient inadequacies have been mainly reported for zinc, selenium, iron, vitamin B12 and folate. The aetiology of these results and possible clinical and biological implications are discussed. In PKU there is not a simple relationship between the dietary intake and nutritional status, and there are many independent and interrelated complex factors that should be considered other than quantitative nutritional intake.

Home enteral tube feeding in children with inherited metabolic disorders: a review of long-term carer knowledge and technique

BACKGROUND

Home enteral tube feeding (HETF) is commonly used in children with inherited metabolic disorders (IMD). It is unclear how caregiver knowledge and their safety in using tube feeding techniques changes over time.

METHODS

Caregivers of children with IMD on HETF from one UK IMD centre had annual interviews over 3 years using a structured questionnaire and observation to assess HETF knowledge and safety techniques.

RESULTS

Thirty-two caregivers of IMD children (median age 5.3 years; range 0.3-13.6 years) were studied. Seventy-eight percent (n = 25) of subjects had been on HETF for >5 years. Over 3 years, many caregivers' HETF techniques deteriorated: accurate feed ingredient measurement decreased from 36% to 11%; correct flushing of tubes decreased from 56% to 44%; checking tube position as recommended decreased from 72% to 56%; and correct hand washing decreased from 38% to 25%. Despite improvements, knowledge of some aspects remained poorly understood: dangers of incorrect tube placement increased from 41% to 56%; correct position for night feeding increased from 38% to 56%; and feed ingredient storage decreased from 87% to 38%.

CONCLUSIONS

The HETF techniques of caregivers of children with IMD declined over time. Caregivers need to understand that HETF, particularly in IMD, is a serious procedure associated with life-threatening risks. Poor HETF practices may cause feed contamination, incorrect feed concentration, feed intolerance, aspiration, peritonitis and even metabolic decompensation. HETF skills should be reassessed annually, with compulsory retraining if basic 'core' HETF competencies are not demonstrated.

Dietary management of urea cycle disorders: UK practice

BACKGROUND

There is no published data describing UK dietary management of urea cycle disorders (UCD). The present study describes dietary practices in UK inherited metabolic disorder (IMD) centres.

METHODS

Cross-sectional data from 16 IMD centres were collected by a questionnaire describing the management of UCD patients on prescribed protein-restricted diets.

RESULTS

One hundred and seventy-five patients [N-acetylglutamate synthase deficiency, n = 3; carbamoyl phosphate synthase deficiency (CPS), n = 8; ornithine transcarbamoylase deficiency (OTC), n = 75; citrullinaemia, n = 41; argininosuccinic aciduria (ASA), n = 36; arginase deficiency, n = 12] were reported; 70% (n = 123) aged 0-16 years; 30% (n = 52) >16 years. Prescribed median protein intake decreased with age (0-6 months: 2 g kg(-1) day(-1); 7-12 months: 1.6 g kg(-1) day(-1); 1-10 years: 1.3 g kg(-1) day(-1); 11-16 years: 0.9 g kg(-1) day(-1) and >16 years: 0.8 g kg(-1) day(-1)) with little variation between disorders. Adult protein prescription ranged 0.4-1.2 g kg(-1) day(-1) (40-60 g day(-1)). In the previous 2 years, 30% (n = 53) were given essential amino acid supplements (EAAs) (CPS, n = 2; OTC, n = 20; citrullinaemia, n = 15; ASA, n = 7; arginase deficiency, n = 9). EAAs were prescribed for low plasma quantitative essential amino acids (n = 13 centres); inadequate natural protein intake (n = 11) and poor metabolic control (n = 9). From diagnosis, one centre prescribed EAAs for all patients and one centre for severe defects only. Only 3% (n = 6) were given branch chain amino acid supplements. Enteral feeding tubes were used by 25% (n = 44) for feeds and 3% (n = 6) for medications. Oral energy supplements were prescribed in 17% (n = 30) of cases.

CONCLUSIONS

In the UK, protein restriction based on World Health Organization 'safe intakes of protein', is the principle dietary treatment for UCD. EAA supplements are prescribed mainly on clinical need. Multicentre collaborative research is required to define optimal dietary treatments.

Diet in phenylketonuria: a snapshot of special dietary costs and reimbursement systems in 10 international centers

BACKGROUND AND AIMS

To gather exploratory data on the costs and reimbursement of special dietary foods used in the management of phenylketonuria (PKU) from ten international specialist PKU centers.

METHODS

Experts from each center provided data on retail costs of the three most frequently used phenylalanine-free protein substitutes and low-protein foods at their center; reimbursement of protein substitutes and low-protein foods; and state monetary benefits provided to PKU patients.

RESULTS

The mean annual cost of protein substitutes across 4 age groups (2 y, 8 y, 15 y and adults) ranged from €4273 to €21,590 per patient. The cost of low-protein products also differed; the mean cost of low-protein bread varied from €0.04 to €1.60 per 100 kcal. All protein substitutes were either fully reimbursed or covered by health insurance. However, reimbursement for low-protein products varied and state benefits differed between centers.

CONCLUSIONS

The variation in the cost and reimbursement of diet therapy and the level of additional state benefits for PKU patients demonstrates the large difference in expenditure on and access to PKU dietary products. This highlights the inequality between healthcare systems and access to special dietary products for people with PKU, ultimately leading to patients in some countries receiving better care than others.

Diurnal variation of phenylalanine concentrations in tyrosinaemia type 1: should we be concerned?

BACKGROUND

Tyrosinaemia type 1 (HT1) is treated with a tyrosine and phenylalanine-restricted diet, amino acids free of phenylalanine and tyrosine, and nitisinone (NTBC). Treatment guidelines recommend plasma tyrosine between 200-400 μm and phenylalanine at least >30 μm. There is little information on the diurnal variation of plasma tyrosine or phenylalanine in HT1. Low plasma phenylalanine <30 μm may be associated with poor growth and cognitive delay. The present study aimed to document diurnal variation of tyrosine and phenylalanine plasma concentrations and growth in children with HT1.

METHODS

Median tyrosine and phenylalanine plasma concentrations were reviewed retrospectively over 3 years in 11 subjects (median age 4 years) with HT1. Subjects routinely collected morning fasting blood samples but afternoon nonfasted samples were taken in the clinic (<10% of samples). Growth Z-scores were calculated.

RESULTS

The percentage of all plasma phenylalanine concentrations <30 μm was 8.6% and <40 μm was 13.6%. Only 2% of fasting morning phenylalanine concentrations were <30 μm, compared to 83% of nonfasting afternoon samples. All but one child had a height Z-score <0.

CONCLUSIONS

Blood phenylalanine concentrations were consistently lower in the afternoon. Taking blood samples at variable time points in the day may lead to variation in interpreting dietary control. A detailed study is necessary to examine the 24-h diurnal variation of plasma phenylalanine and tyrosine in HT1. It is possible that phenylalanine concentrations may be very low for a substantive time over 24 h and the potential impact that this may have on cognitive development and growth in children is unknown.

Acquired progressive kinking of hair affecting the scalp and eyelashes in an adult woman

Acquired hair kinking of scalp hair in adults is an unusual, rarely reported phenomenon. There are several possible aetiologies, including drug-induced changes, diffuse partial woolly hair, and acquired progressive kinking of hair (APKH). We report a case of focal APKH occurring in an adult woman. This was associated with a previously unreported feature, that of eyelash involvement.

Nutrition in phenylketonuria

The same basic principles are used to deliver dietary treatment in PKU that was developed sixty years ago. Dietary treatment is undoubtedly very successful, but it has gradually evolved and been guided commonly by individual experience and expert opinion only. There is little international consensus about dietary practice with improvements in specialist dietary products concentrating on taste and presentation rather than nutritional composition. Many areas of dietary treatment have not been rigorously examined. In particular, the amino acid and micronutrient profile of Phenylalanine-free (phe-free) amino acids requires further study. In different formulations of phe-free amino acids, there are variations in the amino acid patterns as well the amount of essential and non essential amino acids per 100g/amino acids. The amount of added tyrosine and branch chain amino varies substantially, and in PKU specifically, there is little data about their relative absorption rates and bioavailability. In phe-free amino acids, there is evidence suggesting that some of the added micronutrients may be excessive and so the source and amount of each micronutrient should be scrutinized, with a need for the development of international nutritional composition standards exclusively for these products. There is a dearth of data about the life-long phenylalanine tolerance of patients or the nutritional state of adult patients treated with diet. There is a growing need to measure body composition routinely in children with PKU and with the rise in childhood obesity, it is important to measure body fatness and identify those who are at greatest risk of 'co-morbidities' of obesity. There is necessity for international collaboration to ensure robust data is collected on many basic aspects of nutritional care to guarantee that diet therapy is delivered to the highest standard.

Planning for the North Carolina healthy homes initiative

Substandard housing conditions have been linked to widespread childhood environmental health ailments, including two of the leading causes of childhood morbidity: lead poisoning and asthma. In 2009, the United States Surgeon General called for action around healthy homes. Improving home health environments can alleviate the cycle of childhood morbidity and mortality. The North Carolina (NC) Department of Environment and Natural Resources Children's Environmental Health Branch is working to build capacity at the State level to expand the childhood lead poisoning prevention program to respond to additional in-home environmental health issues. To achieve this objective, North Carolina must consider recommendations for assessment, management, and evaluation. This paper will situate healthy homes on the national public health agenda; discuss ways that healthy homes programs address children's environmental health disparities; introduce the NC Healthy Homes Initiative; explore current healthy housing efforts in North Carolina through an examination of the Guilford County Healthy Homes Initiative; and provide recommendations for the NC Healthy Homes Initiative to address children's environmental health disparities.

Accuracy of home enteral feed preparation for children with inherited metabolic disorders

BACKGROUND

Many children with rare chronic disorders require home enteral tube feeds (HETF) consisting of multiple modular ingredients. Feeds are often complex and the risk of errors during their preparation is high. The consequences of over- or under-concentration can be critical. The aim of the present prospective observation study was to assess the accuracy, skills and technique of caregivers when preparing and administering HETF.

METHODS

Fifty-two HETF patients (median age 7.5 years, range 0.7-18.0 years) with inherited metabolic disorders (IMD) requiring special feeds were recruited. Using observation and a structured questionnaire, a practical assessment of feed preparation and storage by the main caregiver was undertaken by an independent dietitian and nurse in the child's home, including hygiene practices, accuracy of measuring recipe ingredients, and storage of both ingredients and prepared feeds.

RESULTS

The majority (85%; n = 44) of feeds were based on >1 ingredient (median 3; range 1-6). Almost half (48%; n = 25) of caregivers measured feed ingredients inaccurately. Of the 31% (n = 16) using scoops, 31% used incorrect measuring spoons and 25% did not level scoops appropriately. Some 45% (n = 20/44) of carers measured liquid ingredients inaccurately. Hygiene practices during feed preparation were poor, including a lack of hand washing (31%: n = 16) and incorrect storage procedures for unused feed ingredients (56%; n = 29).

CONCLUSIONS

Practices in the preparation of modular HETF for children with IMD were not ideal. A combination of inaccuracy, poor hygiene, inappropriate storage, and long feed hanging times increases both metabolic and microbial risk. Better education, regular monitoring and the development of ready-to-use or preweighed ingredients would be beneficial.

Errors in emergency feeds in inherited metabolic disorders: a randomised controlled trial of three preparation methods

OBJECTIVE

Glucose polymer-based emergency feeds (EF), used during illness to prevent metabolic decompensation and encephalopathy in inherited metabolic disorders, should be produced accurately and safely.

DESIGN

In a randomised, prospective, controlled study, the aim was to investigate if when preparing age-appropriate EF, a pre-measured sachet of glucose polymer, compared with scoops and weighing (using digital scales), decreased carer errors.

SUBJECTS

47 carers (3 men, 44 women) of 52 inherited metabolic disorders patients were recruited.

SETTING AND INTERVENTION

The carers made EF using all three techniques (weighing, scoops and pre-measured sachets) under supervision in controlled and home conditions. A 100-ml aliquot of each EF was analysed for carbohydrate concentration.

RESULTS

Under controlled preparation conditions, with 1 litre EFs, the % median glucose polymer concentration closest to target amounts was (1) pre-measured sachets (105%), (2) weighing (107%) and (3) scoops (118%; p<0.001). Similarly, under home conditions, the closest method was (1) pre-measured sachets (111%), (2) weighing (112%) and (3) scoops (118%; p<0.05). Under home preparation conditions, with 200 ml EFs, the pre-measured sachets were more likely to be within 20% of target weight than weighing (p<0.05), but there was no difference with scoops. Common errors observed were inaccurate water measurements (40% controlled and home conditions), incorrect scoop measurements and difficulty using digital scales. CONCLUSIONS; Overall, using pre-measured sachets was more accurate in EF production. Pre-measured sachets are likely to decrease preparation error and, therefore, reduce the risk of feed intolerance, particularly osmotic diarrhoea and consequential metabolic decompensation and encephalopathy.

Monitoring of home safety issues in children on enteral feeds with inherited metabolic disorders

OBJECTIVE

To assess the safety aspects of carers' enteral feeding technique when home enteral tube feeding children with inherited metabolic disorders (IMD).

METHODS

40 patients (median age, 5.1 years; range, 0.3-13.6 years) with IMD requiring pump tube feeding were recruited. 12 patients had glycogen storage disease, 11 organic acidemias, 8 fatty acid oxidation disorders, 4 urea cycle disorders, and 5 had other conditions. 50% of the patients were fed by gastrostomy and 50% nasogastric tube. A questionnaire and practical assessment of feeding process was completed with carers by a dietician and nurse in the child's home. Areas investigated included carer hygiene, feed preparation, tube care, tube changing, use of feeding pumps and equipment, and storage of enteral feeding equipment.

RESULTS

The main issues identified were poor hygiene practices (78% unclean work surfaces; 25% no hand washing); inaccurate ingredient measuring (40%); irregular checking of tube position (40%); inadequate tube flushing (50%); poor knowledge of how to clear tube blockages (80%); incorrect priming of pump sets (50%); incorrect position of child for night feeding (63%); untrained secondary carers (43%); and poor knowledge of pump alarms, battery life, and charging time. Children commonly slept in parent's room as a safety precaution (58%).

CONCLUSIONS

Long term follow-up of children with IMD on home enteral tube feeding suggests that regular updates on knowledge and technique for carers may be necessary to reduce risk.

Mechanisms involved in the regulation of bovine pulmonary vascular tone by the 5-HT1B receptor

BACKGROUND AND PURPOSE

5-HT(1B) receptors may have a role in pulmonary hypertension. Their relationship with the activity of BK(Ca,) a T-type voltage-operated calcium channel (VOCC) and cyclic nucleotide-mediated relaxation was examined.

EXPERIMENTAL APPROACH

Ring segments of bovine pulmonary arteries were mounted in organ baths in modified Krebs-Henseleit buffer (37 degrees C) under a tension of 20 mN and gassed with 95% O(2)/5% CO(2). Isometric recordings were made using Chart 5 software.

KEY RESULTS

Contractile responses to 5-HT (10 nM-300 microM) were inhibited similarly by the 5-HT(1B) receptor antagonist SB216641 (100 nM) and the T-type VOCC blockers mibefradil (10 microM) and NNC550396 (10 microM) with no additive effect between SB216641 and mibefradil. Inhibition by SB216641 was prevented by the potassium channel blocker, charybdotoxin (100 nM). 5-HT(1B) receptor activation and charybdotoxin produced a mibefradil-sensitive potentiation of responses to U46619. Bradykinin (0.1 nM-30 microM), sodium nitroprusside (0.01 nM-3 microM), zaprinast (1 nM-3 microM), isoprenaline (0.1 nM-10 microM) and rolipram (1 nM-3 microM) produced 50% relaxation of arteries constricted with 5-HT (1-3 microM) or U46619 (30-50 nM) in the presence of 5-HT(1B) receptor activation, but full relaxation of arteries constricted with U46619, the 5-HT(2A) receptor agonist 2,5 dimethoxy-4 iodoamphetamine (1 microM) or 5-HT in the presence of 5-HT(1B) receptor antagonism. Enhanced relaxation of 5-HT-constricted arteries by cGMP-dependent pathways, seen in the presence of the 5-HT(1B) receptor antagonist, was reversed by charybdotoxin whereas cAMP-dependent relaxation was only partly reversed by charybdotoxin.

CONCLUSIONS AND IMPLICATIONS

5-HT(1B) receptors couple to inhibition of BK(Ca), thus increasing tissue sensitivity to contractile agonists by activating a T-type VOCC and impairing cGMP-mediated relaxation. Impaired cAMP-mediated relaxation was only partly mediated by inhibition of BK(Ca).

Determination of the lactose and galactose content of cheese for use in the galactosaemia diet

BACKGROUND

Treatment of galactosaemia requires a low galactose diet. In the UK, traditionally, all cheeses have been excluded from the diet, although some types of mature hard cheese are likely to be low in lactose and galactose. The present study aimed to determine the lactose and galactose content of mature cheeses.

METHODS

Over 6 years, the UK Galactosaemia Support Group commissioned the analysis of 109 samples (by two laboratories) of 12 cheese types, in eight batches throughout the year. Cheeses, obtained from retail outlets, were homogenised, sugars were extracted using water or 40% alcohol for fatty samples, and samples were deproteinised. Enzymatic analysis using measuring light absorbance was conducted on filtered extracts.

RESULTS

Cheeses containing undetectable quantities of lactose (<2.8 mg 100 g(-1), Leatherhead Food International, Leatherhead, UK (LFI) analysis; <10 mg 100 g(-1), Laboratory of Government Chemist, Teddington, UK (LGC Limited) analysis) and galactose were: Gruyere (five samples); Emmental (block, sliced and grated) (16 samples); Jarlsberg (six samples); Parmigiano Reggiano and Grana Padano Italian Parmesan (block and grated) (16 samples); and mature Cheddar cheese from the UK West Country Farmhouse Cheese Makers Association (35 samples) only. Lactose containing cheeses included other mature Cheddar cheeses, Gouda and Edam.

CONCLUSIONS

Gruyere, Emmental, Jarlsberg, Italian Parmesan (Parmigiano Reggiano and Grana Padano), and mature Cheddar cheese produced in one area of England where the manufacturing process is standardised and guaranteed are now allowed in the UK galactosaemia diet.