Perspectives of paediatric and adult gastroenterologists on transfer and transition care of adolescents with inflammatory bowel disease

BACKGROUND

Programmes specific to inflammatory bowel disease (IBD) that facilitate transition from paediatric to adult care are currently lacking.

AIM

We aimed to explore the perceived needs of adolescents with IBD among paediatric and adult gastroenterologists and to identify barriers to effective transition.

METHODS

A web-based survey of paediatric and adult gastroenterologists in Australia and New Zealand employed both ranked items (Likert scale; from 1 not important to 5 very important) and forced choice items regarding the importance of various factors in facilitating effective transition of adolescents from paediatric to adult care.

RESULTS

Response rate among 178 clinicians was 41%. Only 23% of respondents felt that adolescents with IBD were adequately prepared for transition to adult care. Psychological maturity (Mean = 4.3, standard deviation (SD) = 0.70) and readiness as assessed by adult caregiver (Mean = 4, SD = 0.72) were prioritised as the most important factors in determining timing of transfer. Self-efficacy and readiness as assessed by adult caregiver were considered the two most important factors to determine timing of transition by both groups of gastroenterologists. Poor medical and surgical handover (Mean = 4.10, SD = 0.8) and patients' lack of responsibility for their own care (Mean= 4.10, SD = 0.82) were perceived as major barriers to successful transition by both paediatric and adult gastroenterologists.

CONCLUSIONS

Deficiencies exist in current transition care of adolescents with IBD in Australia and New Zealand. Standardising transition care practices with strategies aimed at optimising communication, patient education, self-efficacy and adherence may improve outcomes.

Bowel imbrication in the management of anorectal anomalies

Four patients who had imbrication of their proximal rectum and distal sigmoid colon as part of the management of constipation following an anorectoplasty for an anorectal anomaly. Three children with an anorectal anomaly presented with constipation and marked dilation of the rectosigmoid portion of the large bowel; each had longitudinal imbrication of the dilated segment, via a left iliac fossa incision. The forth was born with a cloacal anomaly with associated colonic atresia. The small bowel was used to construct the anorectum following a redo anorectoplasty. Subsequently, the small bowel became ectatic, resulting in the patient developing persistent watery diarrhoea and severe perianal excoriation, which was managed with a 30 cm longitudinal imbrication of the distal bowel during an extensive laparotomy. All 4 have patients now have near normal bowel motions with minimal medication, after only a short hospital stay. Residual problematic dilatation of the rectosigmoid colon in patients with a high anorectal anomaly, in the presence of constipation, can be successfully managed by imbrication of the dilated segment, if carefully selected.

Physiological and psychosocial contributors to malnutrition in children with cystic fibrosis: review

Malnutrition was once thought to be an inevitable consequence of cystic fibrosis (CF). It is now considered preventable but still contributes considerable morbidity in children. Malnutrition is linked to poorer pulmonary function, reduced survival and quality of life. As the anticipated lifespan of children with CF continues to lengthen, the prevention of malnutrition attains greater importance. This review explores the complex organic and psychosocial factors implicated in the aetiology of malnutrition associated with CF.

Effect of butyrate on paracellular permeability in rat distal colonic mucosa ex vivo

BACKGROUND AND AIMS

The effects of butyrate on colonic epithelial barrier function are poorly understood. The aim of this study was to examine the short-term effects of butyrate on paracellular permeability of rat distal colonic epithelium.

METHODS

Mucosa mounted in Ussing chambers was treated with butyrate (1-10 mmol/L) for 4 h. Transepithelial conductance, [51Cr]-EDTA flux, mucosal brush border hydrolase activity and epithelial kinetics, using proliferating cell nuclear antigen (PCNA) staining, were measured.

RESULTS

On exposure to butyrate (10 mmol/L, but not 1 or 5 mmol/L), transepithelial conductance was 65 +/- 2% higher (mean +/- SEM; n = 8, P < 0.05, paired t-test) and the rate coefficient for [51Cr]-EDTA flux was 65 +/- 25% higher (P = 0.03) than those of control tissue. Histologically, the epithelium exhibited no signs of injury, but butyrate-treated tissue exhibited interstitial oedema consistent with water uptake in association with butyrate absorption. Butyrate caused a reduction in crypt column height to 30.6 +/- 1.6 cells from 33.4 +/- 1.8 cells in controls (n = 10, P < 0.03), but the number of cells per crypt column staining with PCNA was unchanged. Butyrate significantly reduced the mucosal activities of alkaline phosphatase by 40 +/- 16%, maltase by 54 +/- 12% and dipeptidyl peptidase IV by 41 +/- 14%.

CONCLUSIONS

Acute exposure to butyrate increased paracellular permeability in rat distal colon. The mechanism involved may relate to the loss of differentiated surface epithelial cells, or as a physiological response to Na+-coupled butyrate uptake.

Modulation of distal colonic epithelial barrier function by dietary fibre in normal rats

BACKGROUND

Dietary fibre influences the turnover and differentiation of the colonic epithelium, but its effects on barrier function are unknown.

AIMS

To determine whether altering the type and amount of fibre in the diet affects paracellular permeability of intestinal epithelium, and to identify the mechanisms of action.

METHODS

Rats were fed isoenergetic low fibre diets with or without supplements of wheat bran (10%) or methylcellulose (10%), for four weeks. Paracellular permeability was determined by measurement of conductance and 51Cr-EDTA flux across tissue mounted in Ussing chambers. Faecal short chain fatty acid (SCFA) concentrations were assessed by gas chromatography, epithelial kinetics stathmokinetically, and mucosal brush border hydrolase activities spectrophotometrically.

RESULTS

Body weight was similar across the dietary groups. Conductance and 51Cr-EDTA flux were approximately 25% higher in animals fed no fibre, compared with those fed wheat bran or methylcellulose in the distal colon, but not in the caecum or jejunum. Histologically, there was no evidence of epithelial injury or erosion associated with any diet. The fibres exerted different spectra of effects on luminal SCFA concentrations and pH, and on mucosal indexes, but both bulked the faeces, were trophic to the epithelium, and stimulated expression of a marker of epithelial differentiation.

CONCLUSIONS

Both a fermentable and a non-fermentable fibre reduce paracellular permeability specifically in the distal colon, possibly by promoting epithelial cell differentiation. The mechanisms by which the two fibres exert their effects are likely to be different.

Current approaches to the nutritional management of cystic fibrosis in Australia

OBJECTIVE

The aim of this study was to determine current Australian practice for the nutritional management of cystic fibrosis (CF) and compare it to USA and UK guidelines.

METHODOLOGY

A structured questionnaire was completed by dietitians from 15 major CF centres. It was estimated that these centres manage or co-manage 84% of Australians with CF.

RESULTS

There was close agreement between UK and USA guidelines and Australian practice for dietary intervention strategies, nutritional monitoring and surveillance, and electrolyte replacement. Infant feeding practices were more closely aligned with the UK. There were some differences in the areas of pancreatic enzyme replacement therapy, vitamin requirements in CF and dietary management of CF-related diabetes.

CONCLUSIONS

Despite the lack of formal agreement, nutritional management practices of most Australian centres are closely aligned with current published international recommendations. However, there is need for consensus in the area of enzyme replacement therapy, management of CF-related diabetes and vitamin supplementation based on optimal clinical outcomes.