Carers' experiences of home enteral feeding: A survey exploring medicines administration challenges and strategies

What is known and objectives

The use of enteral tube feeding at home is becoming more widespread, with patients ranging in age and diseases. Dysphagia and swallowing difficulties can compromise nutritional intake and the administration of oral medications, affecting therapeutic outcomes negatively. Carers’ experiences of medicines administration and medicines optimization have not been explored fully. The objectives of this study were to identify issues carers experience in medicines administration; the strategies they have developed to cope; and suggestions to improve the medicines administration process.

Methods

An online survey was promoted nationally; 42 carers completed it. Descriptive statistical analysis was applied, as well as thematic analysis of open‐ended responses. Results were compared against the 4 principles of medicines optimization.

Results and discussion

93% of respondents administered medications with enteral feeding tubes, but only 62% had received advice from healthcare professionals and only 8% had received written information on how to do so. Responses identified 5 medicines administration issues experienced by carers; 4 strategies they developed to cope; and 3 main areas of suggestions to improve medicines administration via enteral feeding at home.

What is new and conclusion

The 4 principles of medicines optimization have not previously been applied to enteral feeding. We present a novel account of carers’ experiences, for example coping with ill‐suited formulations and a lack of training and support, which should inform better practice (Principle 1). Carers sometimes experience suboptimal choice of medicines (Principle 2). Carers’ practices are not always well‐informed and may affect therapeutic outcomes and safety (Principle 3). There is scope for improvement in carer training, education and support to better support medicines optimization (Principle 4).

Next-generation sequencing as a tool for breakpoint analysis in rearrangements of the globin gene clusters

INTRODUCTION

Next-generation sequencing (NGS), now embedded within genomic laboratories, is well suited to the detection of small sequence changes but is less well adapt for detecting structural variants (SV), mainly due to the relatively short sequence reads. Of the available target enrichment methods, bait capture or whole-genome sequencing appears better suited to detecting SV as there is less PCR amplification and is therefore more representative of the genome being sequenced.

MATERIAL AND METHODS

In 2015, we described the first inversion/deletion causing εγδβ- thalassemia using an NGS approach, with base-pair resolution. Bioinformatic processing of the sequencing data was manual and time-consuming. The methodology relied on detecting the presence or absence of the SV by assessing sequence coverage and then mapping the deletion by capturing and sequencing breakpoint spanning reads (split reads). In the period between developing more automated analytical methods, we identified the first duplication of the entire beta globin cluster.

RESULTS

Detecting the presence of the SV is reliable but capturing the breakpoint spanning reads is challenging. Confirmation by Sanger sequencing a breakpoint spanning amplicon has confirmed the NGS results in all cases.

CONCLUSIONS

We have now streamlined and automated the bioinformatic approach using Exome Depth to assess sequence coverage and Delly to detect split and discordant reads. The combined NGS and bioinformatic strategy has proven to be highly successful and applicable to routine diagnostics.

Drug Residues after Intravenous Anesthesia and Intrathecal Lidocaine Hydrochloride Euthanasia in Horses

Background

Intrathecal lidocaine hydrochloride under general anesthesia has been used as an alternative method of euthanasia in equids. Carnivore, scavenger, and even human consumption of horse meat from carcasses have been anecdotally reported in rural areas after this method of euthanasia. The presence of drug residues in horse meat has not been investigated.

Hypothesis/Objectives

To investigate if drug residues are found in horse tissues and determine their concentrations.

Animals

Of 11 horses requiring euthanasia for medical reasons.

Methods

Prospective descriptive study. Horses were anesthetized with total IV dose of xylazine (mean, 2.5 mg/kg), midazolam (0.1 mg/kg), and ketamine hydrochloride (mean, 5.8 mg/kg). An atlanto‐occipital cisterna centesis for the collection of cerebrospinal fluid (CSF) and administration of lidocaine hydrochloride (4 mg/kg) was performed. Blood samples for both serum and plasma, skeletal muscle (triceps brachii, gluteus medius), and CSF were collected for the determination of drug residues. Frozen skeletal muscle available from 5 additional horses that received standard dosages of drugs for short‐term anesthesia (xylazine 1.1 mg/kg, midazolam 0.1 mg/kg, and ketamine 2.2 mg/kg) also were analyzed.

Results

Drug residues were found in the tissues of all horses, but at extremely low concentrations.

Conclusions and Clinical Importance

Euthanasia by administration of lidocaine intrathecally to horses under IV anesthesia poses a low risk of toxicity to carnivores and scavengers that might consume muscle tissue from a carcass in which this protocol has been used.

Feeding Difficulties and Gastrointestinal Tract Morphology and Innervation in ‘Charge’ Syndrome

BACKGROUND: CHARGE syndrome has been linked to mutations in the CHD7 gene and results in a number of physiological and structural abnormalities. The estimated incidence in the Atlantic Provinces is 1 in 8500 births. Challenges include eating problems, which have a profound impact throughout a child’s life and can lead to complications and even death.

OBJECTIVES: To investigate feeding difficulties and model the morphology and innervation of the gastrointestinal tract in CHARGE syndrome.

DESIGN/METHODS: Three research studies (two clinical, one basic science) were conducted to assess feeding difficulties in CHARGE syndrome. The first study conducted a qualitative analysis of parent interviews to understand packing and problematic feeding behaviors. The second study investigated general eating and GI motility problems by having parents complete a series of feeding questionnaires. The third study modeled CHARGE syndrome in zebrafish by using a morpholino to knock down the expression of CHD7.

RESULTS: Study 1: Twenty parents completed a phone interview, describing their child/adult’s (2-32 years) adverse feeding behaviors. Parents reported food packing most commonly with bread and pasta (33%), and reported that food was held in cheeks for hours after a meal had ended (35%). Packing was reported to prolong mealtimes for over an hour (30%). Parents were worried about choking during eating (30%).Study 2: Sixty-nine parents of children (age 1-18 years) completed the questionnaires. Those who were tube fed had significantly more gastrointestinal symptoms (stomach pain, nausea, etc.) and worse feeding difficulties than those who were orally fed. The CHARGE characteristics of choanal atre-sia/stenosis and cranial nerve IX/X dysfunction were associated with significantly more gastrointestinal symptoms. Parents identified constipation as a major challenge. Study 3: Immunohistochemistry demonstrated changes in the enteric innervation of the gastrointestinal tract in the CHARGE syndrome zebrafish models. There was decreased branching of the gastrointestinal nerve network surrounding the stomach. Use of fluorescent microbeads demonstrated reduced motility and delayed passage of the microbeads through the gastrointestinal tract.

CONCLUSION: These three studies provided a comprehensive analysis of feeding and gastrointestinal difficulties, from mouth to anus, in CHARGE syndrome. They provide a deeper understanding of adverse feeding behaviors, feeding difficulties, and the abnormal morphology of the gastrointestinal system. The information from this study can be useful for general pediatricians and feeding therapy teams who are involved in the care of these individuals starting in infancy. The team-based approach of conducting multiple research projects investigating a common issue may be useful in other genetic disorders.

Bromine content and brominated flame retardants in food and animal feed from the UK

Current occurrence data for polybrominated diphenyl ethers (PBDE) and hexa-bromocyclododecane (HBCD) measured in most commonly consumed foods (n = 156) and animal feeds (n = 51) sampled in the UK, demonstrates an ongoing ubiquity of these contaminants in human and animal diets. PBDE concentrations for the sum of 17 measured congeners ranged from 0.02 ng/g to 8.91 ng/g whole weight for food, and 0.11 ng/g to 9.63 ng/g whole weight for animal feeds. The highest concentration ranges, and mean values were detected in fish, processed foods and fish feeds. HBCD diastereomers (alpha-HBCD was the most commonly detected) generally occurred at lower concentrations (from <0.01 ng/g to 10.1 ng/g for food and <0.01 ng/g to 0.66 ng/g for animal feed) and less frequently than PBDEs, but tetrabromobisphenol A which was also measured, was rarely detected. The total bromine content of the samples was also determined in an attempt to use a mass balance approach to investigate some of these samples for the occurrence of novel and emerging BFRs. Although the approach was further refined by measuring organic bromine content, the concentrations of bromine were too high (in most cases by orders of magnitude) to allow use of the approach. A selected sub-set of samples was screened by GC-MS, for the presence of novel/emerging brominated flame retardants (PBT, TBX, PBEB, DBHCTD, HCTBPH and OBTMPI) but these were not detected at the higher limits of detection that result from full scan (GC-MS) screening. This data will contribute to the EU wide risk assessment on these contaminants.

Influence of reverse Trendelenburg position on aortocaval compression in obese pregnant women

INTRODUCTION

Obese pregnant women are at risk of aortocaval compression and associated hypotension with neuraxial anaesthesia. We hypothesised that addition of reverse Trendelenburg tilt to the standard practice of pelvic tilt may attenuate aortocaval compression.

METHODS

After ethical approval and consent, six women with a singleton pregnancy and booking body mass index of 30-35kg/m(2) underwent magnetic resonance imaging scanning in six different positions: right lateral decubitus; left lateral decubitus; supine with pelvic tilt; and reverse Trendelenburg positions of 5°, 10° and 15°. Dimensions of the inferior vena cava and abdominal aorta at the L2-3 intervertebral disc level were obtained from axial images using medical imaging software OsiriX™.

RESULTS

Inferior vena cava dimensions were higher in left lateral decubitus position compared to supine with pelvic tilt (P=0.002). Inferior vena cava compression was noted in all participants (59±33%, 95% CI 32 to 86). Addition of 15° reverse Trendelenburg tilt to standard pelvic tilt produced a non-statistically significant increase in inferior vena cava area (10.54±9.91cm(2), 95% CI 2.61 to 18.47, P=0.06).

CONCLUSION

A non-statistically significant improvement of aortocaval compression was noted with the addition of 15° reverse Trendelenburg tilt to the supine with pelvic tilt position in obese pregnant women.

Electrophysiologic Study of a Method of Euthanasia Using Intrathecal Lidocaine Hydrochloride Administered during Intravenous Anesthesia in Horses

Background

An intravenous (IV) overdose of pentobarbital sodium is the most commonly used method of euthanasia in veterinary medicine. However, this compound is not available in many countries or rural areas resulting in usage of alternative methods such as intrathecal lidocaine administration after IV anesthesia. Its safety and efficacy as a method of euthanasia have not been investigated in the horse.

Hypothesis/Objectives

To investigate changes in mean arterial blood pressure and electrical activity of the cerebral cortex, brainstem, and heart during intrathecal administration of lidocaine. Our hypothesis was that intrathecal lidocaine affects the cerebral cortex and brainstem before affecting cardiovascular function.

Animals

Eleven horses requiring euthanasia for medical reasons.

Methods

Prospective observational study. Horses were anesthetized with xylazine, midazolam, and ketamine; and instrumented for recording of electroencephalogram (EEG), electrooculogram (EOG), brainstem auditory evoked response (BAER), and electrocardiogram (ECG). Physical and neurological (brainstem reflexes) variables were monitored. Mean arterial blood pressure was recorded throughout the study.

Results

Loss of cerebro‐cortical electrical activity occurred up to 226 seconds after the end of the infusion of lidocaine solution. Cessation of brainstem function as evidenced by a lack of brainstem reflexes and disappearance of BAER occurred subsequently. Undetectable heart sounds, nonpalpable arterial pulse, and extremely low mean arterial blood pressure supported cardiac death; a recordable ECG was the last variable to disappear after the infusion (300–1,279 seconds).

Conclusions and Clinical Importance

Intrathecal administration of lidocaine is an effective alternative method of euthanasia in anesthetized horses, during which brain death occurs before cardiac death.

Adolescent experiences of anti-obesity drugs

Only two anti-obesity drugs (AODs) are frequently prescribed in paediatric obesity, orlistat and metformin. Meta-analyses show modest benefit in clinical trials, yet analyses of prescribing databases show high levels of discontinuation in routine clinical practice. Increased understanding of young people's experiences taking AOD could result in improved prescribing and outcomes. Semi-structured interviews were conducted with young people aged 13-18 years and their parents from three specialist obesity clinics, analysed using a general thematic coding methodology. Theme saturation was achieved after interviews with 15 young people and 14 parents (13 parent-child dyads). Three models were developed. Model 1 explored factors influencing commencement of AOD. Six themes emerged: medication as a way out of obesity, enthusiasm and relief at the prospect of pharmaceutical treatment, last ditch attempt for some but not all, passive acceptance of medication, fear as a motivating factor, and unique treatments needed for unique individuals. Model 2 described the inter-relationship between dosing and side effects; side effects were a significant experience for many young people, and few adhered to prescribed regimens, independently changing lifestyle and dosage to tolerate medications. Model 3 described the patient-led decision process regarding drug continuation, influenced primarily by side effects and efficacy. Use of AODs is challenging for many adolescents. Multiple factors were identified that could be targeted to improve concordance and maximize efficacy.

Passive immunity stimulated by vaccination of dry cows with a Salmonella bacterial extract

Background

Diarrhea because of Salmonella infection is a cause of neonatal calf diarrhea. The stimulation of passive immunity in the calf by vaccinating the dam for Salmonella has shown some success in previous studies; however, there are no data on the use of currently licensed vaccines in the United States.

Objective

To determine whether vaccinating cows at dry‐off with a commercially available Salmonella bacterial extract would stimulate Salmonella‐specific antibodies in the colostrum of cows at calving and whether these antibodies would be transferred to the calf.

Animals

Sixty Holstein cattle and 59 calves from a herd presumed to be naïve to Salmonella.

Methods

Prospective clinical trial. Thirty cows were vaccinated at dry‐off with a Salmonella enterica serovar Newport bacterial extract and again 4 weeks later. An additional 30 cows received only saline. Calves fed fresh colostrum from their dam within 4 hours of birth had blood collected 24 hours later.

Results

Vaccinated cattle had increased Salmonella Newport antibody titers at calving in blood (P = .01) and colostrum (P = .011). Calves that received colostrum from vaccinated cattle also had significant increase in Salmonella antibodies (1.04 ± 0.03) as compared to calves born to unvaccinated cows (0.30 ± 0.02).

Conclusions and Clinical Importance

The results indicate that the use of a commercially available Salmonella vaccine can stimulate antibodies that are passed on to the calf via colostral transfer. Further studies need to be done to determine whether these antibodies will offer protection against Salmonella challenge.

Readability, suitability and comprehensibility in patient education materials for Swedish patients with colorectal cancer undergoing elective surgery: a mixed method design

OBJECTIVE

To characterize education materials provided to patients undergoing colorectal cancer surgery to gain a better understanding of how to design readable, suitable, comprehensible materials.

METHOD

Mixed method design. Deductive quantitative analysis using a validated suitability and comprehensibility assessment instrument (SAM+CAM) was applied to patient education materials from 27 Swedish hospitals, supplemented by language technology analysis and deductive and inductive analysis of data from focus groups involving 15 former patients.

RESULTS

Of 125 patient education materials used during the colorectal cancer surgery process, 13.6% were rated 'not suitable', 76.8% 'adequate' and 9.6% 'superior'. Professionally developed stoma care brochures were rated 'superior' and 44% of discharge brochures were 'not suitable'. Language technology analysis showed that up to 29% of materials were difficult to comprehend. Focus group analysis revealed additional areas that needed to be included in patient education materials: general and personal care, personal implications, internet, significant others, accessibility to healthcare, usability, trustworthiness and patient support groups.

CONCLUSION

Most of the patient education materials were rated 'adequate' but did not meet the information needs of patients entirely. Discharge brochures particularly require improvement.

PRACTICE IMPLICATIONS

Using patients' knowledge and integrating manual and automated methods could result in more appropriate patient education materials.