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Madden AM, Smeeton NC, Culkin A, Trivedi D. Modified dietary fat intake for treatment of gallstone disease in people of any age. Cochrane Database Syst Rev 2024; 2:CD012608. [PMID: 38318932 PMCID: PMC10845213 DOI: 10.1002/14651858.cd012608.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND The prevalence of gallstones varies between less than 1% and 64% in different populations and is thought to be increasing in response to changes in nutritional intake and increasing obesity. Some people with gallstones have no symptoms but approximately 2% to 4% develop them each year, predominantly including severe abdominal pain. People who experience symptoms have a greater risk of developing complications. The main treatment for symptomatic gallstones is cholecystectomy. Traditionally, a low-fat diet has also been advised to manage gallstone symptoms, but there is uncertainty over the evidence to support this. OBJECTIVES To evaluate the benefits and harms of modified dietary fat intake in the treatment of gallstone disease in people of any age. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials in the Cochrane Library, MEDLINE ALL Ovid, Embase Ovid, and three other databases to 17 February 2023 to identify randomised clinical trials in people with gallstones. We also searched online trial registries and pharmaceutical company sources, for ongoing or unpublished trials to March 2023. SELECTION CRITERIA We included randomised clinical trials (irrespective of language, blinding, or status) in people with gallstones diagnosed using ultrasonography or conclusive imaging methods. We excluded participants diagnosed with another condition that may compromise dietary fat tolerance. We excluded trials where data from participants with gallstones were not reported separately from data from participants who did not have gallstones. We included trials that investigated other interventions (e.g. trials of drugs or other dietary (non-fat) components) providing that the trial groups had received the same proportion of drug or other dietary (non-fat) components in the intervention. DATA COLLECTION AND ANALYSIS We intended to undertake meta-analysis and present the findings according to Cochrane recommendations. However, as we identified only five trials, with data unsuitable and insufficient for analyses, we described the data narratively. MAIN RESULTS We included five trials but only one randomised clinical trial (69 adults), published in 1986, reported outcomes of interest to the review. The trial had four dietary intervention groups, three of which were relevant to this review. We assessed the trial at high risk of bias. The dietary fat modifications included a modified cholesterol intake and medium-chain triglyceride supplementation. The control treatment was a standard diet. The trial did not report on any of the primary outcomes in this review (i.e. all-cause mortality, serious adverse events, and health-related quality of life). The trial reported on gallstone dissolution, one of our secondary outcomes. We were unable to apply the GRADE approach to determine certainty of evidence because the included trial did not provide data that could be used to generate an estimate of the effect on this or any other outcome. The trial expressed its finding as "no significant effect of a low-cholesterol diet in the presence of ursodeoxycholic acid on gallstone dissolution." There were no serious adverse events reported. The included trial reported that they received no funding that could bias the trial results through conflicts of interest. We found no ongoing trials. AUTHORS' CONCLUSIONS The evidence about the effects of modifying dietary fat on gallstone disease versus standard diet is scant. We lack results from high-quality randomised clinical trials which investigate the effects of modification of dietary fat and other nutrient intakes with adequate follow-up. There is a need for well-designed trials that should include important clinical outcomes such as mortality, quality of life, impact on dissolution of gallstones, hospital admissions, surgical intervention, and adverse events.
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Affiliation(s)
- Angela M Madden
- School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Nigel C Smeeton
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Alison Culkin
- Nutrition & Dietetic Department, St Mark's Hospital, Harrow, UK
| | - Daksha Trivedi
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
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Culkin A, Brundrett D, Pearson M, Gabe S. A one size vial does not fit all: An evaluation of the micronutrient status of adult patients receiving home parenteral nutrition (HPN). Clin Nutr ESPEN 2023; 57:676-682. [PMID: 37739722 DOI: 10.1016/j.clnesp.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 07/24/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND & AIMS Patients with chronic intestinal failure require HPN. Previous studies have reported a high prevalence of micronutrient deficiencies. We examined the micronutrient status of our patients receiving. METHODS We measured vitamins A, E, D, B12, Folate, Zinc, Selenium and Copper. Patients were excluded if they had undergone surgery or amendments in IV or oral micronutrient provision in the past six months. Blood samples were excluded if C-reactive protein was >15 mg/L. Univariate and multivariate analyses were performed on concentrations below normal to determine if clinical or demographic categories were significant. RESULTS 93 samples were included (33 males:60 females). Samples were excluded due to surgery (n = 8) amendment in micronutrient provision (n = 42) or if C-reactive protein >15 mg/L (n = 18). Vitamins A, D and E were below normal in 26%, 33% and 13% of patients respectively. Lower vitamin A was more likely in patients >50 years (P = 0.02) and lower vitamin E was more likely in men (P = 0.02). No patients had low vitamin B12 or folate whereas 29% and 9% had concentrations above the normal range respectively. Zinc and selenium were below normal in 19% and 13% respectively. Patients with surgical complications were more likely to have lower zinc (P = 0.007) and selenium (P = 0.04). Lower zinc was more likely in patients with a BMI of >25 kg/m2 (P = 0.01) and those who received Additrace® ≤3 day/week (P = 0.06). DISCUSSION Low and high concentrations were observed in our patients but clinical and demographic factors did not impact consistently on micronutrient concentrations highlighting the importance of ongoing monitoring and adequate supplementation as per ESPEN guidelines. Current micronutrient preparations may be inadequate for some patients with dependent on HPN. Our results indicate a need for a preparation with higher amounts of vitamin D.
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Affiliation(s)
- Alison Culkin
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, United Kingdom.
| | - Diane Brundrett
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, United Kingdom.
| | - Morag Pearson
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, United Kingdom.
| | - Simon Gabe
- St Mark's Hospital, Watford Road, Harrow, HA1 3UJ, United Kingdom.
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Olmedo Moreno C, Holman R, Naghibi M, Donnelly S, Culkin A, Malcom L, Vernon N, Gabe S. WITHDRAWN: Usefulness of nabilone as an antiemetic in persistent vomiting due to refractory gastrointestinal disorders. Rev Esp Enferm Dig 2023. [PMID: 37314117 DOI: 10.17235/reed.2023.9719/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Nabilone, a synthetic analogue of delta-9-Tetrahydrocannabinol, is an agonist of cannabinoid receptors (CB-1 and CB-2) approved to treat chemotherapy-induced vomiting refractory to antiemetics. Its use in patients with refractory vomiting due to gastrointestinal dysmotility (GID) has not been reported. Our study aims are to assess nabilone usefulness and side-effects in patients with refractory vomiting due to GID. Patients prescribed nabilone at St. Mark's intestinal rehabilitation unit (January 2017 to September 2022) due to GID vomiting have been retrospectively reviewed. Descriptive analysis has been done. Variables measured: age, sex, comorbidities, antiemetics/prokinetics, enteral or parenteral nutrition, nabilone prescription, subjective symptom improvement and side-effects. Seven patients received nabilone. 5/7 (72%) were females. Median age:25 years (23-37). 3/7 (43%) had gastroparesis (1/3 related to postural orthostatic tachycardia syndrome -POTS- , 1/3 to Ehlers-Danlos' Syndrome, POTS, Crohn's Disease and adrenal insufficiency -AI- and 1/3 to sinus node ablation and AI), 2/7 (29%) had gastroparesis and intestinal dysmotility (1/2 related to POTS and 1/2 related to EDS and other connective tissue diseases) and 2/7 (29%) had intestinal dysmotility (1/2 because of polyglucosan body visceral myopathy and 1/2 to intestinal surgery). All patients had received antiemetics or prokinetics before (median of 5 drugs; 2-11). 1/7 (14%) received enteral supplements, 5/7 (72%) enteral nutrition through enteral tubes and 4/7 (57%) parenteral nutrition. 5/7 (72%) patients received 1mg of nabilone bd orally, 1/7 (14%) 2 mg bd through jejunostomy and 1/7 (14%) started nabilone at 2 mg bd orally, but had to be switched to 1 mg bd because of side-effects. The median treatment's duration was 9 days (7-35). Regarding the efficacy of nabilone, 3/7 (43%) had symptomatic improvement. In terms of side-effects 4/7 (57%) patients reported some incidence under the treatment such as headache, light-headedness, drowsiness, dizziness or hallucinations. Patients with refractory GID vomiting despite multiple anti-sickness are difficult to treat. Nabilone improved symptoms in almost half of the patients although adverse effects appeared in more than 50%. Doses higher than 1 mg bd po did not show benefit. Although our study has important limitations, nabilone might be a temporary measure in these patients. Side-effects should be taken into consideration.
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Affiliation(s)
| | - Richard Holman
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Manni Naghibi
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Suzanne Donnelly
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Alison Culkin
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Lilia Malcom
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Nicola Vernon
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
| | - Simon Gabe
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, United Kingdom
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Jones D, Lal S, French C, Sowerbutts AM, Gittins M, Gabe S, Brundrett D, Culkin A, Calvert C, Thompson B, Cooper SC, Fletcher J, Donnellan C, Forbes A, Lam C, Radford S, Mountford CG, Rogers D, Muggridge R, Sharkey L, Neild P, Wheatley C, Stevens P, Burden S. Investigating the Relationship between Home Parenteral Support and Needs-Based Quality of Life in Patients with Chronic Intestinal Failure: A National Multi-Centre Longitudinal Cohort Study. Nutrients 2023; 15:nu15030622. [PMID: 36771328 PMCID: PMC9921538 DOI: 10.3390/nu15030622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/17/2023] [Accepted: 01/21/2023] [Indexed: 01/27/2023] Open
Abstract
Home parenteral support (HPS) is an essential but potentially burdensome treatment that can affect quality of life (QoL). The aims of this longitudinal study were to understand whether any changes in HPS over time were associated with QoL. The Parenteral Nutrition Impact Questionnaire (PNIQ) was used, and data were collected on HPS prescribed at three time points. Data were analysed using multi-level mixed regression models presented as effect size and were adjusted for confounders. Study recruited 572 participants from 15 sites. Of these, 201 and 145 completed surveys at second and third time-points, respectively. PNIQ score was out of 20 with a higher score indicating poorer QoL. Any reduction in HPS infusions per week was associated with an improved PNIQ score of -1.10 (95% CI -2.17, -0.02) unadjusted and -1.34 (95% CI -2.45, -0.24) adjusted. Per day change to the number of infusions per week was associated with a change in the PNIQ score of 0.32 (95% CI -0.15, 0.80) unadjusted and 0.34 (95% CI -0.17, 0.85) adjusted. This is the largest national study to demonstrate improvements in QoL associated with HPS reduction over time using an HPS-specific and patient-centric tool, adding unique data for use of therapies in intestinal failure.
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Affiliation(s)
- Debra Jones
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
- Correspondence: (D.J.); (S.B.); Tel.: +44-(0)-161-306-1508 (D.J.)
| | - Simon Lal
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford M6 8HD, UK
| | - Chloe French
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Anne Marie Sowerbutts
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Matthew Gittins
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
| | - Simon Gabe
- St Mark’s Hospital, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Diane Brundrett
- St Mark’s Hospital, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Alison Culkin
- St Mark’s Hospital, London North West University Healthcare NHS Trust, London HA1 3UJ, UK
| | - Chris Calvert
- Intestinal Failure and Nutrition Team, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Beth Thompson
- Intestinal Failure and Nutrition Team, Royal Devon and Exeter NHS Foundation Trust, Exeter EX2 5DW, UK
| | - Sheldon C. Cooper
- GI Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Jane Fletcher
- GI Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TH, UK
| | - Clare Donnellan
- Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7JT, UK
| | - Alastair Forbes
- Norwich Medical School, University of East Anglia, Norwich NR4 7UQ, UK
- Institute of Clinical Medicine, University of Tartu, 50090 Tartu, Estonia
| | - Ching Lam
- Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S5 7AU, UK
| | - Shellie Radford
- Nottingham University Hospitals NHS Trust, Queens Medical Centre Campus, Nottingham NG7 2UH, UK
| | | | - Daniel Rogers
- Leicester Intestinal Failure Team, Leicester Royal Infirmary, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
| | - Rebecca Muggridge
- Leicester Intestinal Failure Team, Leicester Royal Infirmary, University Hospitals Leicester NHS Trust, Leicester LE1 5WW, UK
| | - Lisa Sharkey
- Gastroenterology, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK
| | - Penny Neild
- Department of Gastroenterology, St. Georges University Hospitals NHS Foundation Trust, London SW17 0QT, UK
| | - Carolyn Wheatley
- Patients on Intravenous and Naso-gastric Nutrition Treatment, Christchurch, Dorset BH23 2XS, UK
| | | | - Sorrel Burden
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester M13 9PL, UK
- Intestinal Failure Unit, Salford Royal Foundation Trust, Salford M6 8HD, UK
- Correspondence: (D.J.); (S.B.); Tel.: +44-(0)-161-306-1508 (D.J.)
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Culkin A, Gabe SM, Nightingale JMD. A new palatable oral rehydration solution: A randomised controlled cross-over study in patients with a high output stoma. J Hum Nutr Diet 2021; 35:94-101. [PMID: 34323341 DOI: 10.1111/jhn.12935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients with a jejunostomy or high output stoma may need a glucose-sodium oral rehydration solution drink to maintain hydration. These solutions are unpalatable and a new flavoured pre-packaged solution was developed. METHODS After 8 h of fasting, 27 patients took 500 mL of the modified World Health Organization (WHO) cholera solution or Glucodrate® (Vitaflo) on two occasions in a cross-over random order and urine and stomal output was collected for 6 h. RESULTS There was a small but significant difference in net sodium absorption in favour of the modified WHO cholera solution (10 ± 28 mmol modified WHO cholera solution vs. -1 ± 26 mmol Glucodrate®, p = 0.01). However the Glucodrate® was more palatable, with 24 patients (89%) preferring it to the modified WHO cholera solution (p < 0.005). CONCLUSIONS Glucodrate® is a more palatable solution than the modified WHO cholera solution and is almost as effective and so can be used when patients find the modified WHO cholera solution unpalatable.
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Affiliation(s)
- Alison Culkin
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, Harrow, UK
| | - Simon M Gabe
- Lennard-Jones Intestinal Rehabilitation Unit, St Mark's Hospital, Harrow, UK
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Sinclair M, Culkin A, Douds AC, Michalski A, Shotton H. Delay in Transit: selected recommendations from the NCEPOD report on acute bowel obstruction. Frontline Gastroenterol 2021; 13:186-192. [PMID: 35493630 PMCID: PMC8996099 DOI: 10.1136/flgastro-2020-101422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/08/2021] [Indexed: 02/04/2023] Open
Abstract
Delayed in Transit, the report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) on acute bowel obstruction (ABO), highlighted a number of areas for improvement in this group of patients. The overarching finding was that there were delays in the pathway of care for patients with ABO at every stage of the clinical pathway, including diagnosis, decision-making and the availability of operating theatres. Furthermore, basic measures including hydration, nutritional screening and nutritional assessment were noted to be deficient. Patients who were admitted to non-surgical wards had an increased risk of delayed treatment and subsequently a longer starvation period. There was room for improvement of nutritional screening and assessment on admission, throughout the hospital stay and on discharge. A selection of the report recommendations that address these areas requiring improvement is discussed here.
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Affiliation(s)
- Martin Sinclair
- The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Alison Culkin
- Nutrition & Dietetic Department, St Mark's Hospital and Academic Institute, Harrow, London, UK
| | - Andrew C Douds
- Gastroenterology, Queen Elizabeth Hospital Kings Lynn, Kings Lynn, Norfolk, UK,University of East Anglia, Norwich, Norfolk, UK
| | - Antony Michalski
- The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
| | - Hannah Shotton
- The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), London, UK
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Madden AM, Trivedi D, Smeeton NC, Culkin A. Modified dietary fat intake for treatment of gallstone disease. Hippokratia 2021. [DOI: 10.1002/14651858.cd012608.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Angela M Madden
- School of Life and Medical Sciences; University of Hertfordshire; Hatfield UK
| | - Daksha Trivedi
- Centre for Research in Primary and Community Care; University of Hertfordshire; Hatfield UK
| | - Nigel C Smeeton
- Centre for Research in Primary and Community Care; University of Hertfordshire; Hatfield UK
| | - Alison Culkin
- Nutrition & Dietetic Department; St Mark's Hospital; Harrow UK
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Dilke S, Willsmore J, Culkin A, Donnelly S, Naghibi M, Small M, Corr A, Tozer P, Wilson A, Vaizey C, Gabe S. Distal feeding prior to intestinal continuity surgery in patients with intestinal failure on home parenteral nutrition. Clin Nutr ESPEN 2020. [DOI: 10.1016/j.clnesp.2019.12.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bharal M, Morgan S, Husain T, Hilari K, Morawiec C, Harrison K, Bassett P, Culkin A. Volume based feeding versus rate based feeding in the critically ill: A UK study. J Intensive Care Soc 2019; 20:299-308. [PMID: 31695734 DOI: 10.1177/1751143719847321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Underfeeding in intensive care patients on enteral nutrition is commonplace and multifactorial. This can be exacerbated by interruptions caused by routine fasting for procedures and investigations. Our study aims to demonstrate that a volume based feeding protocol can overcome the barriers of underfeeding and safely increase energy and protein delivery in UK intensive care patients, potentially improving clinical outcomes. Methods In this single centre cohort study, data were collected from adult mechanically ventilated patients. We compared the standard care of rate based feeding, from an International Nutrition Survey (2014/15) to the new intervention of volume based feeding, in a mixed medical and surgical intensive care unit. The primary outcomes were the proportion of energy and protein daily targets delivered. Secondary outcomes compared the effects on gastrointestinal tolerance, glycaemic control, mortality, mechanical ventilation days, length of stay in intensive care unit and hospital. Results From a total of 82 patients (rate based feeding = 27, volume based feeding = 55), volume based feeding patients received significantly more prescribed energy (52% versus 81%; p < 0.001) and protein (40% versus 74%; p < 0.001). There was no significant difference in gastrointestinal symptoms such as gastric residual volumes (p = 0.62), glycaemic control (p = 0.94) or insulin usage (p = 0.75). Although there was an improvement in energy and protein delivery, there were no differences in mechanical ventilation days (p = 0.12), mortality (p = 0.06), length of stay in intensive care unit (p = 0.93) and hospital (p = 0.72) between the groups. Conclusion Compared to rate based feeding, volume based feeding significantly improved energy and protein provision with no adverse effects on glycaemic control or gastrointestinal tolerance, clinical outcomes were not affected.
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Affiliation(s)
- Mina Bharal
- London North West University Healthcare NHS Trust, London, UK
| | - Sally Morgan
- Centre for Language and Communication Science Research, School of Health Sciences, City, University of London, London, UK
| | - Tariq Husain
- London North West University Healthcare NHS Trust, London, UK
| | - Katerina Hilari
- Centre for Language and Communication Science Research, School of Health Sciences, City, University of London, London, UK
| | | | - Kirsty Harrison
- Centre for Language and Communication Science Research, School of Health Sciences, City, University of London, London, UK
| | - Paul Bassett
- London North West University Healthcare NHS Trust, London, UK
| | - Alison Culkin
- London North West University Healthcare NHS Trust, London, UK
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Culkin A, Gabe S. Can dietitians prescribe safely? The prescribing practices of a nutrition support Dietitian supplementary prescriber. Clin Nutr ESPEN 2019. [DOI: 10.1016/j.clnesp.2018.12.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Friedli N, Stanga Z, Culkin A, Crook M, Laviano A, Sobotka L, Kressig RW, Kondrup J, Mueller B, Schuetz P. Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm. Nutrition 2017; 47:13-20. [PMID: 29429529 DOI: 10.1016/j.nut.2017.09.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Revised: 09/04/2017] [Accepted: 09/12/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Refeeding syndrome (RFS) can be a life-threatening metabolic condition after nutritional replenishment if not recognized early and treated adequately. There is a lack of evidence-based treatment and monitoring algorithm for daily clinical practice. The aim of the study was to propose an expert consensus guideline for RFS for the medical inpatient (not including anorexic patients) regarding risk factors, diagnostic criteria, and preventive and therapeutic measures based on a previous systematic literature search. METHODS Based on a recent qualitative systematic review on the topic, we developed clinically relevant recommendations as well as a treatment and monitoring algorithm for the clinical management of inpatients regarding RFS. With international experts, these recommendations were discussed and agreement with the recommendation was rated. RESULTS Upon hospital admission, we recommend the use of specific screening criteria (i.e., low body mass index, large unintentional weight loss, little or no nutritional intake, history of alcohol or drug abuse) for risk assessment regarding the occurrence of RFS. According to the patient's individual risk for RFS, a careful start of nutritional therapy with a stepwise increase in energy and fluids goals and supplementation of electrolyte and vitamins, as well as close clinical monitoring, is recommended. We also propose criteria for the diagnosis of imminent and manifest RFS with practical treatment recommendations with adoption of the nutritional therapy. CONCLUSION Based on the available evidence, we developed a practical algorithm for risk assessment, treatment, and monitoring of RFS in medical inpatients. In daily routine clinical care, this may help to optimize and standardize the management of this vulnerable patient population. We encourage future quality studies to further refine these recommendations.
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Affiliation(s)
- Natalie Friedli
- Medical University Department, Clinic for Endocrinology, Metabolism and Clinical Nutrition, Kantonsspital Aarau, Aarau and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Zeno Stanga
- Department of Endocrinology, Diabetes and Clinical Nutrition, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Alison Culkin
- Department of Nutrition and Dietetics, St Mark's Hospital, Harrow, United Kingdom
| | - Martin Crook
- Department of Clinical Biochemistry, Lewisham Hospital NHS Trust, London, United Kingdom
| | | | - Lubos Sobotka
- Department of Medicine, Medical Faculty and Faculty Hospital Hradec Kralove, Charles University, Prague, Czech Republic
| | - Reto W Kressig
- University Center for Medicine of Aging, Felix Platter Hospital and University of Basel, Basel, Switzerland
| | - Jens Kondrup
- Clinical Nutrition Unit, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Beat Mueller
- Medical University Department, Clinic for Endocrinology, Metabolism and Clinical Nutrition, Kantonsspital Aarau, Aarau and Medical Faculty of the University of Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Metabolism and Clinical Nutrition, Kantonsspital Aarau, Aarau and Medical Faculty of the University of Basel, Basel, Switzerland.
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Rye B, Culkin A. SUN-P063: Plenty of Intestinal Failure to Go Around. Referrals to a Newly Formed Nutrition Support Team. Clin Nutr 2017. [DOI: 10.1016/s0261-5614(17)30564-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Wilburn J, McKenna SP, Heaney A, Rouse M, Taylor M, Culkin A, Gabe S, Burden S, Lal S. Development and validation of the Parenteral Nutrition Impact Questionnaire (PNIQ), a patient-centric outcome measure for Home Parenteral Nutrition. Clin Nutr 2017; 37:978-983. [PMID: 28446383 DOI: 10.1016/j.clnu.2017.04.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/05/2017] [Accepted: 04/05/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with Type 3 Intestinal Failure (IF) who need Home Parenteral Nutrition (HPN) face several clinical, psychological and social problems. The study was designed to produce and test the first patient-centric measure for HPN ('PNIQ: Parenteral Nutrition Impact Questionnaire'). The new measure focused on the extent to which patients were able to fulfil their human needs. METHODS Questionnaire content was derived from the analysis of transcripts of interviews conducted with UK HPN patients. Cognitive debriefing interviews (CDIs) were performed to ensure patients found the draft scale clear, relevant and accessible. Finally, a test--retest postal validation survey was conducted to reduce the number of items in the scale and to ensure that; it was unidimensional, reproducible and had construct validity. RESULTS The 30 interview transcripts were analysed to identify issues related to a wide range of needs. Fifteen CDIs showed that patients found the draft scale easy to complete and highly relevant. The postal survey included 233 patients on HPN recruited through two IF units. Items were rejected if they did not fit the Rasch model, had too similar content to other items or displayed differential item functioning related to age, gender or underlying mechanism of IF. A 20-item unidimensional scale was identified with high internal consistency (0.91) and test-retest reliability (0.92). Scores on PNIQ correlated moderately highly with social isolation, emotional reactions and energy level and were related to perceived interference on life of HPN. The underlying cause of IF did not influence the way the scale worked. CONCLUSIONS The PNIQ is a scientifically rigorous, unidimensional outcome measure that provides a complete assessment of the effect of HPN on everyday life. It will prove useful for measuring patient value in clinical practice and for determining outcome in clinical trials, audit, economic evaluations and outcomes-based reimbursement.
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Affiliation(s)
| | - Stephen P McKenna
- School of Health Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK
| | | | | | - Michael Taylor
- Intestinal Failure Unit (H8), Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Alison Culkin
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Middlesex HA1 3UJ, UK
| | - Simon Gabe
- Lennard Jones Intestinal Failure Unit, St Mark's Hospital, Middlesex HA1 3UJ, UK
| | - Sorrel Burden
- School of Health Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK; Intestinal Failure Unit (H8), Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
| | - Simon Lal
- Intestinal Failure Unit (H8), Salford Royal NHS Foundation Trust, Salford M6 8HD, UK
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Wilburn J, McKenna S, Heaney A, Taylor M, Culkin A, Gabe S, Burden S, Lal S. MON-P195: Development and Validation of the Toniq; A Patient-Reported Outcome Measure for Home Parenteral Nutrition. Clin Nutr 2016. [DOI: 10.1016/s0261-5614(16)30829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Culkin A, Gabe S, Nightingale J. PP070-SUN: Outstanding abstract: A Randomised Controlled Crossover Trial to Investigate the Efficacy of a New Oral Rehydration Solution for Patients with a High Output Stoma. Clin Nutr 2014. [DOI: 10.1016/s0261-5614(14)50112-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
We present a 36-year-old female diagnosed with Crohn's disease at the age of 11 years. In 2001, she underwent a total colectomy and further small bowel resection as a result of active Crohn's. Her residual anatomy consisted of 150 cm of small bowel to an end jejunostomy. Subsequently, she developed short bowel syndrome with recurrent episodes of hypomagnesaemia, hypocalcaemia, and hypokalaemia. Dietetic assessment revealed her to be severely underweight at 37 kg with a bodymass index (BMI) of 14.4 kg/m(2) . During her admission, our patient underwent psychiatric assessment and was established on home parenteral nutrition (HPN). At the time of discharge, 1 month later, her weight had increased to 44 kg (BMI = 17.7 kg/m(2) ). Over the following 12-month period, she lost weight (BMI, 15.4 mg/m(2) ; weight, 39.5 kg) and she described a high stoma output (up to 17 L) and dehydration. Assessment of her oral intake found she was consuming an estimated 14,000 kcal and 600 g protein per day. At this time, the possibility of a new form of eating disorder was discussed with the patient and she agreed that her behavior i.e., using her stoma as a purging device, fulfilled the criteria for a diagnosis of bulimia nervosa and she was referred to a specialist eating disorder unit.
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Affiliation(s)
- Alison Culkin
- Department of Nutrition and Dietetics, St Mark's Hospital, Harrow, England.
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Abstract
Liver dysfunction is common in individuals receiving parenteral nutrition (PN) and particularly in neonates and infants. Abnormalities of liver function tests in patients receiving short term PN are usually transient but in individuals receiving long term PN, substantial liver damage and ultimately end stage liver disease may occur. The aetiology is complex, involving a large number of patient related and nutrition related factors. The terminology intestinal failure associated liver disease (IFALD) is therefore more appropriate than PN associated liver disease. Effort should be made to prevent liver dysfunction by managing sepsis, avoiding parenteral overfeeding, employing cyclical parenteral feeding and encouraging enteral nutrition where possible. Intake of soybean based parenteral lipid emulsions should be reduced in individuals with established IFALD, possibly to be replaced by lipid emulsions containing medium chain triacylglycerol, monounsaturated fatty acids or fish oil although larger clinical studies are needed. Similarly, evidence supporting the widespread use of parenteral choline and taurine supplementation in the prevention or treatment of IFALD remains limited. There are more data to support the use of oral antibiotics to treat bacterial overgrowth and oral ursodeoxycholic acid in neonates. Ultimately, severe IFALD may necessitate referral for small intestine and/or liver transplantation.
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Affiliation(s)
- S M Gabe
- Lennard-Jones Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
- Division of Surgery, Oncology, Reproductive Biology and Anaesthetics, Imperial College, London, UK
| | - A Culkin
- Lennard-Jones Intestinal Failure Unit, St Mark's Hospital, Harrow, UK
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Culkin A, Gabe SM, Madden AM. Improving clinical outcome in patients with intestinal failure using individualised nutritional advice. J Hum Nutr Diet 2009; 22:290-8; quiz 300-1. [PMID: 19344376 DOI: 10.1111/j.1365-277x.2009.00954.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with intestinal failure are required to adhere to a complex regimen. Written information may increase knowledge leading to improvements in clinical outcomes. The present study aimed to evaluate the effectiveness of nutrition advice incorporating the use of a booklet. METHODS Each patient completed a questionnaire evaluating their knowledge of the regime and quality of life and kept a diet and gastrointestinal output diary. The diary was assessed and they were given the booklet with a verbal explanation tailored to individual requirements. The booklet explained the causes of intestinal failure, diet and fluid recommendations in relation to intestinal anatomy, information on medications and long-term monitoring. Patients were reassessed at their next appointment using the same tools. The primary endpoint was an improvement in knowledge. Secondary endpoints were an improvement in oral nutritional intake, nutritional status, quality of life and the content of home parenteral nutrition. RESULTS Forty-eight patients completed the study. Knowledge improved significantly after dietetic intervention in association with the provision of the booklet (P < 0.001). Oral energy (P = 0.04) and fat (P = 0.003) intake increased with an improvement in body mass index (P = 0.02). Patients on home parenteral nutrition showed a reduction in parenteral energy (P = 0.02), nitrogen (P = 0.003), volume (P = 0.02) and frequency (P = 0.003). CONCLUSIONS A booklet for patients with intestinal failure in conjunction with personalised dietary counselling improves knowledge and clinical outcomes.
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Affiliation(s)
- A Culkin
- Department of Nutrition and Dietetics, Northwick Park and St Mark's Hospital, Harrow, Middlesex, UK.
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Basch EM, Jia X, Barz A, Heller G, Culkin A, Appawu M, Barnett T, Jason F, Kris MG, Schrag D. Does CTCAE toxicity symptom reporting by patients or clinicians predict clinical outcomes? J Clin Oncol 2008. [DOI: 10.1200/jco.2008.26.15_suppl.6507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Basch EM, Iasonos A, Barz A, Culkin A, Kris MG, Artz D, Fearn P, Speakman J, Scher HI, Schrag D. Long-term toxicity monitoring via electronic patient reported outcomes in end-stage chemotherapy patients. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.9025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
9025 Background: In cancer trials, clinicians are required to report patient toxicity symptoms using the NCI's Common Terminology Criteria for Adverse Events (CTCAE). Alternatively, patients could provide this information directly as patient-reported outcomes (PROs). This strategy is advocated by the FDA and is standard in non-oncology trials. But it remains unclear if this approach is feasible over long periods, or in patients with high symptom burdens. Methods: Lung cancer patients starting chemotherapy were selected for this feasibility assessment because they are relatively older, sicker, and less web avid than other cancer populations. A patient adaptation of the CTCAE was uploaded to a web portal for self-reporting, including 15 items common in this population. Over 16-months, participants were encouraged but not required to login and complete an online questionnaire at clinic visits via a touchscreen computer. Optional home access was provided without reminders. Results: Beginning in June 2005, 125 patients were approached and 107 enrolled. Reasons for refusal included “too distressed” and “dislike computers.” Mean enrollment was 42 weeks (1–71), during which 35% of participants died. The average number of clinic visits was 12 (1–40). At each consecutive visit most patients (75–85%) logged in without significant attrition over time, even up to the 40th visit. Reasons for failure to login included “lack of reminder” and “inadequate time.” Prior computer experience was associated with greater adherence (p=0.017), but there was no relationship with sex, age, education, stage, or performance status. Most (90%) found the system useful and would recommend it to others, but only 77% felt it improved communication. Although 76% had access to home computers, only 15% voluntarily self-reported from home. Conclusions: Self-reporting is a feasible long-term strategy for toxicity symptom monitoring in most chemotherapy patients, including those with high symptom burdens. In future evaluations, adherence may be improved with more consistent personal encouragement to login in clinic, electronic reminders for home users, consistent staff response to patients’ symptom reports and alternative data collection methods for those who fail to report electronically. No significant financial relationships to disclose.
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Affiliation(s)
- E. M. Basch
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - A. Iasonos
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - A. Barz
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - A. Culkin
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - M. G. Kris
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - D. Artz
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - P. Fearn
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - J. Speakman
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - H. I. Scher
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
| | - D. Schrag
- Memorial Sloan-Kettering Cancer Center, New York, NY; National Cancer Institute, Bethesda, MD
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Culkin A, Gabe SM, Bjarnason I, Grimble G, Madden AM, Forbes A. A double-blind, randomized, controlled crossover trial of glutamine supplementation in home parenteral nutrition. Eur J Clin Nutr 2007; 62:575-83. [PMID: 17440526 DOI: 10.1038/sj.ejcn.1602754] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Studies suggest clinical benefit of glutamine-supplemented parenteral nutrition. The aim was to determine if the inclusion of 10 g of glutamine as part of the nitrogen source of home parenteral nutrition (HPN) reduces infectious complications. SUBJECTS/METHODS Thirty-five patients on HPN were recruited and 22 completed the study. Patients were randomized to receive either standard HPN or glutamine-supplemented HPN. Patients were assessed at randomization, 3 and 6 months later then they were crossed over to the alternative HPN and reassessed at 3 and 6 months. Assessments included plasma amino acid concentrations, intestinal permeability and absorption, nutritional status, oral and parenteral intake, quality of life, routine biochemistry and haematology. RESULTS No difference was seen between the groups at randomization. No difference was detected between the treatment phases for infective complications (55% in the standard treatment phase and 36% in the glutamine-supplemented phase P=0.67). There were no differences in nutritional status, intestinal permeability, plasma glutamine concentrations or quality of life. CONCLUSION Although limited by the sample size, the study has shown that glutamine as part of the nitrogen source of parenteral nutrition can be given to patients on HPN for 6 months without any adverse effects.
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Affiliation(s)
- A Culkin
- Department of Nutrition and Dietetics, St Mark's Hospital, Harrow, Middlesex, UK.
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Basch EM, McDonough T, Iasonos A, Siegel E, Culkin A, Kris M, Scher HI, Schrag D. Patient versus clinician symptom reporting using the National Cancer Institute Common Terminology Criteria for Adverse Events. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.8515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8515 Background: During NCI-sponsored clinical trials, clinicians elicit and report patient toxicity symptoms using the Common Terminology Criteria for Adverse Events (CTCAE). Alternatively, patients may be able to report this information directly, but it remains unclear how these patient reported outcomes (PROs) compare to clinician reports. Methods: Language from the CTCAE version 3 was adapted for patient self-reporting and pilot tested to assure comprehension. Then, a paper questionnaire containing 12 common CTCAE symptoms was administered to consecutive outpatients and their clinicians (physicians and nurses) in clinics specializing in lung or genitourinary malignancies at a specialty cancer center. Results: Between March and May 2005, 435 patients and their clinicians were approached in order to obtain 400 completed paired surveys. For most symptoms agreement was high and this was especially true for more observable symptoms (vomiting, diarrhea) compared to more subjective areas (fatigue, dyspnea) (Table). Most discrepancies were within one point. Only rarely would differences have altered treatment decisions (grade <2 vs. ≥3). Patients more commonly assigned greater severity than clinicians. There was no significant difference when patients reported before versus after caregivers. Kappa values did not accurately measure agreement due to asymmetry in the marginal distribution of scores. Conclusion: Patients and clinicians generally agree on CTCAE symptom severity. Future research should examine the impact of symptom PROs on clinical outcomes and the use of real-time reporting for early detection of SAEs. [Table: see text] No significant financial relationships to disclose.
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Affiliation(s)
- E. M. Basch
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - T. McDonough
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - A. Iasonos
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - E. Siegel
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - A. Culkin
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - M. Kris
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - H. I. Scher
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
| | - D. Schrag
- Memorial Sloan-Kettering Cancer Center, New York, NY; Cornell University, New York, NY
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Culkin A. Intestinal failure and rehabilitation: a clinical guide. J Hum Nutr Diet 2006. [DOI: 10.1111/j.1365-277x.2006.00679.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Culkin A, Gabe S, Forbes A, Chadwick C. Glutamine supplementation is safe in home parenteral nutrition (HPN). Clin Nutr 2003. [DOI: 10.1016/s0261-5614(03)80334-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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