Glycemic Control During Enteral Tube Feeding in Patients with Diabetes Mellitus

Introduction

Achieving good glycemic control during enteral tube feeding in patients with diabetes mellitus can be difficult. National guidelines emphasize the need for the early involvement of the dietitian and diabetes specialist nurse, regular capillary blood glucose (CBG) monitoring, and the avoidance of hypoglycemic events. We aimed to assess glycemic control in patients with diabetes during enteral tube feeding.

Materials and methods

A retrospective study, involving patients with diabetes who had enteral tube feeding during their hospital stay from January to December 2016, was performed. Data included feed carbohydrate content, infusion rate and duration, involvement of dietitian and inpatient diabetes specialist nurse, capillary blood glucose monitoring, and documentation of hypoglycemic events.

Results

There were 40 patient episodes. Mean (range) age: 67 (29-94) years, 60% were male, 97.5% had type 2 diabetes, and 60% were on oral hypoglycemic agents prior to admission. The average feed carbohydrate content was 14.6 g/dL and the average feed rate was 73 ml/hour. Dietitians and diabetes inpatient specialist nurses (DISNs) were involved in 100% and 75% of cases, respectively. During enteral tube feeding, capillary blood glucose was controlled using metformin, subcutaneous insulin, or intravenous insulin in 30%, 42.5%, and 15% of cases, respectively. Capillary blood glucose was checked four to six hourly in 100% of cases. The target capillary blood glucose range (6-12 mmol/L) was achieved in 40% of cases. The minimum capillary blood glucose value (median (interquartile range)) was 4.9 (3.9-6.2) mmol/L and the maximum value was 15.1 (11.9-18.8) mmol/L. Using these lower and upper quartile values for minimum and maximum values, respectively, revealed that 57.5% of patients had a capillary blood glucose range of 3.9-18.8 mmol/L. Two patients had hypoglycemic events requiring treatment.

Conclusions

This study demonstrated that despite adequate adherence to our trust's guidelines for glycemic control during enteral tube feeding in patients with diabetes, the target glycemic range was achieved in 40% of cases. The importance of the early involvement of the diabetes inpatient specialist nurse cannot be overemphasized. Early initiation and proactive (daily) dose up-titration of insulin are required to improve glycemic control during enteral tube feeding. A national audit tool for glycemic control and mortality data during enteral tube feeding is required. 

The clinical utility and diagnostic yield of routine gastric biopsies in the investigation of iron deficiency anemia: a case-control study

AIMS

To audit our experience with gastrointestinal investigation of iron deficiency anemia (IDA) and assess whether gastric atrophy associates with and likely causes it.

METHODS

This is a case-control study in a large U.K. teaching hospital. In total, 161 unselected patients undergoing routine investigation for iron deficiency anemia were submitted for the study, of which 5 were excluded for lack of appropriate biopsies. In total, 169 patients identified retrospectively from pathology records who had appropriate biopsies with a normal hemoglobin and no evidence of iron deficiency constituted the control group. In the group with anemia, a further internal case-control study compared cases where no definite cause for anemia was detected with controls who had a definite accepted cause for anemia. The gastric pathology, especially the presence and degree of body atrophy, was assessed by a single pathologist in both groups. Other factors including age, sex, and Helicobacter pylori infection were also evaluated.

RESULTS

The mean age of the cases was 68 yr (95% confidence interval [CI] 34-102), and for the controls, it was 53 yr (95% CI 19-87). In the patients with anemia, 40 of 156 (25.6%) had significant body atrophy compared with just 7 of 169 (4.6%) of controls (P < 0.001). In a multivariate analysis, only significant body atrophy, odds ratio (OR) of 7.6 (3.1-18.6), and age, OR 1.048/yr (1.032-1.064), emerged as significant factors predicting anemia. In the cases, 35 of 156 (22%) patients had another definite cause of anemia. Of these, only 3 of 35 (9%) had significant atrophy, significantly less than the 37 of 121 (31%) without another definite cause (P = 0.008). In this anemic group, there was no difference in age between those with and without atrophy.

CONCLUSIONS

Gastric atrophy is strongly associated with IDA, and this is likely to be causative in some patients and contributory in others. Gastric biopsies, especially from the corpus, may provide valuable information in the investigation of IDA.

Enhancement of intragastric acid stability of a fat emulsion meal delays gastric emptying and increases cholecystokinin release and gallbladder contraction

Preprocessed fatty foods often contain calories added as a fat emulsion stabilized by emulsifiers. Emulsion stability in the acidic gastric environment can readily be manipulated by altering emulsifier chemistry. We tested the hypothesis that it would be possible to control gastric emptying, CCK release, and satiety by varying intragastric fat emulsion stability. Nine healthy volunteers received a test meal on two occasions, comprising a 500-ml 15% oil emulsion with 2.5% of one of two emulsifiers that produced emulsions that were either stable (meal A) or unstable (meal B) in the acid gastric environment. Gastric emptying and gallbladder volume changes were assessed by MRI. CCK plasma levels were measured and satiety scores were recorded. Meal B layered rapidly owing to fat emulsion breakdown. The gastric half-emptying time of the aqueous phase was faster for meal B (72 +/- 13 min) than for meal A (171 +/- 35 min, P < 0.008). Meal A released more CCK than meal B (integrated areas, respectively 1,095 +/- 244 and 531 +/- 111 pmol.min.l(-1), P < 0.02), induced a greater gallbladder contraction (P < 0.02), and decreased postprandial appetite (P < 0.05), although no significant differences were observed in fullness and hunger. We conclude that acid-stable emulsions delayed gastric emptying and increased postprandial CCK levels and gallbladder contraction, whereas acid-instability led to rapid layering of fat in the gastric lumen with accelerated gastric emptying, lower CCK levels, and reduced gallbladder contraction. Manipulation of the acid stability of fat emulsion added to preprocessed foods could maximize satiety signaling and, in turn, help to reduce overconsumption of calories.

Barrett's esophagus specialist clinic: what difference can it make?

A 'Barrett's specialist clinic' was set up in our institution consisting of a specialist nurse, research fellow, and a consultant gastroenterologist. The aim of our study was to examine the impact of this clinic in the management of patients with Barrett's esophagus (BE). Patients with the diagnosis of BE seen in the outpatient departments or in the endoscopy unit were referred to this clinic. Guidelines were introduced modelling the American College of Gastroenterology recommendation. Patients were assessed based on their comorbidity and willingness to undergo surveillance. Reflux symptom control and acid suppression was addressed. All patients were invited to undergo high-resolution enhanced magnification endoscopy (EME) and targeted biopsy to confirm the diagnosis and to form a management plan. During the appointment in the clinic, patients were given an option to fill a questionnaire that inquired about the information given to them regarding BE. One hundred and forty-three patients (92 men, mean age: 62 years) with a diagnosis of BE were seen in the specialist clinic. In 16 patients surveillance was stopped. In 25 patients treatment was changed due to poor control of reflux symptoms. Sixty-five patients (51%) answered the questionnaire. Seventy-five patients (58%) underwent high resolution EME. Twelve patients, had a histological upgrade after EME, in spite of a short mean screening interval (5.5 months). The 'Barrett's specialist clinic' introduced a more structured approach in our institution and changed the way these patients were managed. Our results indicate the need for local guidelines and Barrett's specialist clinics in the UK, and perhaps in the rest of the Western world, wherein the burden of this condition is increasing.

Nutrition care for newborns with congenital heart disease

Those health care professionals entrusted with the care of infants with congenital heart disease require an understanding of the unique nutritional needs of this population. This article defines the congenital, physiologic, and nutritional variables encountered in this population. The nutritional needs, multi-factorial sources of undernutrition, and consequences of inadequate nutrition in infants with congenital heart disease are discussed, as well as medical and nutritional management strategies intended to optimize growth and reduce morbidity.

The short-term effects of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) on bone formation and bone mineral density in acute ulcerative colitis

BACKGROUND

The aetiology of bone loss in ulcerative colitis is multifactorial, but corticosteroid treatment is an important risk factor. A novel formulation of Eudragit-L-coated prednisolone metasulphobenzoate (Predocol) has been developed, in order to deliver high mucosal levels of prednisolone within the colon but with little systemic absorption. The aim of this study was to investigate its efficacy, and short-term effects on bone formation and bone mineral density.

METHODS

In a 12-week longitudinal study 13 patients with active colitis were treated with a reducing dose of Predocol. Disease activity scores were recorded and the bone formation marker osteocalcin was measured before, during and after treatment, with hip and spine bone mineral density assessed at baseline and after treatment.

RESULTS

Eleven of the 13 patients completed the study. Compared with baseline, disease activity scores improved significantly after 4 weeks [difference in means, 6.9; 95% confidence interval (CI), 5.2, 8.7; P < 0.0001] and 12 weeks (difference in means, 5.7; 95% CI, 3.3, 8.2; P < 0.0001) of treatment. Osteocalcin did not fall compared with baseline [16.91 mg/l (95% CI, 12.70, 21.12)], after 4 weeks [13.67 mg/l (95% CI, 8.72, 18.60)] (difference in means, 3.25; 95% CI, 2.37, 8.87; P = 0.23) or 12 weeks [23.91 mg/l (95% CI, 16.10, 31.74)] (difference in means, 13.23; 95% CI, 2.45, 16.48; P = 0.13) of treatment. Similarly, bone mineral density at the hip [0.99 g/cm (95% CI, 0.90, 1.09)] did not change after 12 weeks of treatment [1.00 g/cm (95% CI, 0.89, 1.11)] (difference in means, 0.01; 95% CI, 0.25, 0.34; P = 0.74). Spine bone mineral density did not fall from pre-treatment levels [1.20 g/cm (95% CI, 1.11, 1.30)] after 12 weeks [1.19 g/cm (95% CI, 1.10, 1.29)] (difference in means, 0.01; 95% CI, 0.004, 0.01; P = 0.26).

CONCLUSIONS

These results confirm that Predocol is effective treatment for acute ulcerative colitis and short courses of the steroid have no adverse effects on bone formation and bone mineral density. The encouraging results from this study suggest that Predocol may be a significant advance in preventing corticosteroid induced bone loss in ulcerative colitis.

Audit of a Barrett's epithelium surveillance database

BACKGROUND

Barrett's epithelium is a premalignant condition in which endoscopic surveillance is recommended but remains contentious.

AIM

To audit our Barrett's epithelium surveillance database and to calculate the incidence and natural history of dysplasia and cancer in this cohort.

METHODS

A retrospective analysis of a computerised database of patients with columnar lined oesophagus containing specialised intestinal metaplasia was undertaken over a 5-year period. The surveillance protocol was annual endoscopy with 2-cm interval quadrantic biopsies with patients on continuous acid-suppression therapy.

RESULTS

A total of 138 (102 men) patients underwent active surveillance. The mean age was 62.1 years and the mean Barrett's epithelium length was 5.9 cm. Ten patients had low-grade dysplasia, with a mean age of 73.5 years, a mean Barrett's epithelium length of 7.8 cm, a prevalence of 7.2% over 5 years and an incidence of 1.4% per annum. Low-grade dysplasia regressed in five patients, persisted in four patients, and was associated with a concurrent squamous carcinoma in one patient. Three patients had high-grade dysplasia at index endoscopy, with no incident cases. One progressed to adenocarcinoma after 2 years. A cancer incidence of one per 202 patient-years of surveillance was found, equivalent to 0.5% per year.

CONCLUSION

Short-interval (1-year) endoscopic surveillance of Barrett's epithelium offers little reward. Low-grade dysplasia is uncommon, and no progression to adenocarcinoma was seen in this cohort. No incident high-grade dysplasia was observed. Prospective evaluation of a longer endoscopic surveillance interval in controlled clinical studies is warranted.

Audit of a Barrett's epithelium surveillance database

BACKGROUND

Barrett's epithelium is a premalignant condition in which endoscopic surveillance is recommended but remains contentious.

AIM

To audit our Barrett's epithelium surveillance database and to calculate the incidence and natural history of dysplasia and cancer in this cohort.

METHODS

A retrospective analysis of a computerised database of patients with columnar lined oesophagus containing specialised intestinal metaplasia was undertaken over a 5-year period. The surveillance protocol was annual endoscopy with 2-cm interval quadrantic biopsies with patients on continuous acid-suppression therapy.

RESULTS

A total of 138 (102 men) patients underwent active surveillance. The mean age was 62.1 years and the mean Barrett's epithelium length was 5.9 cm. Ten patients had low-grade dysplasia, with a mean age of 73.5 years, a mean Barrett's epithelium length of 7.8 cm, a prevalence of 7.2% over 5 years and an incidence of 1.4% per annum. Low-grade dysplasia regressed in five patients, persisted in four patients, and was associated with a concurrent squamous carcinoma in one patient. Three patients had high-grade dysplasia at index endoscopy, with no incident cases. One progressed to adenocarcinoma after 2 years. A cancer incidence of one per 202 patient-years of surveillance was found, equivalent to 0.5% per year.

CONCLUSION

Short-interval (1-year) endoscopic surveillance of Barrett's epithelium offers little reward. Low-grade dysplasia is uncommon, and no progression to adenocarcinoma was seen in this cohort. No incident high-grade dysplasia was observed. Prospective evaluation of a longer endoscopic surveillance interval in controlled clinical studies is warranted.

Monitoring of gallbladder and gastric coordination by EPI

PURPOSE

To assess for the first time the potential of echo-planar magnetic resonance imaging (EPI) for measuring simultaneously both gallbladder and gastric emptying.

MATERIALS AND METHODS

Eight healthy subjects ingested 500 mL of an acid-stable liquid test meal containing 15% olive oil and flavoring. Every 20 minutes for three hours thereafter, a rapid EPI multislice set was acquired across the whole abdomen, using a dedicated whole-body 0.5-T EPI scanner.

RESULTS

The bile in the gallbladder and the test meal in the stomach appeared bright in the EPI images, aiding localization and region of interest analysis. We measured the gallbladder emptying curve and fitted the data to a simple analytical model. The mean fasted gallbladder volume was 25 +/- 4 mL, comparable to previously published MRI and ultrasound values. Gastric emptying data fitted well to a linear model linear (R2 = 0.99), and we observed an exponential (R2 = 0.98) relationship between gallbladder and gastric volumes for the first 90 minutes.

CONCLUSION

This study shows the potential of EPI to monitor simultaneously and noninvasively the emptying of the gallbladder and of the gastric lumen. No contrast enhancing agents are needed. This method could overcome the limitations of previous gamma scintigraphy and ultrasound techniques.

Efficacy and one year follow up of argon plasma coagulation therapy for ablation of Barrett's oesophagus: factors determining persistence and recurrence of Barrett's epithelium

INTRODUCTION

Barrett's epithelium (BE) has malignant potential. Neither acid suppression nor antireflux surgery produce consistent or complete regression of the metaplastic epithelium. Endoscopic thermoablation with argon plasma coagulation (APC) offers a different approach but factors influencing its outcome have not been systematically examined.

AIM

To assess the efficacy of APC and factors influencing initial and one year outcome.

METHODS

Fifty patients, mean age 61.4 years, mean BE length 5.9 cm (range 3-19), underwent APC therapy at four weekly intervals while receiving proton pump inhibitor (PPI) therapy. BE margins were marked by India ink tattooing and extent was documented by grid drawings, photography, and 2 cm interval quadrantic jumbo biopsies. Twenty four hour ambulatory oesophageal pH studies were done while on PPIs before and after APC therapy, and Bilitec bilirubin monitoring after APC completion.

RESULTS

A total of 68% of patients achieved >90% BE ablation after a median of four APC sessions. Persistent BE (>10% original BE area) was associated with longer initial BE length despite more APC sessions. Persistent acid and bile reflux on PPIs, although commoner in this group, were not significantly different from those successfully ablated. Fifteen of 34 patients (44%) with successful macroscopic clearance had buried glands, present in 8.3% of a total of 338 biopsies. At the one year follow up, only 32% of those with initial successful ablation showed no recurrence. BE recurred or increased in most with mean segment length increases of 1.1 cm and 1.6 cm, respectively, in patients with previous full ablation and those with persistent BE. The presence of buried glands did not predict BE recurrence. Patients who reduced their PPI dose had significantly greater BE recurrence.

CONCLUSIONS

APC is most effective for shorter segment BE ablation but "buried" glands do occur. Recurrence of BE is common at one year, especially in those with initial persistent and/or long segment BE and those who reduce their PPI dose.

Post-operative fatigue following coronary artery bypass surgery: relationship to emotional state and to the catecholamine response to surgery

Post-operative fatigue is an important subjective problem for surgical patients, but its basis is unknown, and the possibility of a psychological component has been neglected. To investigate its putative physiological and psychological bases, 74 patients undergoing coronary artery bypass graft surgery were studied. Circulating catecholamine levels were measured at intervals perioperatively and questionnaires were used to measure fatigue, depression and anxiety up to 30 days post-operatively. We tested whether fatigue was related either to the catecholamine or to the emotional responses to surgery. The second element to the design was a controlled randomized study: patients underwent different forms of psychological preparation or a no-treatment control procedure in an attempt to test whether post-operative fatigue was amenable to psychological manipulation. Psychological preparation had no effect. Fatigue at 30 days was greatest in patients whose noradrenaline levels were greatest perioperatively. Independently of this relationship, fatigue at 30 days correlated with concurrent levels of depression and anxiety. Post-operative fatigue has both physiological and psychological correlates.

Cognitive responses and the control of post-operative pain

This paper examines the relationship between spontaneous cognitive responses and reported pain experience in an acute pain population. Fifty-two patients, admitted for planned major surgery, had their pain intensity, distress and coping responses assessed 48 hours post-operatively. Significant correlations were obtained between negative responses and ratings of pain intensity and distress. No significant correlation was obtained between the analgesic dose and any other variable. The implications of the findings for the management of post-operative pain are discussed.